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Emergency Contraception: A Modality Whose Time Has Come Allan Rosenfield, MD Unplanned pregnancy is a reproductive health problem of tremendous significance worldwide. In the United States, approximately 50% of all pregnancies are unplanned at the time of conception. Although this represents a decline over the past decade from a high of slightly under 60%, the percentage remains significantly higher than in Western Europe and Canada. Similarly, there are large percentages of unplanned pregnancies throughout the developing world. High percentages of unplanned pregnancies are aborted worldwide (approximately 50% in the United States, and 78% for teens). Where it is illegal, abortion is most commonly carried out clandestinely, often at very high risk to the health of the women. Unplanned pregnancies result from unexpected midcycle intercourse, from failure to use a regular method of contraception, or from method failure, such as condom breakage. Emergency contraception (EC) has been discussed as an option ever since the first articles on the "Yuzpe" method appeared many years ago. This special issue of JAWMA devoted to EC presents an important series of articles that will help to update the field on the rapidly evolving and exciting developments in this area. Emergency contraception is used to prevent pregnancy after unprotected midcycle sexual intercourse. It was first used for women who had been raped, but later became available for unprotected intercourse, no matter the reason. Various methods are available, the most common being the original Yuzpe method in which oral contraceptives are used, in a higher dose than usual, within 72 hours of intercourse and then again 12 hours later. Two other approaches are also effective, namely the use of levonorgestrol (available in Europe but not in the United States) or the insertion of a copper-bearing intrauterine device (IUD). The Yuzpe regimen reduces the chance of becoming pregnant by 75%. Interestingly, although the IUD has a much higher rate of protection, it is much less commonly used for EC. The mechanism of action of EC has been debated, and those opposed to abortion maintain that it is simply another abortifacient. But taken within 72 hours of midcycle unprotected intercourse, the major action of the Yuzpe method is interference with ovulation, with fertilization or, in some cases with implantation. There are no data to suggest that oral contraceptives have any effect on an already implanted ovum. Similarly the IUD interferes primarily with the process of implantation. Many of those involved in studying this modality believe that it should be made widely available and that there should be ready access to information and referral. Some believe it is an especially important and appropriate method for teens, particularly if society is serious about decreasing the high rates of teen pregnancy. In this issue, Goodyear and McGinn review the urgent need for EC in camps for refugees and displaced persons. Rape or coerced sex is quite common in such camps and the situations of conflict surrounding them, and yet few, if any, reproductive health services are available. A clear case is made for the relevance of EC in this context. Petitti et al describe some strategies that Kaiser Permanente physicians have developed to better educate their clientele about EC. They discuss the repackaging of oral contraceptives for use as an emergency contraceptive, the development of educational and promotional materials, and the training of personnel, including physicians. Delbanco et al report on a 1997 survey of men and women age 18 to 44. They found that 66% of women and 51% of men knew about EC, a small increase since an earlier survey in 1994. Only 1% had used the method, however, and only about 11% knew enough about it to know what to do. A study of physicians showed that while 85% of obstetrician/ gynecologists and 50% of family practitioners considered the method to be safe and effective, very few actually offered it to their patients. Von Hertzen describes the potential for levonorgestrol as an alternative hormonal approach to EC. Although not yet available in the United States, it is a promising approach. Bird et al describe a focus groups study among Mexican women and found that, while few knew anything about EC, most would be interested if the need arose. Camp describes dedicated products specially packaged for this use. Cohall et al review data on inner-city adolescents, showing that more than 50% were sexually active at least once during the past six months without use of a contraceptive. Very few (about 30%) knew about EC, but close to 70% would consider using it if it were available. Interest is increasing in the availability of EC off prescription to speed access. From a medical point of view, I see no contraindication to making small packets of hormonal pills available over the counter or via pharmacist distribution, as discussed by Ellertson et al. Hutchings et al describe the experience in Washington State where pharmacists have used collaborative agreements to make EC available without a physician's prescription. No problems have been reported, and access has increased significantly. This appears to be a safe compromise for those opposed to over-the-counter distribution. Blanchard discusses other innovative strategies health care providers and others can use to help women gain information and access at the time of need, when rapid response is necessary to the success of the method. Breitbart et al show that most teenagers in their study learned about the method from friends, and most needed it because of condom breakage. Interestingly some of the teens in their study voiced caution about expanded distribution of this method. Trussell et al describe the very effective telephone hotline that has helped thousands of women learn about EC. There is great promise for this new modality to play an important role in decreasing the incidence of unwanted pregnancy and of abortion. The articles in this special JAMWA issue are of great significance in helping to inform providers about this option.
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