Emergency Contraception

Key Messages

• Emergency contraception is not a form of abortion, but is the ability to prevent ovulation and fertilization. 
• Emergency contraception can be taken up to 120 hours (5 days) after unprotected intercourse; therefore it does not work if a woman is already pregnant.
• Depending on the method used, emergency contraception can reduce a woman’s risk of becoming pregnant from a single act of intercourse up to 99 percent.
• Displaced women are particularly vulnerable to gender-based violence (GBV) and unprotected sexual intercourse and have a heightened risk of pregnancy complications; it is their right to have access to emergency contraception.
• It is essential to increase providers’ and displaced persons’ knowledge about emergency contraception and to ensure that emergency contraception is readily accessible.
• Women who are already overwhelmed by their displacement, struggling for their basic needs and those of their children, should have an opportunity to prevent an unintended pregnancy.

Overview

Emergency contraception (EC) is a contraceptive method used by a woman after unprotected sexual intercourse or rape to prevent an unwanted pregnancy. For women forcibly displaced by conflict, access to EC is not only a right but also a critical need that can help to maintain and improve their reproductive health (RH).

While maternal mortality is a common cause of death among women living in resource-poor settings, the stressful living conditions of displaced women make delivering a child even more difficult and life-threatening. By offering a “second chance” to those whose regular contraceptive method has failed, EC provides a woman or adolescent girl with the opportunity to avoid an unplanned or forced pregnancy and can reduce her risk of death or illness due to complications from childbirth or unsafe abortion. In emergency situations, EC is a vital RH service because women are often at risk due to unprotected sex as a result of rape or coercive sex, lack of availability of contraception, or powerlessness to negotiate contraceptive use.

There are currently two methods of EC: oral emergency contraceptive pills (ECPs) and the copper-bearing intrauterine device (IUD). ECPs are sometimes referred to as “morning-after” or “post-coital” pills, but since these terms do not convey the correct timing for EC use, the preferred term is “emergency contraceptive pills”. ECPs can be used up to 120 hours (5 days) after unprotected intercourse.[1] ECPs prevent pregnancy by delaying or inhibiting ovulation, preventing fertilization, inhibiting transport of the fertilized egg to the uterus or preventing implantation. ECPs are not harmful to an existing pregnancy and will not induce abortion. Therefore, ECPs can be used by women whose pregnancy status is unclear (though it is recommended that a woman not use ECP if she knows she is pregnant). ECPs are not a substitute for family planning as the pregnancy rate of ECPs used frequently as a substitute for regular contraception would be much higher than the pregnancy rate of regular hormonal contraceptive pills in standard dosage.

A copper-bearing IUD can also be used as an emergency contraceptive when inserted within seven days of unprotected intercourse.[2] Research shows that the IUD acts primarily by preventing fertilization. The pregnancy rate reported among women using the copper-releasing IUD as an emergency contraceptive is around 1 percent. The IUD can remain in place to serve as a regular contraceptive for up to 5-10 years; it may be removed by a trained health care provider whenever the client wishes.

To address the RH needs and rights of displaced women and girls, health care workers must make EC services available from the beginning of a response to a humanitarian crisis as part of the Minimum Initial Service Package (MISP). Staff training is especially critical in these settings and clear information on available services must be communicated immediately to newly arriving displaced populations, who may be unaware of EC as an option.

Facts

Global Statistics

• It has been calculated that the levonorgestrel-only regime reduces the risk of pregnancy by 60 percent to 93 percent or more, while combined oral contraceptives reduce the chance by 56 percent to 89 percent.[3] Copper IUDs prevent approximately 99 percent of the pregnancies that would occur if no EC were used.[4]
• The Alan Guttmacher Institute estimates that EC usage prevented 51,000 abortions in the US in 2000 and accounted for a 43 percent decrease in total abortions between 1994 and 2000.[5]
• Women given easy access to EC use it more than do women with restricted access, according to the research conducted in 2005. However, EC availability does not change sexual habits or use of other contraceptive methods.[6] This demonstrates that providing women with EC does not adversely affect the routine use of contraception.
• Despite fears that EC availability would substitute for barrier methods that protect against sexually transmitted infections, researchers report that teenage mothers who are given ECPs were no less likely to use condoms.[7]

Refugee/Internally Displaced/Conflict-affected Statistics

• A survey of displacement settings in 33 countries, comprised of 82 percent refugees and 18 percent IDPs, revealed that EC was available to survivors of rape in 60 percent of the sites.[8]
• A study by the International Rescue Committee in Tanzania reported that 26 percent of 3,803 randomly selected Burundian refugee women between the ages of 12 and 49 had experienced sexual violence since becoming refugees.[10]
• The lack of familiarity among both providers and displaced women, compounded by the shortage of EC supplies, are constraints to better availability of EC for displaced populations.[11] For example, in another study by the International Rescue Committee, EC was available in only four out of 14 refugee sites.[12]
• An investigation by the Population Council found that less than half of the Somali and Sudanese refugees in a Kenyan refugee camp were aware that anything could be done to prevent a potential pregnancy following unprotected sex.[13] This study also reflected the lack of knowledge and training on EC among health care providers serving the refugees.
• A study of young refugees in South Africa found that only 16 percent of women aged 15 to 24 knew that using ECPs could prevent pregnancy after having unprotected sex.[14]

Case Studies

EC plays an important role in responding to rape

Florence, 45, had been collecting firewood deep in the forest with her 13-year-old daughter and two women friends, ages 36 and 43. They had knowingly ventured beyond the legal camp boundary which was controlled by a UN military unit in search of firewood. During the walk home, the women were attacked and stripped naked. All were gang raped for several hours. Florence came to the camp health center, which was managed by the American Refugee Committee (ARC), because she had sustained a large machete wound to her hip. During her consultation with the doctor, she related her ordeal. ARC had a confidentiality protocol already in place at the health center for such cases, which was put into practice. Florence received immediate counseling and agreed to continue coming to the health center for counseling if she so wished. She also decided she wanted antibiotics in the event she had contracted a sexually transmitted infection and ECPs even though she was 45-years-old. All information concerning the attack was related on to UN security anonymously. Florence encouraged her daughter and friends to visit the ARC health center, which they did. They each received treatment and ECPs to avoid becoming pregnant and none of them had an unwanted pregnancy. Florence's daughter received counseling for many weeks.

EC as a back-up plan to method failure

Anna is a 31-year-old internally displaced woman. She had sex on Saturday night with her husband, but the condom broke. Already caring for three children, the couple did not want to have any more. Because of transportation problems, she was not able to reach the clinic until three days later and did not think there was anything she could do to prevent a pregnancy. However, upon arrival she was told that she was still in time to use EC if she wanted to prevent a pregnancy. Anna decided to use ECP and was able to avoid an unplanned pregnancy.

EC should be available to women unable to negotiate condom use

Fatmeh is an 18-year-old refugee. She had unprotected sex last night with an older man, whom she has been seeing lately in exchange for food and money. They had always used a condom before, but the man refused this time and offered her more money if they did not use a condom. Fatmeh does not want to become pregnant. She asked a friend to go with her to the local clinic. The doctor at the clinic told her she could use EC to reduce her risk of becoming pregnant. Fatmeh chose an IUD and decided to use this as her regular method of contraception, too. The doctor counseled her that this method would not protect her from sexually transmitted infections. Fatmeh was successful in preventing an unplanned pregnancy; however her future – like that of many women refugees - is uncertain because she must depend on others for her survival needs.

Updated September 2006