NEW FRONTIERS FOR EMERGENCY CONTRACEPTION IN AFRICA

1. NEW FRONTIERS FOR EMERGENCY CONTRACEPTION IN AFRICA

2. SETTING THE STAGE • Describe what EC is • Review the current status of EC services in Africa • Introduce a new regional network on EC and describe its mission and activities • Highlight three issues of significance to the future of EC services in Africa and women’s access to them

3. WHAT IS EC? • Method of preventing pregnancy after unprotected sexual intercourse • Method that can not interrupt an established pregnancy • Not the “abortion pill”

4. TYPES OF EC • Combined OCs: 2 doses of pills containing ethinyl estradiol (100 mcg) & levonorgestrel (0.5 mg) taken 12 hrs apart → 75% reduction in risk (2/100 vs. 8/100 will get pregnant) • Progestin-only OC’s – in preferred regimen one dose of 1.5 mg levonorgestrel (or can be in 2 doses of 0.75mg, 12 hrs apart) → 88% reduction in risk (1/100 will get pregnant); less side effects (nausea and vomiting) than with COCs, 6% vs 23%

5. HOW DOES EC WORK? Possible means of action • Interferes with ovulation (only mechanism clearly supported by data) • alter endometrium, impairing implantation • alter cervical mucus, thus trapping sperm • change tubal transport of gametes or embryo • EC does not affect an established pregnancy

6. Percentage of pregnancies prevented 100 90 80 70 60 50 40 30 20 10 0 up to 24 hours 25-48 hours 49-72 hours Progestin-only Combined EFFICACY OF EC

7. FIRST APPEARANCES… • Twenty-six countries currently have a dedicated EC product registered with their national regulatory authorities Norlevo/Vikela Postinor 2 • Between 1995 and 2000, six African countries undertook pilot studies, designed to introduce EC into the public sector health care system • Across Africa, a plethora of initiatives are underway to expand access to EC

8. …CAN BE DECEIVING • Product registration does not mean availability • In not one of the six pilot countries has the delivery of EC services been maintained, let alone mainstreamed within in the public sector at a national level • Throughout Africa as a whole, only 13 countries include EC within their national national FP/RH guidelines and protocols – and only 9 of those are found in countries with a dedicated ECP

9. REMAINS LOW KNOWLEDGE AND USE OF EC KNOWLEDGE AND USE OF EC REMAINS LOW

10. WHY THE FAILURE TO MAINSTREAM EC SERVICES? • There are incentives that sustain the delivery of other contraceptives that do not exist for EC • Governments are unfamiliar with the status of post-introduction EC services • There are no natural constituencies in-country to shepherd EC through the system or to advocate for its mainstreaming • Africa remains marginalized from current international discourse over EC

11. THE SOLUTION? • A broad-based exchange of information, unencumbered by linguistic barriers, in support of efforts to introduce, deliver and mainstream quality emergency contraception services • A concerted, participatory effort at the national level to get EC “back on track” – especially in the countries where the method has already been introduced

12. GOALS OF ECAFRIQUE • To serve as a forum for exchanging of ideas among health care professionals engaged in efforts to expand EC services in Africa • To inspire interest and encourage new initiatives in the provision of EC services where there is an unmet need for them • To build collectively the knowledge and experience base needed to introduce, improve, and mainstream quality EC services, with a specific focus on the needs and challenges of Africa.

13. ECAFRIQUE TODAY • Worldwide network of 20 founding members, and over 200 corresponding institutional and individual members • Active in over half of all countries in Africa • Developed a comprehensive data-base of institutional and individualmembers

14. ECAFRIQUE TODAY • Published and distributed five issues of ECAFRIQUEbulletin • Provided technical support to partner agencies, and other regional consortia under the auspices of ECAFRIQUE (proposal writing, translation, material development, information dissemination) • Attracted/leveraged new funding for EC-related research and service delivery in Africa • Disseminated information at international fora • Has already established itself as a respected, independent body for supporting EC initiatives across Africa

15. PRIVATE SECTOR PROVISION: SOME LIMITATIONS • Commercial pricing can be a barrier to wider product access • Private sector distribution favors urban settings • Commercial distributors and/or licensees can restrict (or dictate) the terms of product availability • Private sector distribution can impede the provision of accurate information on EC coverage or utilization • Emphasis on dedicated ECP can undermine provision of Yuzpe formulation

16. PRIVATE SECTOR PROVISION: SOME ADVANTAGES • Private sector provision frees EC availability from dependence on private sector/donor procurement • Commercial interests have spawned a host of social marketing and private/public sector collaborations to increase product access • Increases product acceptability on the part of certain population segments • Market interests can further efforts to disseminate information on EC

17. ADDRESSING SEXUAL VIOLENCE AND RAPE • Traditional service delivery outlets are not necessarily (or even typically) the first points of contact for assault survivors • Existing policies and protocols are typically designed to satisfy the needs of the legal system – not the health needs of the victim • Despite the logical connection between the prevention of pregnancy and of HIV transmission, one must not become the “ball and chain” of the other

18. THE NEEDS OF YOUTH • Discourse on EC – both positive and negative - is dominated by concerns over HIV/AIDS • Young people are at especially high risk of unwanted pregnancy • Use of EC does not undermine continued use of regular contraception • We need better information on those who use EC and on the interplay between EC and condom use