HomeIntroductionOverview of
the consortium
Report &
 Report & Recommendations
Back to Table of Contents
Controversial Issues in EC Introduction : A Debate

Should Emergency Contraception be made available over the counter?

– Dr Nutan Aggarwal, AIIMS - Dr Amita Suneja, GTB Hospital

As the name itself denotes, it is a need of emergency, time of personal crisis for women, therefore, an easy and early access of emergency contraceptive to the women is a must. The following relevant points will favour the availability of ECPs over the counter.

• Everything depends on time. The first ECP dose must be taken within 72 hours after unprotected sex. Task force study by WHO has found out that sooner the ECPs are taken after unprotected sex, more effective they are. Greatest efficacy is achieved within its first 24 hours. It may not be possible for a woman to attend a clinic or contact a doctor in this short time-frame. So, availability over the counter would ensure the ECP use well in time.

• Woman determines her own need for Emergency Contraception and professional assistance is not necessary.

• Neither a pelvic examination nor a pregnancy test is required before initiating the treatment with ECPs. There is no absolute contra-indication for the use of ECPs except confirmed pregnancy.

• The dose of ECP is fixed and does not need to be adjusted for an individual woman and there is no potential threat of overdose. So ECP packs can be prepared and dispensed by the pharmacist over the counter. Instructions for use can be given with the drug.

• There are no major side-effects. Till now there are no reports indicating any major problem with ECP use. It can be used even by women for whom regular use of oral contraceptive pills is otherwise contra-indicated, as medical experts believe that one-time emergency use of birth control pills does not carry the same risk.

• Follow-up and monitoring is not required. Most of the women get their subsequent periods at the expected time.

• As far as the issue of misuse of ECP is concerned, studies have dispelled the fear of misuse of ECP by easy accessibility. ECP was used more effectively and pregnancy rates were less in women who had ECP provided before need, in comparison to the group where women had to go to get a prescription for the same. Regular contraception was not abandoned with the availability of ECP before need.

• There are certain social issues which support making ECP as an OTC product. These include :

– travelling a distance to approach the clinic may discourage the women to use ECPs.

– women may be embarrassed to tell the family members at home the reason for going to a doctor. Most of the women would like to keep it confidential.

– many clinics are closed on weekends, whereas this may be the time when Emergency Contraception is expected to be needed more frequently.

Report from New Zealand on abortion clients indicated that 57% of women stated that they would have used ECP if these would have been available over the counter. Another study on abortion clients in United Kingdom has shown that 2.2% women could not get appointment with their physician to get an Emergency Contraceptive. Several emergency contraceptive researchers have advised that ECPs should be sold directly over the counter. Ellertson et al said that prescription to ECPs will hardly do any benefit. In Washington, marketing of ECP without prescription has already been initiated. Easy and early availability will increase awareness and its timely use will enhance efficacy.

There is no doubt that Emergency Contraception is the need of the day but I have serious objections to its availability over the counter. Emergency contraceptive pill is not a multivitamin, which can be taken by anybody at anytime and for ‘n’ number of times. It does contain high doses of steroids whether estrogen and progesterone or progesterone alone. If left to self-administration for the self-created emergency, it might have a dangerous end. Repercussions of over the counter availability of Emergency Contraception include :

• It will deprive the client of appropriate counselling : Counselling consists of explaining to the client the various options of Emergency Contraception. She might be a likely case for intra-uterine device, which is the most effective method for post-coital contraception. Moreover, it can be inserted within 5 days of unprotected act and provides continued contraception. if she is a likely candidate for emergency contraceptive pill, then she must know the exact dosage schedule. Many times, pill intake may be associated with vomiting and if it occurs within 3 hours of taking the pill, then dose has to be supplemented.

The client has to understand very clearly that single course of post-coital pills will protect against one unprotected act and not the further acts. She should know exactly when to suspect pregnancy as Emergency contraceptive pill has a high failure rate (2%) as compared to regular combined pills (0.1%). There are very few contra-indications to its use. ECP containing estrogens should not be taken with current jaundice, focal migraine and history or presence of deep vein thrombosis.

• Tendency to overtake : Whenever anything is freely available, there is a tendency to overuse or misuse it. Clients seeking EC are tense, as there is fear of pregnancy and might take another course of pills if expected period does not occur in time. If she is not pregnant, heavy withdrawal bleeding may occur because of overdose. However, if she is pregnant, then the risk of teratogenicity because of high doses of steroids cannot be ruled out. Although the literature about emergency contraceptive pill says that there is no risk of teratogenicity with recommended dosage, we must not forget the tragic history of Diethylstilbestrol exposure in pregnancy, which was used for 30 years in the market, considering it safe during pregnancy. We have to be wiser from our past and cannot let the emergency contraceptive pill be used as over-the-counter drug for its overuse or misuse. Its easy availability over the counter might replace the regular use of oral combined pills, which, in turn, will lead to menstrual irregularities because of off and on withdrawal bleeding.

• Increased risk of reproductive tract infections: Emergency contraceptives do not prevent against reproductive tract infections. Moreover EC does not involve the male participation, and at times, male partners might refuse to use barrier contraceptives, knowing that the ‘magic drug’ is there over the counter. Free availability of the drug and the publicity for its sale will remove the fear of pregnancy and may result in increased adolescent sexuality. All these factors will increase the risk of sexually-transmitted diseases and HIV.

To conclude, I would say that the time is not yet ripe to introduce emergency contraception over the counter.


Back to Top   |   Back to Table of Contents

Introduction | Overview of the Consortium | Consensus Statements
Report & Recommendations | Future Guidelines | Training Manual
 For more information contact ec_india@hotmail.com | Credits