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Case Studies in Emergency Contraception from Six Countries by Anna Glasier, Evert Ketting, V.T

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Case Studies in Emergency Contraception from Six Countries by Anna Glasier, Evert Ketting, V.T Case Studies in Emergency Contraception From Six Countries By Anna Glasier, Evert Ketting, V.T. Palan, Lesley Browne, Susheel Kaur, Xiao Bilian, Josue Garza-Flores, L. Vasquez Estrada, Grace Delano, Grace Faoye, Charlotte Ellertson and Elizabeth Armstrong n countries where emergency contra- emergency contraceptive methods are mar- ment after five days “might be considered ception is offered, its availability and keted legally, but family planning organi- an abortion.”3 The following year, an an- Iuse vary widely, according to such fac- zations shy away from offering them. tiabortion lobbying group filed several tors as regulations and policies regarding In China, postcoital methods have long complaints against clinics providing emer- the method, providers’ and women’s un- been offered by the government family gency contraception; the group based its derstanding of and attitudes toward it, planning service. However, these meth- argument on the Offences Against the Per- and cost. The experiences with the meth- ods have not been separated into those ad- son Act of 1861, which made it illegal for a od in six countries—the United Kingdom, vocated for emergency use only and those woman or her doctor to “intend to procure the Netherlands, Malaysia, China, Mexi- recommended for ongoing use. a miscarriage.” In response, the attorney co and Nigeria—illustrate a range of is- Finally, in Mexico and Nigeria, aware- general ruled that emergency contracep- sues involved in introducing and en- ness of emergency contraception contin- tion administered within 72 hours after in- couraging the acceptability of emergency ues to be low among both health care tercourse was not a criminal offense, rea- contraception. providers and the public. soning that “preventing implantation is not Emergency contraception first became Research, both on a way to create knowl- procurement of a miscarriage.”*4 available in most of these countries in the edge of emergency contraception and on At the request of the Department of late 1960s and early 1970s. Today, in the Unit- a way to publicize the methods, has been Health, the Committee on Safety of Med- ed Kingdom and the Netherlands, the meth- largely concentrated in European coun- icines undertook a review of emergency od is an accepted part of family planning tries; many developing countries, and even contraception in 1983 and determined that practice and is well-known among doctors many developed ones, have yet to conduct the method was “acceptably safe for oc- and women. This acceptance may be part- any research on this topic. For example, casional use.” The pharmaceutical com- ly due to the method’s inclusion in the health Mexico’s first clinical trial of an emergency pany Schering submitted an application insurance systems of these countries. contraceptive method (a combination of for a product based on Eugynon 50 to the Another factor explaining the estab- levonorgestrel and ethinyl estradiol, ad- Medicines Division in August 1983 and re- lished role of emergency contraception, at ministered orally or vaginally) is under ceived a license in January 1984. PC4 (50 least in the Netherlands, is the lack of way, fully 30 years after the original re- mcg of ethinyl estradiol and 0.5 mg of moral debate surrounding the method. search on the method was conducted. norgestrel in each of four tablets) was on Only its side effects and efficacy seem to In the case studies that follow, we sum- the market by October 1984. engender controversy; the need for emer- marize information on experiences with Discussion is under way with regard to gency contraception is acknowledged and emergency contraception in each of these making PC4 available from pharmacists accepted even for teenagers, for whom countries. We then draw on these experi- without a doctor’s prescription, a step that sexual activity is socially sanctioned. ences to suggest lessons for other coun- most professional organizations support. By contrast, in Malaysia, as in other coun- tries seeking to introduce or expand the The Royal College of Obstetricians and tries where abortion is strictly regulated, use of this method. Gynecologists organized meetings about the matter in December 1994 and July Anna Glasier is a consultant gynecologist and director United Kingdom 1995. It is up to Schering to apply to of family planning at Family Planning and Well Women History of Emergency Contraception change the license, and the company thus Services, Edinburgh, United Kingdom. Evert Ketting is a sociologist and deputy director at the Netherlands In- Although British doctors occasionally ad- far seems reluctant to do so. stitute of Social Sexological Research, Utrecht, Nether- ministered high-dose estrogen or insert- lands. V.T. Palan is regional director, and Lesley Browne ed an IUD for the purpose of emergency Availability and Prevalence is program adviser, East & South East Asia and Oceania contraception in the early 1970s, it was not