In countries where emergency contraception is offered, its availability and use vary widely, according to such factors as regulations and policies regarding the method, providers' and women's understanding of and attitudes toward it, and cost. The experiences with the method in the United Kingdom and the Netherlands illustrate some of the issues involved in introducing and encouraging the acceptability of emergency contraception.
Emergency contraception first became available in Europe in the late 1960s and early 1970s. Today, in the United Kingdom and the Netherlands, the method is an accepted part of family planning practice and is well-known among doctors and women. This acceptance may be partly due to the method's inclusion in the health insurance systems of these countries.
Another factor explaining the established role of emergency contraception, at least in the Netherlands, is the lack of moral debate surrounding the method. Only its side effects and efficacy seem to engender controversy; the need for emergency contraception is acknowledged and accepted even for teenagers, for whom sexual activity is socially sanctioned.
We summarize here information on experiences with emergency contraception in these two countries. We then draw on these experiences to suggest lessons for other countries seeking to introduce or expand the use of this method.
United Kingdom
History of Emergency Contraception
Although British doctors occasionally administered high-dose estrogen or inserted an IUD for the purpose of emergency contraception in the early 1970s, it was not until 1974 and the publication of the first article on emergency contraception using a combined estrogen-progestogen regimen that the method's use became widespread in the United Kingdom.l The National Association of Family Planning Doctors met in 1982 to discuss emergency contraception and a year later published a set of clinical guidelines establishing two combined pills, Ovran and Eugynon 50, as the preferred hormonal regimens.2
In 1982, the Department of Health stated that treatment up to 72 hours postcoitally was "probably legal," but that treatment after five days "might be considered an abortion."3 The following year, an antiabortion lobbying group filed several complaints against clinics providing emergency contraception; the group based its argument on the Offences Against the Person Act of 1861, which made it illegal for a woman or her doctor to "intend to procure a miscarriage." In response, the attorney general ruled that emergency contraception administered within 72 hours after intercourse was not a criminal offense, reasoning that "preventing implantation is not procurement of a miscarriage."4
At the request of the Department of Health, the Committee on Safety of Medicines undertook a review of emergency contraception in 1983 and determined that the method was "acceptably safe for occasional use." The pharmaceutical company Schering submitted an application for a product based on Eugynon 50 to the Medicines Division in August 1983 and received a license in January 1984. PC4 (50 mcg of ethinyl estradiol and 0.5 mg of norgestrel in each of four tablets) was on the market by October 1984.
Discussion is under way with regard to making PC4 available from pharmacists without a doctor's prescription, a step that most professional organizations support. The Royal College of Obstetricians and Gynecologists organized meetings about the matter in December 1994 and July 1995. It is up to Schering to apply to change the license, and the company thus far seems reluctant to do so.
Availability and Prevalence
General practitioners are the major source of emergency contraception in the United Kingdom. Everyone in the United Kingdom is entitled to register with a general practitioner. For contraceptive services, women may also visit a general practitioner other than the one they are registered with, although this option is not widely known.
Women in most cities and large towns may also seek emergency contraception at National Health Service family planning clinics. Since 1972, these clinics have provided contraceptives free of charge. The clinics offer anonymity to women reluctant to consult their general practitioner and may be open in the evenings and on weekends; however, not all towns-and few villages-have such centers, and at least half of these clinics are open only once a week.
The nonprofit Brook Advisory Centres, which provide services to young people in cities throughout England and in Edinburgh, Scotland, provide emergency contraception. Some hospitals' accident and emergency departments also provide hormonal emergency contraception.
National data on the prevalence of emergency contraception do not exist, but reports from clinics suggest that use has been rising rapidly. Knowledge of emergency contraception is fairly high; surveys from the late 1980s found that 65-75% of women undergoing induced abortion had heard of emergency contraception.5 A small, unpublished survey conducted by Schering in 1994 found that 90% of women had heard of emergency contraception. However, many women continue to be unaware of the 72-hour time limit or of the method's ready availability. Levels of knowledge of postcoital IUD insertion are low.
Schering's sales data for PC4 indicate that about 353,700 packets were sold in 1992, and 420,500 were sold in 1993. Schering has sold 2.5 million packets of PC4 since the regimen was licensed in 1984. One clinic in Edinburgh reports that the use of emergency contraception has doubled in the last five years and now accounts for about 4% of the 47,000 visits made to the facility annually.
There is no way of estimating the extent to which Ovran is prescribed for emergency contraception or how many IUDs are inserted for postcoital indications, since these contraceptives are also used on an ongoing basis.
Cost
All contraception in the United Kingdom, including emergency contraception, is free to the patient. Schering sells the PC4 combination to the National Health Service at a cost of about U. S. $2.20 per treatment. Many family planning clinics and some general practitioners make up their own supplies using Ovran, at a cost of about 25 cents for the four tablets. The actual cost to the clinic is somewhat higher because of packaging costs. In addition, some clinics provide six tablets, to leave a woman with two spares in case she vomits. Others add an antiemetic, at a cost of around 16 cents per tablet. An IUD costs the National Health Service about $11-$16, although clinics that buy in bulk may pay considerably less.
A recent study of the cost-effectiveness of contraception estimated considerable savings to the National Health Service from the use of emergency contraception to prevent unintended pregnancy.6 Even on the basis of failure rates as high as 25 births per 100 users of emergency contraception per year, the study estimated that prescribing PC4 costs between $19 and $74, depending on the provider, and saves the government health service $727-$806. Estimates of costs averted did not include such costs to society as those associated with education and social services.
Netherlands
History of Emergency Contraception
Emergency contraception has been used in the Netherlands since 1964 7and is widely known and accepted there. The Netherlands places a high priority on preventing unwanted pregnancy, and information on emergency contraception has always been included in family planning education programs and materials. The level of contraceptive use is generally high, and the incidence of unwanted pregnancy and abortion is low. Thus, while emergency contraception is free of moral debate, is not considered an abortifacient and is considered acceptable for teenagers, the need for it is reduced by the high levels of effective contraceptive use among women of all ages.8
As early as 1970, emergency contraception was covered in the first family planning handbook for Dutch doctors,9 and within a few years, the method became widely available through general practitioners, who form the backbone of the Dutch health care system. (Every citizen is registered with a general practitioner.) The Dutch Family Planning Association, the Rutgers Stichting, also began offering the method in the early 1970s. However, overall use of emergency contraception declined by 50% between 1974 and 1983, primarily because of a sharp increase in the use of ongoing methods of contraception after their inclusion in the national health insurance program.
