AMWA Updates Position Paper on Emergency Contraception

AMWA’s mission includes strong support of sound policies and programs to improve women’s health.  AMWA believes that the number of unintended pregnancies in the US is unacceptably high (3.2 million annually, with over ½ million of these being teens) (Shrader SP, 2011), and that this has a detrimental impact on women’s health.  AMWA supports programs which reduce the rate of unintended pregnancies, as these will improve women’s health. A 2011 committee of the IOM recently found sufficient evidence to support certain preventive services that support women’s overall health.  The first of their recommendations includes a fuller range of services  … to help women better avoid unwanted pregnancies and space their pregnancies to promote optimal birth outcomes.” (IOM)
About one half of unintended pregnancies are the result of contraceptive failure. Barrier methods of contraception have failure rates of 12-21% during the first year of typical use. An estimated 1.5% of condoms break.  In addition to contraceptive failure, unintended pregnancy may result when women do not have control over the timing of sexual intercourse or the use of contraception, especially in the case of rape. (amwa) A 2003 survey found that only 6% of women have ever used emergency contraception
(EC) despite the fact that nearly 70% know EC is available.  Additionally, multiple randomized controlled trials have failed to demonstrate a reduction in unintended pregnancy or abortion rates with increased access to EC.) (Shrader SP, 2011)
The consequences of unintended pregnancy are significant and can affect women and families in profound and irrevocable ways.  Approximately ½ of all unintended pregnancies end in abortion, resulting in approximately 1.3 million abortions annually in the US.  For pregnancies carried to term, the mother of an unintended pregnancy is at greater risk for depression, physical abuse, and failing to achieve her educational, financial, and career goals.  Relationships that she may find herself in are at a three times greater risk of dissolution.  The child of an unintended pregnancy is at a greater risk of having low birth weight, dying in the first year of life, not receiving resources necessary for healthy
development, and being abused or neglected. (amwpp) EC has the potential to prevent an estimated 1.7 million unintended pregnancies annually and, in turn, avoid abortions. (Jones R, 2002) AMWA believes that emergency contraception can play a much stronger role in reducing unintended pregnancy and unnecessary abortion in our nation.
Emergency contraception is the use of any drug or device to prevent pregnancy after an act of unprotected intercourse or contraceptive failure.  Intercourse can result in pregnancy only on the day of ovulation and the 5 days preceeding ovulation. (Shrader SP, 2011)  Emergency contraceptive pills (ECPs) provide a short, high dose of combined estrogen and progestin, or progestin alone, and are 75% effective in preventing pregnancy within 72 hours after unprotected intercourse. Several studies have shown that ECPs may inhibit or delay ovulation when given before or at the time of ovulation.
Respected organizations such as the National Institutes of Health and the American Congress of Obstetricians and Gynecologists (ACOG) define pregnancy as beginning with implantation.  Emergency contraceptive pills work prior to implantation and therefore are considered by these organizations and AMWA as a contraceptive, not as an abortifacient.  Emergency contraceptive pills do not affect an established pregnancy and numerous studies of the teratologic risk of conceiving during regular use of oral contraceptives (including the use of older, higher dose, preparations) found no increase in risk.
Research does not support that increased access to EC increases sexual risk-taking behavior.  Several methods of EC are available and FDA approved:  Combined estrogen/progestogen (Yuzpe), progestin alone (two levonorgestrel products available), intrauterine devices (the copper T380A), and  a newer progesterone receptor agonist-antagonists (Ulipristal). Mifepristone is not available for this indication in the US, but is used in other countries.  The most effective methods are levonorgestrel alone, ulipristal, and the IUD.  Levonorgestrel alone has been shown to be superior to the Yuzpe method, (83% vs 57% effective).  And it shows less nausea as a side effect.  (4% vs 18% nausea).
Emergency contraception is safe. The World Health Organization noted that because ECPs are given over such a short time period, experts believe they have no clinical effect on conditions such as cardiovascular disease, angina, acute focal migraine, and severe liver disease. As such, the medical restrictions that apply to the conventional use of combined oral contraceptives or progestin only contraceptives are not relevant to ECP use.  The World Health Organization, ACOG, and the International Planned Parenthood Federation have stated that there are no absolute contraindications to use of emergency contraceptive pills except pregnancy.  The pregnancy exception relates to the fact that the regimen is not effective during pregnancy, not to any teratogenic effects.
Since February of 1997 ,the FDA has endorsed  ways of making emergency contraceptive pills available to women.  In 1997, the FDA announced that certain combined oral contraceptives are  safe and effective.  In 1998, the FDA accepted a commercially available product containing ethinyl estradiol and levonorgestrel designated for use as an emergency contraceptive (the Yuzpe method).  In 1999, the FDA approved the first progestin-only contraceptive (Plan B).  This product is 83% effective, with less incidence of nausea and vomiting.   In 2006, the FDA approved nonprescription status (behind the counter) of levonorgestrel for any female age 18 or older to purchase with valid photo ID. In 2009, the
age restriction was reduced to include 17 year olds. Younger females can obtain levonorgestrel with a valid prescription and pharmacists with prescriptive authority can dispense without a provider prescription. Ulipristal (Ella One) was approved in the US as an EC in 2009.  When taken before the ovulatory peak, it has been shown to be 100% effective.  It is effective up to 120 hours after exposure, as compared to the progestin only pills, which have to be taken within 24-72 hours.  It is similar in cost to progestin only methods.  Unfortunately, it does not yet have “behind the counter” approval.
AMWA acknowledges that increasing women’s access to EC is critical to more effectively use this unique contraceptive method.  In one study where pharmacists prescribed ECPs, 50% of women seeking emergency contraception reported that they sought ECPs on a weekend or after 6pm on a weeknight, times when it may have been difficult to contact their regular reproductive health care provider.  In addition, 18% of these women did not have a current provider. AMWA applauds the FDA in its action to approve easier immediate access to ECPs, and strongly supports approval for all women and girls who have been exposed to unplanned pregnancy.  Provision of prescriptions for these products to patients at routine office visits, prior to need, will vastly improve their accessibility and timely use.  A Cochrane review determined that advance provision of EC did not increase sexually transmitted infections or increase frequency of unprotected intercourse. Easy access to ECPs was critical for 42% of the women in a program survey who reported that if they had not received ECPs directly from a pharmacist, they would have taken no action and waited to see if pregnancy ensued.  Because of the stated importance of accessibility, AMWA is particularly concerned over any pharmacy refusal to stock or dispense EC.  (The American College of Clinical Pharmacy has developed a position statement supporting the prerogative of pharmacists to decline to provide professional services based on conscience.)
AMWA affirms its commitment to supporting reproductive choice for women and believes that emergency contraception is an important option.  AMWA is committed to promoting awareness of and improving access to emergency contraception for women of diverse ethnic and socioeconomic backgrounds.