General practitioners are the major source Region (ESEAOR), International Planned Parenthood until 1974 and the publication of the first of emergency contraception in the Unit- Federation (IPPF), London. At the time this article was written, Susheel Kaur was operations research officer, article on emergency contraception using ed Kingdom. Everyone in the United ESEAOR, IPPF, Kuala Lumpur, Malaysia. Xiao Bilian is a combined estrogen-progestogen regi- Kingdom is entitled to register with a gen- director emeritus, National Research Institute for Fam- men that the method’s use became wide- eral practitioner. For contraceptive ser- ily Planning, Beijing. Josue Garza-Flores is senior scien- spread in the United Kingdom.1 The Na- vices, women may also visit a general tist, Department of Reproductive Biology, National In- tional Association of Family Planning practitioner other than the one they are stitute of Nutrition Salvador Zubiran, and director, Center for the Assistance in Human Reproduction, Mexico City. Doctors met in 1982 to discuss emergency registered with, although this option is not L. Vasquez Estrada is head, Obstetrics and Gynecology contraception and a year later published widely known. Unit, Hospital Gea Gonzalez, Mexico City. Grace Delano a set of clinical guidelines establishing two is vice president, and Grace Faoye is program director, combined pills, Ovran and Eugynon 50, *Abortion is legal in the United Kingdom under the terms Association for Reproductive and Family Health, Ibadan, as the preferred hormonal regimens.2 of the 1967 Abortion Act, which requires agreement by Nigeria. Charlotte Ellertson is program associate at The two doctors that a woman has grounds for terminating Population Council, New York. Elizabeth Armstrong is In 1982, the Department of Health stat- a pregnancy. A report of the abortion, signed by the two a doctoral candidate at the University of Pennsylvania, ed that treatment up to 72 hours post- doctors and specifying the grounds for termination, must Philadelphia, Penn., USA. coitally was “probably legal,” but that treat- be made to the Department of Health. Volume 22, Number 2, June 1996 57 Case Studies in Emergency Contraception Women in most cities and large towns with two spares in case she vomits. Oth- (This regimen is commonly known as the may also seek emergency contraception at ers add an antiemetic, at a cost of around 5x5 method.) In around 1980, the “Yuzpe National Health Service family planning 16 cents per tablet. An IUD costs the Na- method” was introduced in the Nether- clinics. Since 1972, these clinics have pro- tional Health Service about $11–$16, al- lands. This regimen, which came to be vided contraceptives free of charge. The though clinics that buy in bulk may pay known as the 2x2 method for its two doses clinics offer anonymity to women reluctant considerably less. of two pills taken 12 hours apart, quickly to consult their general practitioner and A recent study of the cost-effectiveness replaced the 5x5 method; for example, by may be open in the evenings and on week- of contraception estimated considerable 1985, 83% of prescriptions for emergency ends; however, not all towns—and few vil- savings to the National Health Service contraception from general practitioners10 lages—have such centers, and at least half from the use of emergency contraception and 97% of those from the Rutgers Stich- of these clinics are open only once a week. to prevent unintended pregnancy.6 Even ting were for the Yuzpe method.11 How- The nonprofit Brook Advisory Centres, on the basis of failure rates as high as 25 ever, over the last 10 years, the side effects which provide services to young people births per 100 users of emergency contra- and efficacy of both methods have been in cities throughout England and in Ed- ception per year, the study estimated that the subject of vigorous debate among inburgh, Scotland, provide emergency prescribing PC4 costs between $19 and practitioners and researchers. Several spe- contraception. Some hospitals’ accident $74, depending on the provider, and saves cialists feel that the 5x5 method provides and emergency departments also provide the government health service $727–$806. far too heavy a hormonal dose, while oth- hormonal emergency contraception. Estimates of costs averted did not include ers are of the opinion that the 2x2 meth- National data on the prevalence of emer- such costs to society as those associated od is not sufficiently reliable. gency contraception do not exist, but re- with education and social services. This debate has spilled over into the ports from clinics suggest that use has been general public’s consciousness and has at rising rapidly. Knowledge of emergency Netherlands times affected the willingness of physi- contraception is fairly high; surveys from History of Emergency Contraception cians to prescribe certain regimens and of the late 1980s found that 65–75% of women Emergency contraception has been used women to use them. The 5x5 method, undergoing induced abortion had heard in the Netherlands since 19647 and is sometimes referred to in the mass media of emergency contraception.5 A small, un- widely known and accepted there.
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