Emergency contraception ec and the prevention of unintended pregnancy
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1. Emergency Contraception (EC) and the Prevention of Unintended Pregnancy. Kenneth D. Rosenberg, MD, MPH Oregon Office of Family Health Portland, Oregon 8 th Annual MCH Epidemiology Conference December 12, 2002 Clearwater Beach, Florida. 2.

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Emergency Contraception (EC) and the Prevention of Unintended Pregnancy

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Emergency contraception ec and the prevention of unintended pregnancy

1

Emergency Contraception (EC) and the Prevention of Unintended Pregnancy

Kenneth D. Rosenberg, MD, MPH Oregon Office of Family Health

Portland, Oregon

8th Annual MCH Epidemiology Conference

December 12, 2002

Clearwater Beach, Florida


Why is emergency contraception needed

2

Why Is Emergency Contraception Needed?

  • About 10 million couples have sexual intercourse every night in America

  • Approximately 27,000 condoms break or slip

  • Even perfect contraceptors can and do experience contraceptive failure

    • Others may fail to use contraception at all

Source:Trussell & Kowal, 1998.


Unintended pregnancy

3

Unintended Pregnancy

  • Pregnancy that is unwanted or mistimed at conception

  • Approximately half of all unintended pregnancies end in abortion

  • Greater risks for mother

    • depression, physical abuse, risk of not achieving educational, financial, career goals, relationship challenges

  • Greater risks for child

    • low birthweight, infant mortality, abuse, neglect

Source:Institute of Medicine, 1995.


The institute of medicine recommends that the nation adopt a new social norm

4

The Institute of Medicine Recommends That the Nation Adopt a New Social Norm

All pregnancies should be intended – that is, they should be consciously and clearly desired at the time of conception.

Source:Institute of Medicine, 1995.


Current proportion of unintended pregnancy

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Current Proportion of Unintended Pregnancy

United States: 49%

Oregon: 51%

43% of live births

95% of abortions

Source:Henshaw, 1998, Oregon Health Division, 1997.


What is emergency contraception

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What Is Emergency Contraception?

  • Emergency Contraceptive Pills (ECPs)

    • Have been in use since the 1960s

    • Often referred to as “the morning-after pill”

  • IUD Insertion

    • Within 5 days (120 hours) of unprotected sex

    • Can also be a long-term contraceptive method


Emergency contraceptive pills

7

Emergency Contraceptive Pills

  • Consist of two doses of the same hormones found in birth control pills

  • Must be taken within three days (72 hours) of unprotected sex

  • Can be used to prevent pregnancy AFTER unprotected sex


Emergency contraception ec and the prevention of unintended pregnancy

ECPs Can Be Used Any Time Unprotected Intercourse Has Occurred

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  • A woman was raped

  • No contraception used

  • Condom slipped, leaked, or broke

  • Diaphragm or cervical cap inserted incorrectly, removed too soon, or torn

  • Two consecutive birth control pills were missed

  • An IUD was partially or totally expelled

  • A three-month contraceptive injection was missed by more than two weeks

  • A one-month contraceptive injection was missed by more than three days


Limitations of ecps

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Limitations of ECPs

  • ECPs are not a good long-term method of contraception

    • Should be used as a bridge to a regular form of birth control

  • ECPs do not protect against STDs


Are ecps safe

10

Are ECPs Safe?

  • ECPs are safe and easy to use

    • The amount of active ingredient (hormone) is small

    • Short-term use

  • Repeated use is safe

Source: WHO, 1996.


Emergency contraception ec and the prevention of unintended pregnancy

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What if a Woman Is Already Pregnant?

  • ECPs cannot dislodge an established pregnancy

    • They do not cause abortion

  • ECPs do not affect fetal development

Source: Lancet, 1998.