To achieve this goal, AMWA is committed to:

• Informing its membership about emergency contraception pill availability, its optimal use, potential concerns and success rate;
• Encouraging the widespread release of this information to the medical community, women’s groups, health groups, the public, and the media;
• Encouraging the display of informational brochures, posters, and wallet cards in health care facilities;
• Recommending the provision of preprinted prescriptions and instructions for use of emergency contraceptive pills at routine exams, in advance of the need for their use, and
• Advocating for programs that provide improved access to emergency contraception pills for women through collaborative agreements, especially for high use after-hours need .
• Advocating for prompt, non-judgmental referral to other pharmacies in the cases where a pharmacist uses the “conscience clause” to deny needed access.

Foundation, K. F. (2003). Women’s health care providers experiences with emergency contraception.

Jones R, D. J. (2002). Contraceptive use among U.S. women having abortions. Perspect Sex Reprod
Health , 34, 294-303.

Shrader SP, H. L. (2011). Updates in Hormonal Emergency Contraception. Pharmacotherapy , 31 (9), 887-895.

Wilcox AJ, W. C. (1995). Timing of Sexual Intercourse in relation to ovulation: effects on the probability of conception, survival of the pregnancy and sex of the baby. N Engl J Med , 333, 517-21.

Read other position papers from AMWA !

AMWA develops position papers based on resolutions passed by the organization.  These papers serve as a valuable resource for members and staff in communicating AMWA policy on key issues and may act as a focus of our research and education efforts.

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