Emergency Contraception and Emergency

Contraceptive Pills (ECPs)

Transparencies to accompany Emergency Contraceptive Pills:

South East Asia Regional Training Manual

Available at www.popcouncil.org/frontiers

Session 1

Emergency Contraception

3

Session Objectives

After the session the participants will have sufficient knowledge to be able to:

Understand need for Emergency Contraception (EC)

Define and describe EC Describe situations when EC can be used Describe methods of Emergency Contraception Describe Emergency Contraceptive Pill (ECP),

types, and mode of action Describe dose, interval between doses, and

time limit when ECP can be used Describe effectiveness of ECPs Describe indications and contraindications of

ECP Discuss side effects of ECPs

4

Consequences of Unwanted Pregnancies

It is estimated that worldwide each year:

20-22 million unsafe abortions are performed (WHO). 6.5 million in India.

67,000-204,000 maternal deaths occur each year. Almost all are in developing countries (IPPF).

Innumerable women suffer long term morbidities including permanent infertility.

15 percent of maternal deaths in India are due to abortion complications (WHO 2004, BMMS 2003 and Singh et al. 1997).

5

Modes of Prevention

Many abortion-related deaths and morbidities can be averted by:

Promoting family planning use to avoid unwanted pregnancy.

Strengthening postabortion services in all clinics and making them widely and easily accessible.

Educating women about the high risks or traditional methods of pregnancy termination.

Introducing and educating women about ECP as a back-up support to avoid unwanted pregnancy from method failure or unprotected intercourse.

6Emergency Contraceptive Pills: Reproductive Health

Intervention

Offers back-up contraceptive support at a crucial time.

ECP prevents possible unwanted pregnancy from unprotected intercourse.

Reduces need for abortion and use of traditional methods for pregnancy termination.

Decreases maternal morbidity and mortality.

7What is Emergency Contraception (EC)?

Emergency contraception (EC) refers to contraceptive methods that can be used by women in the first few days following unprotected intercourse to prevent an unwanted pregnancy (WHO 1998).

8Situations When EC Should Be Used

Voluntary sexual intercourse where no contraceptive is used.

When there is a contraceptive method failure or a method is used incorrectly, such as: Condom leakage Failure to take OCP for 3 consecutive days Delaying contraceptive injection more than 2

weeks Miscalculation of the infertile (safe) period Failed coitus interruptus

Involuntary sex such as rape/sexual assault

9Methods of Emergency Contraception

Emergency contraception can be provided using one of two methods:

1. Emergency contraceptive pills (ECPs) Use within 72 hours

2. Intra-uterine devices (IUDs) Insert within 5 days and continue use

as long term method(CEC 2004; FHI 2002;

WHO 1998)

This presentation focuses on ECPs only.

10

Types of ECP

ECPs are hormonal methods that can be used to prevent pregnancy following unprotected intercourse. This includes:

Increased doses of Combined Oral Contraceptive (COC) Pills: containing ethinyl estradiol and levonorgestrel

High doses of Progestogen-only Oral Contraceptive (POC) Pills: containing levonorgestrel only

11

Who Could Use ECP?

All women can use ECPs, even those who are advised not to use OCP as a regular method.

Breastfeeding mothers also can use ECP.

One major contraindication for the use of ECP is pregnancy or suspected pregnancy. This is PRIMARILY because they will not be effective.

(CEC 2004; FHI 2002; WHO 1998)

12

ECPs: Possible Mechanism of Action

Possibly inhibit or delay ovulation.

May prevent fertilization or transport of sperm or ovum.

Exact mechanism still not clear. Depending on when used during cycle:

(WHO 1998)

13

What is the Regimen?

Combined OCPs (COC) (ethinyl estradiol + levonorgestrel)Low-dose or Standard-dose COC:

Each dose should contain at least 100 microgram (0.1mg) ethinyl estradiol and 500 microgram (0.5mg) levonorgestrel

Progestogen-only pill (levonorgestrel) Each dose should contain 750

microgram (0.75mg) levonorgestrel alone

Combined OCPs (COC) (ethinyl estradiol + levonorgestrel)Low-dose or Standard-dose COC:

Each dose should contain at least 100 microgram (0.1mg) ethinyl estradiol and 500 microgram (0.5mg) levonorgestrel

Progestogen-only pill (levonorgestrel) Each dose should contain 750

microgram (0.75mg) levonorgestrel alone (CEC 2004; FHI 2002; WHO 1998)

14Emergency Contraceptive

Pill: How It Should Be Taken

When to take?Start as soon as possible. First dose must be started within 72 hours (3 days) of an unprotected intercourse

How many doses?

Hours between two doses?

2 doses

12 hours

(CEC 2004; FHI 2002; WHO 1998)

Each dose must

contains at least 0.75

mg of levonorgest

rel

15

Effectiveness: Progestogen-only ECP

If 100 women have a single act of unprotected intercourse during the 2nd – 3rd week of cycle:

If 100 women have a single act of unprotected intercourse during the 2nd – 3rd week of cycle:

(CEC 2004; FHI 2002; WHO 1998)

Eight women may become pregnant without ECPs.

If all of them use ECPs within 72 hours of unprotected intercourse; only one woman may become pregnant.

Thus, ECPs are 85% effective. It is more effective if used within 12-24 hours of unprotected intercourse.

