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Curriculum for Non-Clinical Providers in Washington State Notes to the trainer: PATH is a nonprofit, nongovernmental organization dedicated to improving health, especially the health of women and children. The Emergency Contraception: Increasing Awareness in Diverse Communities Project is a two-year project to increase awareness of and access to emergency contraception among low-income and diverse audiences. This curriculum was developed using information gathered through a 1999 assessment of the knowledge of and attitudes toward emergency contraception among medical providers and men and women in diverse communities in Washington State. The purpose of this training is to augment their knowledge by providing accurate, up-to-date information about emergency contraception in a time-efficient format. The training is designed to be conducted within one hour. It can be used in a variety of settings including in-service training, new employee orientation, and staff meetings. The trainer’s notes that follow are intended to guide the trainer through the issues related to emergency contraception; they are not meant to be used as a lecture script. Key messages are included as bullet points at the beginning of each section. Points of particular importance have been marked with arrows in the text. Question slides have been included to promote discussion and an interactive learning environment. These can be used as an opportunity for dialogue that may help non-clinical providers begin to think about applying this emergency contraception information to their own client interactions. The presentation can be used in three formats: slides, overhead transparencies, or PowerPoint. PATH encourages the trainer/presenter to adapt and modify the training curriculum to best meet the needs of the audience. In addition to the training presentation, a packet of materials on emergency contraception should be provided to each training participant to reinforce the key points covered in the training. The packet includes: Questions and answers regarding emergency contraception Prototype client materials Comprehensive bibliography of curriculum references and citations List of agencies and organizations endorsing emergency contraception Emergency Contraception: Client Materials for Diverse Audiences booklet List of pharmacies in Washington State that provide emergency contraceptive pills through prescriptive authority (for Washington State providers) For more information or clarification, please contact the following PATH staff: Jennifer Winkler, Program Associate Barbara Crook, Program Officer Jane Hutchings, Senior Program Officer PATH 4 Nickerson Street Seattle, WA 98109 (206) 285-3500 Website: http://www.path.org E-mail: [email protected] Trainer’s Notes Section One – Introductions and Overview Key Messages: Stress that curriculum was developed based on recent needs assessment Emphasize practical focus of training Explore current knowledge of emergency contraception Slide 1 Introductions and welcome. (Ask participants to share their prior experiences with emergency contraception.) In late 1999, PATH conducted a needs assessment with non-clinical providers regarding their knowledge of and attitudes toward emergency contraception. This training is a result of those findings; efforts were made to include only practical, time-efficient tools and techniques to accommodate providers’ challenging schedules. Non-clinical providers are in a unique position to raise awareness around the important topic of emergency contraception. Many providers work with clientele at high risk for unintended pregnancy. These providers have an opportunity to get the word out to their clients about the role emergency contraception can play in the prevention of unintended pregnancy. This training contains a wealth of practical information that service providers can communicate directly to their clients. It also contains background information on the ways in which emergency contraception works, which providers would not be expected to share with clients in the course of a brief appointment. This depth of information, however, should assist providers in better communicating key points of information to their clientele. Slide 2 Learning objectives: Understand the critical role of EC in pregnancy prevention Understand EC safety and effectiveness Clarify role of non-clinical providers in educating clients about EC Identify mechanisms for raising awareness of EC within client population Increase awareness of EC resources Non-Clinical Providers 2 Section Two – Unintended Pregnancy Key Messages: Understand magnitude of problem of unintended pregnancy Clarify potential role of emergency contraception in reducing unintended pregnancy Slide 3 Slide 4 Why is emergency contraception needed? Because there is no perfect form of contraception and there are very few perfect contraceptors. Around 10 million couples at risk for unintended pregnancy have sexual intercourse every night in America.1 On any given night, approximately 27,000 condoms break or slip.1 It is important to remember that even those couples using contraception faithfully and correctly can experience contraceptive failure The most recent data show that annually 49%, or approximately 2.65 million pregnancies are unintended at the time of conception.2 In Washington, that proportion is even higher: 55% (57,000 pregnancies). 