Emergency Contraception: Have We Come Full Circle?

By Elizabeth Westley and Francine Coeytaux and Elisa Wells, RH Reality Check. Posted August 27, 2009.

Two decades ago, Dr. Felicia Stewart, then serving as Medical Director of the Planned Parenthood affiliate in Sacramento California, began her campaign to let out of the closet "America's best-kept secret" - emergency contraception. The method had been suppressed because many providers thought the method was "not effective enough," or would lead women to use it "too much" (in place of using other more effective methods). Advocates disagreed, believing that emergency contraception could help some women prevent pregnancy, that women could learn to use the method appropriately, and that women had the right to this important option.

When Dr. Stewart and other women's health advocates pushed to move emergency contraception "from secret to shelf," they had women's needs in mind - in particular the need for a method that, unlike others, could be used after sex and one that was safe enough to provide without the barrier of a medical interface. The success of this twenty year effort is evident in the many dedicated emergency contraception products now available worldwide, the increase in women's awareness and use of EC, and, in the United States, the full-on direct to consumer marketing of emergency contraception by a pharmaceutical company, not to mention the popularity of the method among women.

Today, in the midst of this forward trajectory of increased access and awareness, we have encountered a curve ball that has us circling back to where we started. Recent analyses suggesting that emergency contraception is not as effective in reducing unwanted pregnancy rates at a population level as we once hoped seem to have put the brakes on funding and have revived the original arguments that emergency contraception is "not effective enough" to be promoted as an option and that women are "abusing" it, using it repeatedly instead of using other more effective methods. Some in the field have also again voiced concerns that by providing it directly to women we are missing opportunities to provide women with a full range of reproductive health services.

Our response to this recent round of questioning is that emergency contraception still fills a unique and important role in the mix of available contraceptive methods, that it is effective enough to be promoted as a contraceptive option, and that women's use of the method does not constitute a problem (in terms of lower effectiveness) but rather contributes in a positive way to every woman's significant challenge of how to avoid unplanned pregnancies over her lengthy fertile years.

Emergency Contraception Is Unique

Emergency contraception is unique and fills a much needed niche. It is the only method a woman can easily use post-coitally, thus occupying a very critical place in the array of currently available methods. The post-coital niche is important not only for women who have had no control over their exposure to sex, as in the case of sexual violence, but also for couples who find themselves in need of contraception after sex. The growing sales figures for emergency contraception in the United States and around the world suggest that significant numbers of women continue to need a post-coital method.

Some of the researchers who are concerned about the "low-efficacy" of oral emergency contraceptives are now trying to promote emergency IUD insertion as an alternative post-coital method. But the logistics and cost of obtaining it make it an unrealistic option for most women.  And it ignores what many women tell us is the biggest appeal of emergency contraceptive pills - the convenience of being able to directly access the method without having to see a doctor or health care provider.

Emergency contraception is one of only a few methods that can be obtained without having to make an appointment for a medical office visit. Women value the privacy, confidentiality, and convenience of accessing emergency contraceptive pills through pharmacies, which are open long hours and on weekends. The fact that women are willing to pay more for emergency contraceptive pills than for a month of oral contraceptive pills requiring a clinic visit and prescription should tell us a lot about what women want and how our current family planning services are failing them.

Emergency Contraception Is Effective Enough

Asserting that emergency contraception is "not effective enough" begs two questions: what level of effectiveness is enough and who decides this - women or providers?

Our expectations for EC's effectiveness were biased upwards by an early estimate that expanding access to emergency contraception could dramatically reduce the incidence of unintended pregnancy and subsequent abortion. This estimate made a compelling story and is likely a key reason why donors and others were willing to support efforts to expand access to EC. Now that we realize that this was an overly optimistic calculation - not because emergency contraception is ineffective in stopping pregnancy in individual women who use it, but because women with enhanced access to emergency contraception do not seem to always use it when they need it - we seem unable to acknowledge that individual women have a right to use the contraceptive method that best suits them, not the one that best contributes to overall demographic indicators.  And we seem to have forgotten that an important way to increase contraceptive coverage and reduce fertility at the population level is by enhancing the choice of contraceptive methods available.

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