EMERGENCY CONTRACEPTION WAS licensed for use in Ireland for the first time in 2001. At the time, women seeking to use this medication were required to attend their GP or family planning clinic for a consultation, after which a prescription would be issued.
In spring 2011, a change in licensing regulations cleared the ground for women to access one form of emergency contraception called NorLevo, commonly known as the morning after pill, over the counter from their community pharmacy. What did this change mean?
Did the sky fall in on our heads? No.
Did social breakdown ensue? Was there a dramatic erosion of morality? No.
How about an increase in the numbers of predatory females having multiple unprotected sexual encounters? Again, No.
There’s no evidence whatsoever that easier availability of emergency contraception leads to increased promiscuity – for those who still use that term – or an increase in prevalence rates of sexually-transmitted infections (STIs).
As far as social breakdown and moral bankruptcy are concerned, we can still look to the Celtic Tiger political culture, the failed regulators and the bankers for that.
Instead, women were, for the first time, able to easily access emergency contraception. Many of these women were already using a routine form of contraception but might have forgotten to take their pill at the appropriate time; others experienced contraceptive failure (such as a condom splitting), while a smaller proportion might simply not have planned to have sex with their partner and got carried away in the moment.
In other words, in seeking emergency contraception they were, and are, doing the personally and socially responsible thing in wanting to avoid a crisis pregnancy.
“She travelled for 6 hours to get to Dublin to get emergency contraception”
Up until spring 2011, Well Woman’s city centre clinic in Dublin opened on Sundays to provide a walk-in emergency contraception service. Over the eight years in which this service operated, we recorded visits by women from literally all corners of the country, with many travelling from as far afield as Kerry, Cavan and Mayo. Once, memorably, a young woman boarded a bus in Donegal and, after travelling for 6 hours to get to Dublin, told us that two local GPs had refused to prescribe emergency contraception for her on grounds of ‘conscientious objection’.
One can only imagine the sense of humiliation she felt when local doctors rejected her request. Not to mention her growing sense of panic as she made her way to Dublin and the clock continued to tick; you see, the emergency contraceptive pill available at the time (the version now available over-the-counter in pharmacies) is most effective if taken in the first 24 hours after sex – when it has around 95 per cent effective rate - and drops to 58 per cent effectiveness if taken in the third 24-hour period.
Thus, the move to make NorLevo available over-the-counter is hugely significant. In our view, it is extremely important – from an affordability and equity point of view – that women are now able to get this safe medication directly from their community pharmacy.
However, as a healthcare provider, Well Woman would like to see a stronger connection between accessing emergency contraception and a programme of holistic sexual healthcare. In our experience, emergency contraception visits tended to act as a woman’s first route into formal sexual health services. This entry-point is effectively no longer there with over-the-counter availability of emergency contraception.
Emergency contraception is a very safe form of medication, but it is not a substitute for being on a more long-term routine form of contraception, such as the oral contraceptive pill or mini-pill, patch, or injection.
There are also long-acting reversible contraceptives (LARCs) which include implants and intra-uterine devices, and which will provide contraceptive cover for anything between three and ten years. Increasing numbers of young women are choosing to use a LARC, as many of them have decided they do not wish to become pregnant for the next number of years, and it avoids the need for the proverbial ‘magic bullet’ that reminds them to take their contraceptive pill correctly.
The need to tackle STIs
There is also a huge need to raise awareness around sexual health and STIs. In Well Woman, our doctors always use the occasion of an emergency contraception or routine contraception visit to discuss sexual health concerns with the patient.
To take one of the most prevalent STIs as an example – chlamydia – most young women are aware of chlamydia, and we find they are open to being tested if the testing is discreet, confidential and easily accessible. In our experience, chlamydia is very much a young person’s infection, with around 10% of the under-25s being infected, often with no symptoms. And chlamydia can be cured with a simple course of antibiotics if diagnosed in time, so it’s important to have this conversation with the patient!
There is also a certain amount of confusion for women in that, since NorLevo went over-the-counter, a newer, more effective Emergency Contraceptive has been licensed by the Irish Medicines Board (in May 2012). It’s called ellaOne and it is available only on prescription from a G.P. or family planning doctor.
Women have a choice when it comes to emergency contraception…
So, what’s available in terms of emergency contraception? The good news is that women now have choice (not something traditionally in generous supply in Ireland as far as family planning or reproductive issues are concerned):
- The post-coital coil – this is the most effective form of emergency contraception (99 per cent +) and must be fitted by a family planning doctor or appropriately qualified GP up to 5 days after unprotected sex. The copper in the coil reduces sperm movement, stopping sperm and egg from meeting. It is the most expensive option, and potentially the most painful (being an invasive procedure).
- EllaOne – an emergency contraceptive pill, which can be taken for up to 5 days after unprotected sex. It is as effective on day 5 as on day 1, and almost halves the risk of becoming pregnant, when compared to average efficacy rates in the over-the-counter offering, NorLevo. It requires a visit to a GP or family planning doctor, and is less expensive than a post-coital coil.
- NorLevo – available over-the-counter from community pharmacies. It can be taken for up to 3 days after unprotected sex, and is approximately 95 per cent effective on Day 1, 85 per cent on Day 2, and 58 per cent on Day 3. It’s the most affordable, but also the least effective, of the three options.
Neither ellaOne nor NorLevo is an abortifacient; both act in the same way, by inhibiting or delaying ovulation. Both carry the same potential side effects, which can include nausea, headache and/or light stomach cramping.
A woman needing emergency contraception might not require ellaOne (depending on where she is in her cycle and other aspects of her medical history) but she is best advised to discuss this with her GP or family planning doctor, as it does require a medical consultation to identify which form of Emergency Contraception is best for her.
Alison Begas is the chief executive of the Dublin Well Woman Centre. For further information see www.wellwomancentre.ie