3 It is important to keep in mind that unintended pregnancy is not just a problem of teens or unmarried women. The Institute of Medicine found in 1995 that the proportion of pregnancies that were unintended at the time of conception was high for every group of women.4 77% of women over age 40 40% of married women 82% of teens age 15-19 88% of never-married women 75% of women at or below poverty level 45% of women above poverty level Non-Clinical Providers 3 Slide 5 Slide 6 The definition of unintended pregnancy is: Pregnancy that is unwanted or mistimed at conception. Unintended pregnancy does not mean unwanted births or unloved children. It does mean less opportunity to prepare: Pre-pregnancy risk identification Management of preexisting conditions Changes in diet and vitamins Avoidance of alcohol, toxic exposure, and smoking Consequences of unintended pregnancies can be significant: Approximately half of all unintended pregnancies end in abortion. If the pregnancy is carried to term, the mother is at greater risk of depression and physical abuse; she is at greater risk of not achieving her educational, financial, and career goals; and her relationship is at three times the risk of dissolution, as compared with women whose pregnancy is intended. The child of an unintended pregnancy is at greater risk of being born at low birthweight, dying in the first year of life, and being abused and neglected, compared to a child who was planned.4 Also, the economic consequences of unintended pregnancy are substantial. In Washington State, 53% of Medicaid-funded births are unintended, translating into annual estimated costs of $136 million in maternity care, labor and delivery, and medical costs. 5,6 Slide 7 The important public health implications of unintended pregnancy led the Institute of Medicine to recommend that the nation adopt the following new social norm: All pregnancies should be intended–that is, they should be consciously and clearly desired at the time of conception.4 Non-Clinical Providers 4 Section Three – Emergency Contraception Key Messages: Women are not informed about EC Providers are not talking about it Slide 8 Slide 9 One major step in addressing this issue is to increase knowledge and awareness of emergency contraception. Emergency contraception can be used to prevent pregnancy AFTER sex. However, there currently are obstacles to the widespread use of emergency contraception: Many women do not know about the method: a 1997 survey showed that only 11% of women knew the basic facts about EC, and only 1% had ever used it.7 Data on health care providers reveal that few discuss EC with their clients. Approximately 1 in 10 providers routinely discusses EC with his/her clients.7 These data are supported by PATH’s 1999 interviews and surveys with medical providers and women from diverse communities. PATH found that the topic of emergency contraception is rarely raised in the context of a medical visit and many clients have never heard about EC. Many factors make it difficult for clients to open the discussion about EC: Shame about improper use of, or lack of use of, contraception Discomfort discussing topics related to sexuality Cultural issues related to provider/client relationship Fears about confidentiality (particularly with adolescents and individuals from ethnically and racially diverse communities) Without education about emergency contraception, women are unable to make truly informed contraceptive choices. It is important that a wider range of service providers work to raise awareness. Within the context of your interactions with clients, you have the opportunity to play a pivotal role in expanding women’s awareness of, and access to, this critical contraceptive option. Non-Clinical Providers 5 Section Four – Background on EC Key Messages: EC has been in use for over 30 years Two types of EC: pills and IUD ECPs must be taken within 72 hours of unprotected sex Slide 10 Key point Key point Slide 11 Emergency contraception is not new. High-dose estrogens were used for emergency contraception in the 1960s, but their availability was not widely recognized until recently. There are two primary types of emergency contraception: Emergency contraceptive pills (ECPs) are two high doses of the same hormones found in ordinary birth control pills. ECPs must be initiated within 3 days (72 hours) of unprotected sex. They are sometimes referred to as “the morning-after pill,” despite the 3-day window of opportunity for their use. ECPs are not the same as RU486—the French abortion pill—and will not disrupt an established pregnancy. IUD insertion within 5 