Elizabeth WestleyI,*; Anna GlasierII
IInternational Consortium for Emergency Contraception, 588 Broadway (Suite 503), New York, NY, 10012, United States of America
IINational Health Service, Edinburgh, Scotland
Emergency contraceptive pills (ECPs) are now available in many countries, but have failed to have the desired impact on unwanted pregnancy rates. Why is this? Earlier barriers to access are becoming less and less prevalent. A market for ECPs has been demonstrated and numerous manufacturers and distributors are keen to supply products; in many countries they are starting to be mainstreamed into norms, pre-service training and services.
Yet knowledge continues to be an important barrier in much of the world. This post-coital contraceptive method is still relatively unknown in many countries, according to data from Demographic and Health surveys1 and other country-level surveys. A 2007 survey of adolescents in New York City schools2 revealed that fewer than half of these young people had heard about emergency contraceptive pills, despite extensive public outreach and media publicity surrounding their over-the-counter status in the United States of America (USA).
Even when knowledge of this type of contraceptive is higher, use often remains fairly low, as in the United Kingdom of Great Britain and Northern Ireland, where 91% of women had heard of "the morning-after pill" but only 7% had used it in the past year.3 One reason for low correct use of ECPs is the very poor basic understanding of fertility, contraception and pregnancy risk that seems widespread in both developed and developing countries. In France, a survey of women seeking abortion indicated that more than half were unaware of their pregnancy risk at the time that they became pregnant or could not identify the specific act of intercourse that led to the pregnancy; only a minority of women used emergency contraceptive pills.4 In the United Kingdom, a study of abortion and pre-natal care clients showed that emergency contraceptive pills were used by only one in ten women who definitely did not wish to become pregnant, and even fewer used the method every time they were at risk of pregnancy.5
Unfortunately, the already substantial misinformation that women have about pregnancy risk and emergency contraceptive pills (along with other contraceptive methods) is being compounded by recent media coverage. "Besides side effects, like nausea, heavy bleeding and cramps, regular use of emergency contraception may cause infertility and in some instances increase the risk of cancer," declared one BBC story on emergency contraceptive pills in Kenya.6 "EC [emergency contraceptives] come with an increased risk for things like blood clots and hormone-related cancers, like many traditional forms of birth control," stated a mainstream newspaper in the USA.7 These statements are factually incorrect but unfortunately are widespread. Such negative and sometimes inflammatory media coverage only alarms women and may keep some from using the method when they most need it.
Indeed, media and public health can be a volatile mix. The potential association between childhood vaccination and autism proposed in one article in the Lancet in 1998 (and officially retracted in 2010) was picked up by media around the world, and led to resistance to vaccination, millions spent on studies and many years of research to refute the claim.8,9 The effects have persisted: a 2009 survey found that fully one quarter of American parents agreed that "some vaccines cause autism in healthy children" and more than one in ten had refused a vaccine for their child.10
Today, the echo chamber that is the Internet can quickly spread and amplify media stories, particularly if they are sensational. An e-mail circulating for several years describes a "true story" of a woman who died of a stroke while on hormonal birth control;11 recently, this story morphed and now states "the cause of death continuously taking the morning-after pill". The fear-mongering media coverage around emergency contraceptive pills is likely to be driven by concerns about "irresponsible" sexuality, hiding behind false "scientific" justification for such concerns.
Public health and medical professionals cannot afford to ignore the role of today's media. Accurate media coverage has played an important role in spreading the news about health risks, healthy behaviours and new products; sensationalist and frightening coverage can have the opposite effect. In the case of levonorgestrel-alone emergency contraceptives, safety has been clearly demonstrated through countless studies and many decades of use: no new research needs to be conducted. The urgent question is how we can explain and disseminate the science in simple terms.
While countering every health-related rumour on the Internet and inaccurate story in local newspapers and magazines is surely a fool's errand, it is increasingly important to be ready with the facts when reporters, community members and patients voice concerns. A team of experts from around the world has produced a short, simple statement on the safety of levonorgestrel-alone emergency contraceptive pills, responding directly to articles that appeared in the mainstream media in 2009 and written for non-scientists. This co-production of the World Health Organization, the International Federation of Obstetrics and Gynaecology, the International Planned Parenthood Federation and the International Consortium for Emergency Contraception can be accessed on the WHO web site.12
1. Khan S, Mishra V, Arnold F, Abderrahim N. Contraceptive trends in developing countries [CHS comparative reports 16]. Calverton: Macro International;. 2007. Available from: http://www.measuredhs.com/pubs/pdf/CR16/CR16.pdf [accessed 9 March 2010] .
2. Teen pregnancy in New York City, 1997-2007. New York, N.Y.: New York City Department of Health and Mental Hygiene; 2007. Available from: http://www. nyc.gov/html/doh/html/ms/ms-nyctp-97-07.shtml [accessed 9 March 2010] .
3. Lader D. Contraception and sexual heath, 2008/09 [Opinions survey report no. 41]. Newport: Office for National Statistics; 2009.
4. Moreau C, Bouyer J, Goulard H, Bajos N. The remaining barriers to the use of emergency contraception: perception of pregnancy risk by women undergoing induced abortions. Contraception 2005;71:2027. doi:10.1016/j. contraception.2004.09.004 PMID:15722071
5. Lakha F, Glasier A. Unintended pregnancy and use of emergency contraception among a large cohort of women attending for antenatal care or abortion in Scotland. Lancet 2006;368:17827. doi:10.1016/S0140- 6736(06)69737-7 PMID:17113427
6. Mawathe A. Kenya concern over pill popping. BBC News website, 15 July 15 2009. Available from: http://news.bbc.co.uk/2/hi/africa/8145418.stm [accessed 9 March 2010] .
7. Piccoli K. When Plan B becomes Plan A. Long Island Press, 17 September 2009.
8. Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M et al.Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998;351:63741. doi:10.1016/ S0140-6736(97)11096-0 PMID:9500320
9. Murch SH, Anthony A, Casson DH, Malik M, Berelowitz M, Dhillon AP et al.Retraction of an interpretation. Lancet 2004;363:750. doi:10.1016/ S0140-6736(04)15715-2 PMID:15016483
10. Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. Parental Vaccine Safety Concerns in 2009. Pediatrics 2010. doi:10.1542/peds.2009-1962 PMID:20194286
11. Another birth control death. Snopes.com [Internet site]. Available from: http://www.snopes.com/medical/drugs/dishuk.asp [accessed 9 March 2010] .
12. Fact sheet on the safety of levonorgestrel-alone emergency contraceptive pills (LNG-ECPs). Geneva: World Health Organization; 2010. Available from: http://www.who.int/reproductivehealth/publications/family_planning/HRP_RHR_10_06 [accessed 9 March 2010] .