16

Possible Side Effects

Common Common side side

effects:effects:

Nausea

Vomiting

Generally, less than 20% women suffer from any side effects, and none last more than 24

hours

(CEC 2004; FHI 2002; WHO 1998)

Menstrual disturbanc

e

Fatigue

Dizziness

Headache

Breast tendernes

s

Session 2

ECP Service Delivery Guidelines

18

Session Objectives

After the session the participants will have the knowledge and be able to understand:

Who should be provided with ECP services

How the clients are informed and provided with ECP services

Counsel clients what, when, and how to come back to regular FP methods

Guidelines in providing ECP, particularly in cases of method failure

Guidelines in managing side effects What could be done in case of ECP failure

19Who Should be Provided ECP

Service?

ALL potential contraceptive users

Regular FP clients using temporary methods

20How Will Clients Be

Informed and Provided with ECP Service?

Routinely inform all clients about ECP

Distribute BCC materials

Inform and address any misconceptions about ECP

21 How Will Clients Be

Informed and Provided with ECP Services?

1. Ask and assess Date of last menstrual period Length of woman’s normal menstrual

cycle Number of hours since the first

unprotected intercourse

2. Inform client about ECP use3. Remind client about salient points on ECP4. Utilize opportunity for counseling on

other FP methods5. Counsel clients on how to resume regular

contraception after use of ECP

(cont.)

22What FP Methods Could Be

Started After the Use of ECP?

Condom

OCPs

Injection

IUD

Norplant

Permanent Method

Methods When could be startedImmediately after ECP use

Next day after the 2nd dose of ECP or 1-7 days of next

menses1-7 days of starting of next period1-7 days of starting of next period1-7 days of starting of next period1-7 days of starting of next period

(CEC 2004; FHI 2002; WHO 1998)

Natural Method 1-7 days of starting of next period

23Missed OCP for 3

Consecutive Days: What Should Be Done?

Those who have started menstrual bleeding should be advised to continue the national guidelines as follows: Stop taking OCP and discard rest of the pills and Start a new packet of OCP on the 1st day of the

next menses Those who have not started menses and had

intercourse should be advised to: Take two doses of ECP 12 hours apart and Continue to take rest of the OCPs-one tablets

daily or Use condom for any further intercourse and Start a new packet of OCP on the first day of the

next menstrual cycle

24

Missed Injection Due Date: What Should Be Done?

Take two doses of ECP 12 hours apart and Use condom until start of the next

menstrual bleeding and Receive an injection at the first day of the

next menstrual bleeding

Missed injection due date

Can take injection up to 14 days late.

Give her new injection.

Have passed 14 days and come after

unprotected intercourse.

25Condom Bursts or

Leaks: What Should Be Done?

The client should be advised to: Take two doses of ECP 12 hours apart and Use condom again until beginning of the

next menstrual bleeding and Start using a condom again from the

beginning of the next menstruation orIf the client wants to change the method:

Start a new packet of OCP after the second dose of ECP if want to change or

Start any other method, such as injection, on the 1st day of the next menstruation

26Management of Side Effects

Nausea may be reduced for some users if ECP is taken with food.

Paracetamol and aspirin is effective against headache and breast tenderness. Can even use ibuprofen.

No treatment is necessary for menstrual problems.

Most side effects disappear within 24 hours.

27

What Could be Done in Case of ECP Failure?

Client became pregnant

Used ECP

Assure her there will be no harm to the

fetus

Session 3

Counseling on ECP

29

Session Objectives

After the session the participants will have the knowledge and be able to:

Describe whom and what to be counseled about ECP.

Understand what, when, and how to start regular contraception after the use of ECP (contraception options).

Answer common questions related to ECP.

30Whom and What to Be Counseled About ECP?

Potential Contraception Users: Methods available for contraception Details about FP methods Scope of ECP as a back-up method

Regular Temporary Family Planning Clients: When and how to use ECP Side effects of ECP and their management Methods of contraception after the use of

ECP What to do when they miss cycle for more

than 7 days

31

Whom and What to Be Counseled About ECP?

Special attention must be given to OCP users:

Properly explain what to do if they miss three pills

When and how to use ECP What to do with the rest of the pills in the

packet Why they need to use a condom for any future

intercourse What to do when miss cycle for more than 7

days How to come back to regular use of OCP in the

next menstrual cycle Why ECP can not be used as a regular method

(cont.)

32

Whom and What to be Counseled about ECP?

For a client who has requested ECP, the following four steps could be followed. Before providing ECP, assess whether ECP is appropriate for the client then:

1. Inform about correct use of ECP, how it works, cannot use it regularly, its efficacy and failure rates2. Explain when it is more effective3. Remind of side effects and their management and when she should come back for follow-up4. Return consult when and how to return to the regular FP methods

(cont.)

33When Should Client

Come Back for Follow-up?

There is no need for follow-up in case of ECP use. However, clients should come back to the service provider if:

Her period is more than 7 days late Menstrual bleeding is too light in terms of

color She wants to use regular FP method She needs some clarification about ECP use

(CEC 2004; FHI 2002; WHO 1998)

34Frequently Asked Questions about ECP

What will be the impact of ECP on menses? Would it be effective for the next days of the

cycle? How many times can one take ECP in a

month? Will ECP cause abortion? Can a breastfeeding mother take ECP? Do women need to use ECP during the safe

period?

35Frequently Asked Questions about ECP

Can women use ECP before intercourse? Does ECP work if multiple intercourse occurs? If ECP fails to protect against pregnancy, will

it cause harm to the fetus? Can ECP be used after 72 hours of

unprotected intercourse? What should women do if they vomit within 1

hour of ECP use?

(cont.)

36Please refer to the accompanying publication:

Emergency Contraceptive Pills: South East Asia Regional Training

Manual

by Sharif Mohammed Ismail Hossain, M.E. Khan, Moshiur Rahman, and Mary Philip Sebastian. New Delhi: Population Council. 2005.

Available at www.popcouncil.org/frontiers