days (120 hours) of unprotected sex is also an effective form of emergency contraception and has the added benefit of providing the client with a long-term contraceptive method. Because ECPs can be used more widely, they are the focus of this training. ECPs can be used any time unprotected intercourse has occurred: A woman was raped No contraception was used A condom slipped, leaked, or broke, or was used incorrectly A diaphragm or cervical cap was inserted incorrectly, removed too soon, or torn Two consecutive birth control pills were missed in a cycle 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 Non-Clinical Providers 6 Slide 12 Key point ECPs are not as effective as regular contraceptive methods. The discussion or use of ECPs should be used as a bridge to explore the client’s long-term birth control options. Repeated use of ECPs is not known to be harmful, but should be discouraged due to high cumulative failure rates. If ECPs were to be used frequently, the failure rate during a full year of use would be higher than that of regular hormonal contraceptives and most other contraceptive methods. ECPs do not protect against STDs. People at risk for STDs should be encouraged to use condoms for STD protection. ECPs may serve as a good back-up contraceptive method in case of condom breakage or slippage. Non-Clinical Providers 7 Section Five – ECP Safety and Effectiveness Key Messages: ECPs are safe and effective No absolute contraindications Do not interfere with an established pregnancy Key point Slide 13 There are no known conditions that would prevent a woman from taking ECPs. The use of hormones is short-term, the dosage is very small, and the hormones leave the body quickly. Because the duration of use is short, experts believe that even women who cannot take oral contraceptives (e.g., smokers) can safely use ECPs. 8 The American College of Obstetricians and Gynecologists (ACOG) emergency contraceptive practice patterns state that no published studies have reported evidence-based criteria contraindicating the use of this treatment. ACOG further states that there is neither evidence of increased risk nor evidence of decreased safety among women who have contraindications to oral contraceptives. 9 The International Planned Parenthood Federation has stated there are no absolute contraindications to emergency contraceptive pills due to the small overall hormone dose and short duration of use.10 Key point Slide 14 Slide 15 Regarding pregnancy: ECPs cannot dislodge an established pregnancy—that is, they do not cause an abortion. Studies of oral contraceptives taken inadvertently in early pregnancy show that ECP hormones do not have an adverse effect on fetal development. 11 There are two types of ECPs: the progestin-only regimen and the combined regimen. This summary table shows that: The progestin-only regimen is more effective than the combined regimen. It is associated with a lower incidence of nausea and vomiting. Regardless of which method is used, the first dose must be taken with 72 hours after intercourse. The second dose follows 12 hours later. 12 Non-Clinical Providers 8 Slide 16 The effectiveness of ECPs varies depending on the type prescribed. An ECP called Plan B™, which contains only progestin, reduces the risk of pregnancy by 89%. This means if 100 women had unprotected sex once during the second or third week of their cycle, 8 would likely become pregnant. If all 100 used the progestin-only regimen, only one would become pregnant, an 89% reduction.12, 13 Slide 17 An ECP called Preven™, which contains a combination of estrogen and progestin, reduces the risk of pregnancy by 75%. This means if 100 women had unprotected sex once during the second or third week of their cycle, 8 would likely become pregnant. If all 100 used the combined regimen, only 2 would become pregnant, a 75% reduction. 13, 14 Non-Clinical Providers 9 Section Six – ECP Mechanism of Action Key Messages: Mechanism of action is unclear Clear communication with clients is an essential component of informed choice Slide 18 Key point Emergency contraceptive pills work through several possible mechanisms of action. Clinical studies have shown that ECPs work the same way as ordinary birth control pills, by preventing or delaying the release of a woman’s egg (ovulation).15,16,17 ECPs may prevent pregnancy by affecting the uterine lining or endometrium, so that a fertilized egg cannot implant. However, research on these effects of ECP treatment is not clear on whether the changes in the uterine lining would prevent implantation.15,16,18,19,20 It is also possible that ECPs could prevent fertilization by affecting the movement of sperm and their ability to fertilize an egg, but no conclusive data exist regarding this possible mechanism of action. Timing plays a key role in how ECPs work; the menstrual cycle day of intercourse and treatment both affect how ECPs function. 