Emergency Contraception

and Emergency
Contraceptive Pills (ECPs)

Transparencies to accompany
Emergency Contraceptive Pills:
A 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.
Emergency Contraceptive 6

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.
What is Emergency
7

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).
 Situations When EC 8

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

 Methods of Emergency
9

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

 Possibly inhibit or delay

ovulation.
 May prevent fertilization
or transport of sperm or
ovum.
(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 (CEC 2004; FHI 2002; WHO 1998)
 14

Emergency Contraceptive Pill:

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

How many 2 Each dose

doses? doses must
contains at
Hours between least 0.75
12 mg of
two doses? levonorgest
hours rel
(CEC 2004; FHI 2002; WHO 1998)
 15

Effectiveness:
Progestogen-only ECP
If
If 100
100 women
women have
have aa single
single act
act ofof unprotected
unprotected
intercourse
intercourse during
during the
the 2
2nd –– 3
nd
3rd week
rd
week of
of cycle:
cycle:

 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.
(CEC 2004; FHI  Thus, ECPs are 85% effective. It is
2002; WHO 1998) more effective if used within 12-24
hours of unprotected intercourse.
 16

Possible Side Effects

Generally, less than 20% women suffer from
any side effects, and none last more than 24
Common hours
side Headache
effects:
Dizziness
Nausea
Breast
Vomiting tendernes
s
Menstrual
Fatigue disturbanc
e
(CEC 2004; FHI 2002; WHO 1998)
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
 Who Should be 19

Provided ECP
Service?

 ALL potential contraceptive users

 Regular FP clients using temporary

methods
 How Will Clients Be 20

Informed and Provided with

ECP Service?

 Routinely inform all clients about ECP

 Distribute BCC materials

 Inform and address any

misconceptions about ECP
 How Will Clients Be 21
Informed and Provided with
ECP Services? (cont
.)

1. Ask and assess

 Date of last menstrual period
 Length of woman’s normal menstrual
cycle
 Number of hours since the first
unprotected intercourse
1. Inform client about ECP use
2. Remind client about salient points on ECP
3. Utilize opportunity for counseling on
other FP methods
4. Counsel clients on how to resume regular
contraception after use of ECP
 What FP Methods Could Be 22

Started
After the Use of ECP?
Methods When could be
started
Immediately after ECP use
Condom
Next day after the 2nd dose
OCPs of ECP or 1-7 days of next
Injection menses
1-7 days of starting of next
IUD period
1-7 days of starting of next
period
Norplant 1-7 days of starting of next
period
Permanent 1-7 days of starting of next
Method period
Natural Method 1-7 days of starting of next
period(CEC 2004; FHI 2002; WHO 1998)
 Missed OCP for 3 23

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?
Missed injection due date

Can take injection Have passed 14 days

up to 14 days late. and come after
Give her new unprotected
injection. intercourse.
 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
 Condom Bursts or 25

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 or
If 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
 Management of Side 26

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?
Used ECP

Client became
pregnant

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.
 Whom and What to Be
30

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?(cont.)
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
 32

Whom and What to be

Counseled about ECP? (cont.)

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
rates
2. Explain when it is more effective

3. Remind of side effects and their management

and when she should come back for follow-up
4. Return consult when and how to return to the
regular FP methods
 When Should Client 33

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)

 Frequently Asked
34

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?
 Frequently Asked
35

Questions about ECP(cont.)

 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?
 Please refer to the
36

accompanying publication:
Emergency Contraceptive Pills:
A 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
End of Slide Show
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