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Oregon PRAMS: Presentations

Emergency Contraception (EC) and the Prevention of Unintended Pregnancy

Slide 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

Slide 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.

Slide 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.

Slide 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.

Slide 5:

Current Proportion of Unintended Pregnancy
  • United States: 49%
  • Oregon: 51%
    • 43% of live births
    • 95% of abortions

Source: Henshaw, 1998 Oregon Health Division, 1997.

Slide 6:

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

Slide 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

Slide 8:

ECPs Can Be Used Any Time Unprotected Intercourse Has Occurred
  • 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

Slide 9:

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

Slide 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.

Slide 11:

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.

Slide 12:

Two Types of ECPs

Progestin-only       Estrogen and Progestin
• Reduces the risk of • Reduces the risk of
   pregnancy by 89%    pregnancy by 75%
• Side effects • Side effects
   º Nausea (23%)    º Nausea (50%)
   º Vomiting (6%)    º Vomiting (20%)

Both Methods:
First dose within 72 hours after intercourse
Second dose 12 hours later Source: Lancet, 1998.

Slide 13:

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.

Slide 14:

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.

Slide 15:

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.

Slide 16:

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.

Slide 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 pil" (RU486), which is used after pregnancy is already established

Slide 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

Slide 19:

Oregon PRAMS Survey
  • Annual survey of postpartum women
  • Since 1998
  • Survey about 2000 women/year
  • Sample drawn from birth certificates
NOTES: The Pregnancy Risk Assessment Monitoring System (PRAMS) is a DHS Office of Family Health survey of new mothers that began in November 1998. The PRAMS survey asks new mothers if they have ever heard of EC.

Slide 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
NOTES: In 1998-99, 70% of new mothers said that they had heard of EC. The women most likely to have not heard about EC were mothers with less than a high school education, with an annual family income below $30,000, and whose pregnancies were unintended.

Slide 21:

Advance Prescription of ECPs
  • More effective when taken sooner
  • Reduces access barrier
  • Not more likely to use repeatedly
  • Filled or not filled

Slide 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

Slide 23:

Spread the Word:
  • Routinely discuss ECPs
  • Make ECP materials available in agency settings
  • Encouraging advance prescriptions
  • College providers
  • Emergency providers

Slide 24:

Additional Resources

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