21 [NOTE: These are the same ways oral contraceptive pills work] Slide 19 Slide 20 ECPs’ role in preventing pregnancy: The National Institutes of Health (NIH), The Food and Drug Administration (FDA), and ACOG all define pregnancy as beginning at the completion of implantation. 11,22,23 It takes about 6 days after ovulation for a fertilized egg to begin to implant. Therefore, use of ECPs within 72 hours cannot result in abortion. Lastly, as mentioned earlier, ECPs are not effective if implantation has occurred and a woman is already pregnant. Some women will want to base their decision on whether to use ECPs on how they work. Thus, it is important that women clearly understand how pills are believed to work in order to make an informed choice. Non-Clinical Providers 10 Slide 21 Important points to communicate to clients about the mechanism of action are that ECPs: Will not interrupt or harm an established pregnancy (i.e., it is not a medical abortion) Will not affect future fertility Are not the same as mifepristone (RU486, the “abortion pill”), which is used to terminate an established pregnancy Work through various mechanisms Non-Clinical Providers 11 Section Seven – Key Messages Key Messages: ECP discussions should be brief but thorough ECP discussions should address clients’ concerns Slide 22 (Discussion) Slide 23 The training has covered a substantial amount of information up to this point. Realizing that all of you have limited time with clients, what key points on EC would you want to get across to your clients? When discussing ECPs with clients, it is important to provide these key messages: ECPs must be taken within 72 hours of unprotected sex; however, effectiveness is higher the sooner ECPs are used. ECPs are safe and effective in preventing pregnancy after sex. Women should clearly understand how ECPs work so that they can make an informed choice about the method (for example, knowing that ECPs may block implantation of a fertilized egg). Do not cause abortion The potential for nausea and vomiting should be explained. It should be stressed that ECPs are not as effective as regular contraceptive methods. The need for ECPs can highlight a need for clients to know more about other birth control methods. It is important to emphasize that ECPs do not protect against STDs. Know the nearby locations that distribute emergency contraception so that clear, accurate referrals can be provided. [NOTE: It is important to keep in mind that all women at risk of an unintended pregnancy need to know about emergency contraception [regardless of age or marital status] and would benefit from this discussion.] Slide 24 (Discussion) In addition to these key clinical points, clients may come in with their own set of concerns about the use of ECPs that should be addressed in the course of a discussion. Based on your experience, what do you think are concerns and questions your clients may have about ECPs? Non-Clinical Providers 12 Slide 25 PATH research among women and men of diverse communities revealed the following client concerns: The impact of ECPs on future childbearing. ECP use does not have an impact on future fertility. The threat to potential pregnancy. As we discussed earlier, research presented to the FDA shows no evidence of negative effects on a potential pregnancy. Relationship to abortion. ECPs do not disrupt an established pregnancy and are medically defined as contraception and pregnancy prevention. Religion is not predictive of individual’s interest in or willingness to use emergency contraception. Expense of ECPs. ECPs are covered by Medicaid. Current out-of-pocket costs will be discussed later in training. Concerns about confidentiality were raised repeatedly in the course of our research. Adolescents and members of diverse communities were especially concerned about the issue of confidentiality and need reassurance about the confidential client-provider relationship. Concerns about the importance of maintaining confidentiality extend to interpreters as well. Non-Clinical Providers 13 Section Eight – Providing ECPs Key Messages: There are many ways to get ECPs Advance distribution/prescribing can improve client access to ECPs Slide 26 Slide 27 Women can obtain ECPs in several ways: Women can obtain ECPs or an ECP prescription in advance of need from their doctor, nurse practitioner, or pharmacist. Medical clinics provide ECPs through either a scheduled appointment or a walk-in visit when requested by clients. In some cases, ECPs can be provided by telephone by medical clinics to clients upon request (many Planned Parenthood clinics will prescribe ECPs over the telephone). In Washington State, pharmacists can establish a collaborative drug therapy agreement with a medical provider that enables the pharmacist to provide ECPs directly to women. To locate the clinic site or pharmacy nearest to the client, call the Emergency Contraception Hotline, at 1-888-NOT-2-LATE (1-888-668-2528), or call the Washington State Family Planning Hotline at 1-800-770-4334 for family planning information by county. Referring women to sources of ECPs in advance of need can greatly improve the