Two types of ecps

Progestin-only

Reduces the risk of pregnancy by 89%

Side effects

Nausea (23%)

Vomiting (6%)

Estrogen and Progestin

Reduces the risk of pregnancy by 75%

Side effects

Nausea (50%)

Vomiting (20%)

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Two Types of ECPs

Both Methods:

First dose within 72 hours after intercourse

Second dose 12 hours later

Source: Lancet, 1998.


Emergency contraception ec and the prevention of unintended pregnancy

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Effectiveness: Progestin Only

100 women have unprotected sex in

the 2nd or 3rd week of their cycle

8 will become pregnant without

emergency contraception

1 will become pregnant using progestin-only ECPs

(89% reduction)

Source: FDA, 1997.


Effectiveness combination pill estrogen progestin

14

Effectiveness: Combination Pill (Estrogen + Progestin)

100 women have unprotected sex in

the 2nd or 3rd week of their cycle

8 will become pregnant without

emergency contraception

2 will become pregnant using combined ECPs

(75% reduction)

Source: Trussell, Rodriguez, and Ellertson, 1998.


How do ecps work

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How Do ECPs Work?

  • The same way as ordinary birth control pills

    • They can prevent or delay the release of a woman’s egg (ovulation)

  • ECPs may affect the uterine lining so that a fertilized egg cannot implant

  • ECPs may prevent fertilization by affecting the movement of sperms and their ability to fertilize an egg

Source: Swahn et al., 1996; Ling et al., 1979; Rowlands et al., 1986;

Ling et al., 1983; Kubba et al., 1986; Taskin et al., 1994; Von Hertzen & Van Look, 1996.


Pregnancy prevention

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Pregnancy Prevention

  • NIH, FDA, and ACOG all define pregnancy as beginning with implantation

  • It takes about 6 days for a fertilized egg to begin to implant

  • Intervention within 72 hours cannot result in abortion

  • ECPs are not effective if a woman is already pregnant

Source: Code of Federal Regulations, 1998; Hughes, 1972.


Key points on mechanism of action

17

Key Points on Mechanism of Action

  • Will not interrupt or harm an established pregnancy

  • Will not affect future fertility

  • ECPs are not the same as the “abortion pill” (RU486), which is used after pregnancy is already established


Where can women get ecps

18

Where Can Women Get ECPs?

  • Medical provider

    • Walk-in visit/appointment

    • Telephone screening

  • Call the Emergency Contraception Hotline for nearest location: 1-888-NOT-2-LATE (1-888-668-2528) or visit the website at

    http://not-2-late.com


Oregon prams survey

19

Oregon PRAMS Survey

  • Annual survey of postpartum women

  • Since 1998

  • Survey about 2000 women/year

  • Sample drawn from birth certificates


Prams survey results

20

PRAMS Survey Results

  • 1998-99: 70% of postpartum women had heard of “the morning-after pill”

  • Most likely to have not heard:

    • Less than 12 years education

    • Annual family income <$30,000

    • Pregnancy unintended


Advance prescription of ecps

21

Advance Prescription of ECPs

  • More effective when taken sooner

  • Reduces access barrier

  • Not more likely to use repeatedly

  • Filled or not filled


Expanded access through pharmacies

22

Expanded Access Through Pharmacies

  • Collaborative agreement between pharmacists and prescribers in Washington State

    • Pharmacists counsel and dispense without physician prescription

    • In first sixteen months of project almost 12,000 women received ECPs directly from a pharmacist

  • New laws in California and Alaska


Spread the word

23

Spread the Word:

  • Routinely discuss ECPs

  • Make ECP materials available in agency settings

  • Encouraging advance prescriptions

  • College providers

  • Emergency providers


Additional resources

24

Additional Resources

  • www.backupyourbirthcontrol.org

  • American College of Obstetrics and Gynecology: www.acog.org/…

  • Program for Appropriate Technology in Health (PATH): www.path.org/…

  • CD Summary article: www.oshd.or/cdsum/2002/ohd5111.htm

  • List of retail pharmacies that stock EC: http://www.go2planB.com


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