Download Emergency Contraception for Medical Providers

Emergency Contraception
for Non-Clinical Providers
in Washington State
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Learning Objectives
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Understand the critical role of emergency
contraception (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
Why Is Emergency Contraception
Needed?
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Around 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
Source: Trussell & Kowal, 1998.
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Current Proportion of
Unintended Pregnancy
United States: 49%
Washington State: 55%
Source: Henshaw, 1998; Schrager, 1997.
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Definition of Unintended Pregnancy
 Pregnancy that is unwanted or mistimed at conception
 Does not mean unwanted births/unloved children
 Does mean less opportunity to prepare:
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Pre-pregnancy risk identification
Management of preexisting conditions
Changes in diet and vitamins
Avoidance of alcohol, toxic exposure, and smoking
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Consequences of Unintended Pregnancy
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Approximately half of all unintended pregnancies
end in abortion
Greater risks for mother
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depression; physical abuse; not achieving educational,
financial, career goals; relationship challenges
Greater risks for child
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low birthweight, dying in first year of life, abuse, and
neglect
Source: Institute of Medicine, 1995.
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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.
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Emergency contraception
prevents pregnancy
AFTER sex
Emergency Contraception
Obstacles to Use

Most women don’t know about the method
 11%
of women know the basic facts about EC
 1% have used it
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Most health care providers do not routinely
discuss EC with their clients
 approximately
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1 in 10 routinely discuss EC
These data are supported by PATH’s local
assessment
Source: Kaiser Family Foundation, 1997.
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What Is Emergency Contraception?
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Emergency Contraceptive Pills (ECPs)
 Have
been in use since the 1960s
 Often
referred to as “the morning-after pill”
 Birth
control pill hormones taken in high doses
within 3 days (72 hours) of unprotected sex
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IUD Insertion
 Within
 Can
5 days (120 hours) of unprotected sex
also be a long-term contraceptive method
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ECPs Can Be Used Any Time
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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
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Limitations of ECPs
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ECPs are not as effective as regular
contraceptive methods
 Should
be used as a bridge to long-term birth control
options
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ECPs do not protect against STDs
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Are ECPs Safe?
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ECPs are safe and easy to use
 The
amount of active ingredient (hormone) is small
 Short-term use
 Hormones leave the body quickly
Source: WHO, 1996.
What if a Woman Is Already
Pregnant?
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ECPs cannot dislodge an established
pregnancy
 They
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do not cause abortion
ECPs do not affect fetal development
Source: FDA, 1997.
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Two Types of ECPs
Progestin-only
 Reduces the risk of
pregnancy by 89%
 Side effects
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Estrogen and Progestin
 Reduces the risk of
pregnancy by 75%
 Side effects
Nausea (23%)
Vomiting (6%)
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Nausea (50%)
Vomiting (20%)
Both Methods:
First dose within 72 hours after intercourse
Second dose 12 hours later
Source: Task Force on Postovulatory Methods of Fertility
Regulation, 1998.
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Effectiveness: Single-Use 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)
Adapted from ARHP, 1999. Source: Task Force on Postovulatory Methods of Fertility Regulation, 1998.
Effectiveness:
Single-Use Combination Pill
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)
Adapted from ARHP, 1999. Source: Trussell, Rodriguez, and Ellertson, 1998.
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How Do ECPs Work?
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The same way as ordinary birth control pills by
 Preventing
or delaying the release of a woman’s
egg (ovulation)
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ECPs may affect the uterine lining so that a
fertilized egg cannot implant
 ECPs may prevent fertilization by affecting the
movement of the sperm and their ability to
fertilize an egg
 Timing impacts how ECPs work
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.
Medical Definition of Pregnancy
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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 women is already
pregnant
Source: Code of Federal Regulations, 1998; Hughes, 1972.
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Providing EC Information
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Some women will want to base their
decision on whether to use ECPs on how
they work.
It is important that women clearly
understand how pills are believed to work
so they can make an informed choice.
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Key Points on Mechanism of Action
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ECPs will not interrupt or harm an
established pregnancy
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ECPs will not affect future fertility
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ECPs are not the same as the “abortion
pill” (RU486), which is used after
pregnancy is already established
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ECPs work through various
mechanisms
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What are the key messages to get
across to your clients?
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Key Messages for Clients
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72-hour time frame (but sooner is better)
Safe and effective
Mechanism of action (informed choice)
Do not cause abortion
Side effects: nausea and vomiting
Not as effective as other contraceptives for
regular use
 Potential bridge to regular contraception
ECPs do not protect against STDs
Sources for accessing ECPs
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What other issues might be of
importance to clients?
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Key Topics of Importance to Clients
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No future impact on childbearing
No threat to potential pregnancy
Not abortion
Religion (individual’s religious background not
always predictive of EC interest)
Expense of ECPs (covered by Medicaid)
Confidentiality
 Adolescents
 Diverse communities
 Interpreters
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Where Can Women Get ECPs?
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Advance-of-need prescribing/distribution
 Doctor or clinic
 Walk-in visit/appointment
 Telephone screening
 Some pharmacies in Washington State can
provide ECPs directly to women
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Advance Distribution or
Advance-of-Need Prescribing of ECPs
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ECPs are more effective when taken sooner
Advance prescription reduces access barrier
Women are not more likely to use ECPs
repeatedly
Advance prescription does not decrease the use
of other birth control methods
Source: Glasier and Baird, 1998.
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Expanded Access Through Pharmacies
in Washington State
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Collaborative drug therapy agreement between
pharmacist and independent prescriber
Trained pharmacists participating in a collaborative
agreement can provide ECPs directly to women
who request them
Currently over 145 pharmacies participating
In first 16 months of project pharmacists wrote and
filled almost 12,000 prescriptions for ECPs
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Medicaid Coverage of ECPs
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Medicaid covers ECP prescriptions
 Medicaid covers pharmacist counseling time
for women who receive ECPs directly from
pharmacist
 Medicaid will also cover advance-of-need
prescriptions
Cost of ECP
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For prescriptions written by medical providers
(MDs, ARNPs, PAs):
 If
covered by insurance:
 If no insurance coverage:
• Plan B™:
• Preven™:
$5-10 co-pay
$18-35
$20-35
– Note: client also must pay for office visit to get prescription
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For prescription and consultation at pharmacy:
 Pills
and counseling:
$35-45
 As dedicated products become more widely used, cost
may rise slightly:
$40-45
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Resources Included in Provider Packet
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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
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EC Materials for Diverse Audiences
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Provides EC information in
13 languages:
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Amharic
Arabic
Cambodian
Chinese
English
Haitian-Creole
Korean
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Laotian
Portuguese
Russian
Somali
Spanish
Vietnamese
Clinics and Pharmacies That Provide
ECPs in Your Area
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EC Hotline
 1-888-NOT-2-LATE
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(1-888-668-2528)
EC website
 http://not-2-late.com
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Planned Parenthood website
 http://plannedparenthood.org
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Washington State Family Planning Hotline
 1-800-770-4334
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How will you emphasize ECPs
in your setting?
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Tell Your Clients About ECPs by:
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Routinely discussing ECPs
 Making ECP materials available in agency
setting
 Encouraging advance-of need-prescribing
JWVP15058 (8/24/00)