convenience of the method and can help ensure that women have access to treatment as soon as they need it. 24 This is particularly important in view of research that demonstrates ECPs are more effective the sooner they are used. Transportation was cited as a significant barrier for access to ECPs; advance prescribing or distribution helps to minimize this barrier. Non-Clinical Providers 14 [Previous Slide, Continued:] Some people raise concerns about whether providing ECPs to women ahead of time will make them more likely to use them irresponsibly. It is important to keep in mind the idea that the decision to use ECPs following unprotected sex is a responsible decision. Also, women who have used ECPs do not plan to use them as a regular contraceptive method or expect that their partner would suggest their use for regular contraception. A study evaluating women’s experience receiving ECPs through a demonstration project from Kaiser Permanente in San Diego found that the overwhelming majority (97%) of women reported that they would use ECPs again only in an emergency. Among the 84% who had informed their partner, 92% agreed that using ECPs would not make their partner less willing to practice contraception.25 Slide 28 In Washington State, collaborative agreements enable trained pharmacists to provide ECPs directly to clients who request them (either in advance or as needed). The pharmacist uses screening criteria when dispensing the pills and regularly participates in a quality-assurance review with the authorizing prescriber. Currently, there are over 145 pharmacies participating in collaborative agreements in Washington State. In the first 16 months of the project, almost 12,000 ECP prescriptions were provided directly by pharmacists. A list of participating pharmacies in Washington State is included in the information packet. Updated information about accessing ECPs via participating pharmacies is also available through the EC Hotline at 1-888-NOT-2-LATE (1-888-668-2528). Non-Clinical Providers 15 Section Nine – Cost and Cost-Effectiveness Key Messages: Medicaid covers ECPs Current retail prices are $18 to $35 for pills alone Slide 29 Medicaid covers ECP prescriptions: In Washington State, medical coupons cover both Preven and Plan B as well as regular birth control pills prescribed in special doses for use as emergency contraception. Slide 30 Medicaid also covers both pills and pharmacist counseling time for women who receive ECPs directly from their pharmacist. For clients using private insurance or private pay, the current (2000) retail prices at pharmacies in the Seattle area are: For filling Preven or Plan B prescriptions written by providers: If the pills are covered by insurance, then the client commonly pays a co-pay of $5 to $10. If the client has no insurance coverage, the prices vary from $18 to $35 for Plan B and $20 to $35 for Preven. If the client obtains ECPs directly through the pharmacist, they would need to pay for both the prescription and the consultation. In 2000, average pharmacist charges are $35 to $45 for ECPs and counseling. Non-Clinical Providers 16 Section Ten – Opportunities for ECP Discussion Key Messages: It is important that service providers discuss ECPs with all their clients Informational tools are available for service providers and for clients Slide 31 Slide 32 Slide 33 The following resources related to emergency contraception are included in the training packets. Q & A for non-clinical providers Key messages to convey to clients EC referral card Emergency Contraception: Client Materials for Diverse Audiences booklet List of pharmacies that provide ECPs in Washington State EC reference list One key resource in the packet is the booklet entitled “Emergency Contraception: Client Materials for Diverse Audiences.” The pages of the booklet are designed to be photocopied into pamphlets that contain EC information in 13 languages These resources can help clients to locate clinics and pharmacies in their area. The Emergency Contraception Hotline number (1-888-NOT-2-LATE or 1-888-668-2528) provides ECP information as well as a directory of clinics and Washington State pharmacies listed by zip code. The website www.not-2-late.com provides the same information online. Planned Parenthood offers information online at http://plannedparenthood.org. The Department of Social and Health Services sponsors a Washington State Family Planning Hotline (1-800-770-4334). Non-Clinical Providers 17 Slide 34 (Discussion) In thinking about how you can emphasize ECPs in your interactions with clients at risk of unintended pregnancy, some questions to consider include: When do you plan to discuss ECPs? With what groups of women will you discuss ECPs? Who will you refer for ECPs? Where will you refer clients? In planning for emergency contraception services, it is important to keep in mind the short time frame for treatment and to eliminate as many barriers as possible. Slide 35 In closing, we would like to emphasize that the most important step service