Emergency contraception: a vital component of reproductive health programs.

Abstract

see also p 188 Emergency contraception (EC) refers to contraceptive methods that may beused in the first few days after unprotected intercourse to prevent pregnancy.Although EC is an essential reproductive health option, it remains vastlyunderused. The use of analogs of the female hormones, estrogen and progesterone, aspostcoital contraception was first described in the scientific literature morethan 30 years ago. However, only within about the past 7 years has EC begun tomove from being the “best-kept secret” into the contraceptivemainstream. The most common method of EC involves taking an increased dose of oralcontraceptive pills as soon as possible—optimally, within 72 hours (3days)—after unprotected sex. A second dose is taken 12 hours later.Insertion of an intrauterine device within 5 days of unprotected sex isanother, less frequently used, method of EC. Although intrauterine devices areeffective, and their use is an appropriate method for many women, pills areeasier to administer and may be taken by a wider user group. In many countries, dedicated products are available for use as EC, althoughstandard oral contraceptives can also be used in the absence of a specificallylabeled EC product. In the United States, the Food and Drug Administration hasendorsed off-label ECprescribing.1 Unlike many other health priorities, the need for EC education for bothclients and providers of health services and increasing EC access are notlimited to one particular country or region of the world. In both developingand developed countries, EC remains not only an underused but alsomisunderstood and often completely unknown method of contraception. However,the morbidity and mortality associated with unintended pregnancy in thedeveloping world are particularly striking. About 75 million unintended pregnancies occur in the developing worldannually, and each year 8 to 30 million women experience contraceptivefailure.2,3Women who have an unintended pregnancy often seek abortion; of the estimated45 million pregnancies that are terminated by abortion each year, about halfare performed under unsafeconditions.4 In most of the developing world, such as in sub-Saharan Africa and LatinAmerica, where access to safe abortion services is severely restricted,maternal deaths due to septic abortion can exceed those from all other causes.Women who survive unsafe abortion often suffer debilitating and chronicmorbidity, including infertility; increased risk of ectopic pregnancy;abdominal adhesions that cause chronic pain; structural damage to vagina,cervix, uterus, bladder, or rectum; and exacerbation of chronic anemia. Inaddition to this burden of unnecessary human suffering, the cost of providingremedial health services to these acutely ill women robs countries of fundsneeded for more cost-effective preventive care. Adolescent girls, in particular, suffer disproportionately from unintendedpregnancies and unsafe abortion. Worldwide, pregnancy-related deaths are theleading cause of death for girls aged 15 to 19 years (married or unmarried).Women in this age group face a 20% to 200% greater chance of dying inpregnancy than women from 20 to 24 yearsold.5 Girls whochoose to terminate a pregnancy characteristically wait longer than olderwomen and suffer more life-threatening complications, which result in asubstantial number of abortion-attributabledeaths.6 Increasing awareness of and access to EC is one critical way to improve thehealth and well-being of all women, including adolescents, by preventingunintended pregnancy and abortion. A recent study by the World HealthOrganization found that 60% of induced abortions in Shanghai, China, couldhave been prevented if women had used levonorgestrel-onlyEC.7 However,despite the important role EC can play in both reducing unintended pregnancyand decreasing abortion rates, there exists a significant knowledge gap aboutEC among both possible users and health care professionals.