providers can take to improve the consistent and appropriate use of contraception is to talk about it with their clients. Results from the PATH needs assessment with diverse populations in Washington State show that awareness regarding EC is extremely limited. This means that you can play a critical role in reducing unintended pregnancy by educating clients about EC and referring for EC when appropriate. The following recommendations can increase clients’ awareness of EC: Routinely discuss the availability of ECPs as a back-up method for contraceptive accidents. Make EC informational materials available in your settings (waiting rooms, restrooms, offices) and distribute EC client materials during appointments. Encourage all (not just high-risk) clients to obtain advance-of-need prescription for ECPs. Slide 36 Close Non-Clinical Providers 18 Reference List Washington State Non-Clinical Curriculum 1. Trussell J, Kowal D. The Essentials of Contraception: Safety, Effectiveness, and Personal Considerations. In Contraceptive Technology, 17th ed. New York: Irvington Publishers, 1998. 2. Henshaw S. Unintended pregnancy in the United States. Family Planning Perspectives 30:24-29,46, 1998. 3. Schrager L. First Steps Database: Unintended Pregnancy. Olympia, WA: Research and Data Analysis, Department of Social and Health Services 7(1):1-12, 1997. 4. Institute of Medicine. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, D.C.: National Academy Press, 1995. 5. PRAMS Surveillance Report. Washington State Department of Health, 1998. 6. State Covered Maternity and Abortion Report. Washington State Department of Social and Health Services, February 1999. 7. Emergency Contraception: Is the Secret Getting Out? Menlo Park, CA: The Henry J. Kaiser Family Foundation, 1997. 8. World Health Organization. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. WHO/FRH/FPP/96.9. Geneva:31-33, 1996. 9. ACOG practice patterns. Emergency oral contraception. Number 3, December 1996. American College of Obstetricians and Gynecologists. International Journal of Gynecology and Obstetrics 56(3):290-297, 1997. 10. International Planned Parenthood Federation. IMAP statement on emergency contraception. IPPF Medical Bulletin. 28(6):1-2, 1994. 11. Food and Drug Administration. Prescription drug products; certain combined oral contraceptives for use as post-coital emergency contraception; Notice. Federal Register. 62:8610-8612, 1997. 12. Task Force on Postovulatory Methods of Fertility Regulation. Randomized controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 352:428-433, 1998. 13. Association of Reproductive Health Professionals (ARHP). Emergency Contraception: Train the Trainer. Washington D.C.: ARHP, 1999. Available online at www.arhp.org/ec/. 14. Trussell J, Rodriguez G, Ellertson C. New estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception 57:363-369, 1998. 15. Swahn M, Westlund P, Johannisson E, Bygderman M. Effect of post-coital contraceptive methods on the endometrium and the menstrual cycle. Acta Obstetricia et Gynecologiica Scandinavica 75:738-744, 1996. Non-Clinical Providers 19 16. Ling W, Robichaud A, Zayid I, Wrixon W, MacLeod S. Mode of action of DL-norgestrel and ethinylestradiol combination in postcoital contraception. Fertility and Sterility 32:297-302, 1979. 17. Rowlands S, Kubba A, Guillebaud J, Bounds W. A possible mechanism of action of danazol and ethinylestradiol/norgestrel combination used as a postcoital contraceptive agency. Contraception 33:539-545, 1986. 18. Ling W, Wrixon W, Acorn T, Wilson E, Collins J. Mode of action of dl-norgestrel and ethinylestradiol combination in postcoital contraception. III. Effect of preovulatory administration following the luteinizing hormone surge on ovarian steroidogenesis. Fertility and Sterility 40:631-636, 1983. 19. Kubba A, White J, Guillebaud J, Elder M. The biochemistry of human endometrium after two regimens of postcoital contraception; a dl-norgestrel/ethinylestradiol combination or danazol. Fertility and Sterility 45:512-516, 1986. 20. Taskin O, Brown R, Young D, Poindexter A, Wiehle R. High doses of oral contraceptives do not alter endometrial 1 and 3 integrins in the late implantation window. Fertility and Sterility 61:850-855, 1994. 21. Von Hertzen H, Van Look P. Research on new methods of emergency contraception. Family Planning Perspectives 28(2):52-57, 88, 1996. 22. Office for Protection from Research Risks Reports. Protection of human subjects. Code of Federal Regulations, 45 CFR 46.203, 1998. 23. Committee on Terminology, The American College of Obstetricians and Gynecologists. Obstetric-Gynecologic Terminology. Hughes E (ed.). Philadelphia, PA: F.A. Davis Company, 1972. 24. Glasier A, Baird D. The effects of self-administering emergency contraception. New England Journal of Medicine 339:1-4, 1998. 25. Harvey MS, Beckman LJ, Sherman C, Pettiti D. Women’s experience and satisfaction with emergency contraception. Family Planning Perspectives 31(5):237-240, 260, 1999. JWVP15057.doc Non-Clinical Providers 20