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Emergency contraceptive pills (ECPs) are a method of preventing pregnancy after unprotected intercourse, when regular contraception fails, when a woman fears that her regular contraception may have failed, or when a woman has been sexually assaulted. ECPs are not the only method of emergency contraception available in the United States, but it is the method most commonly recommended for teenage women. As such, ECPs are an option that could annually avert as many as 50 percent of pregnancies and consequent abortions among American teens.¹ ECPs cannot cause abortion because the pills have no effect after a pregnancy is established.^* Women 18 or over can obtain ECPs without a prescription.

Although some doctors have been prescribing ECPs for over 30 years, relatively few adolescents know about the use of oral contraceptives as emergency contraception. Fewer than one-third of teen females have heard of ECP or are aware that they can do anything to prevent pregnancy after sexual intercourse.^2,3 Only 40 percent of teens who know about ECP also understand that the pills should be taken after, and not before, unprotected sex. Although teen females are slightly more likely than males to know when ECP should be taken (43 percent versus 37 percent, respectively)⁴ few teens understand that ECP is most effective when taken within 24 hours after unprotected sexual intercourse.

Moreover, teens who do know about ECP may experience actual (logistical) and perceived barriers to obtaining the pills. For example, health care providers' lack of knowledge about ECP is a barrier to teens' obtaining emergency contraception. In one survey of pediatricians with adolescent patients, only 20 percent reported prescribing ECP and only 24 percent counseled teens about ECP.⁵ Other logistical barriers include cost, time constraints, lack of insurance, lack of transportation, and clinics' hours of operation. Perceived barriers include teens' fears of confidentiality being violated, of procedures such as blood tests or pelvic exams, and of side effects.

In July 2006, the FDA ruled that women (and men) 18 years and older are able to receive EC without a prescription. Young people under age 18 are still required to obtain a prescription from a health care provider before being able to obtain emergency contraception.

Please note (July 2009): The newly approved Plan B One-Step is now available without a prescription for women and men 17 and older.

Innovative Efforts Provide Information About and Access to ECP.

The general lack of information about and access to ECP underscores the need for multifaceted, targeted strategies to make ECP accessible to teens. A few programs demonstrate innovative examples of national, state, and local strategies to provide information about and access to emergency contraception, especially ECP.

National Web Site

The Emergency Contraception Web site (http://not-2-late.com) provides information and a directory of providers willing to prescribe emergency contraception. The Web site also tells clinicians how they can be added to the directory. Those listed should be able to provide women with an appointment or a telephone prescription in less than 72 hours.

National Initiative to Expand Awareness of ECP

EC Does It was a pilot initiative that sought to build the capacity of organizations across the United States to expand awareness of and access to emergency contraception. The initiative also sought to defeat or repeal public and private sector policies that restrict access to ECP. Components of the initiative included demonstrating public support for ECP, creating new coalitions, and providing training and technical assistance at the grassroots level to increase communities' support for emergency contraception.⁶ 

Pharmacy Availability in Washington State

One project has made ECP more readily available to women in Washington State by allowing pharmacists to deliver the product. By June 1999, 130 participating pharmacies had provided 11,969 packages of ECP. Evaluation results indicated that women receiving ECP via a pharmacist were satisfied with the quality of care they received and valued the increased accessibility. Pharmacy records revealed that most women received ECP when the method is most effective—within 24 hours of unprotected sexual intercourse. Women in the state continue to be able to obtain ECP directly from pharmacists.⁷ Other states are examining the legal aspects of making ECP available through similar means.

A Culturally Specific Campaign in Philadelphia, PA

The Reproductive Health Technologies Project and Motivational Educational Entertainment (MEE Productions) recently introduced After the Fact, After the Act in Philadelphia, PA. This culturally specific ECP campaign—designed for low-income, African American women—uses multiple strategies to raise awareness about ECP, including radio and television public service announcements (PSAs), the Internet, community-based organizations, peer networks, street teams, and outreach.⁸ 

Social Marketing in Sacramento, CA

The Pacific Institute for Women's Health and Population Services International developed a social marketing project in Sacramento, CA that promotes awareness of and access to ECP as a back-up contraceptive option among sexually active white, Latina, and African American women ages 15 to 24. The project aims to reduce the incidence of unintended pregnancy and abortion among young women. Project components include training health care providers to better promote and prescribe ECP, strategically mobilizing the community, a media campaign targeting young women, and evaluation.

Education in Boulder County, CO

The Boulder County Health Department launched the Unintended Pregnancy Project to educate students at the University of Colorado and residents of Boulder about ECP and to reduce the rate of unintended pregnancies. The university campus and nine local businesses participated in the program, displaying posters and wallet-sized information cards. Patrons of the businesses—almost half were men—took over 5,000 cards. In all, the project distributed nearly 14,000 cards. Evaluation showed that, among women who sought ECP during the seven-week program, 50 percent did so because of a broken condom and 33 percent did so after unprotected sexual intercourse. Twice as many packages of ECP were prescribed in April 2000 as compared to April 1999, and the Health Department felt confident that the program increased awareness of ECP.

Actions to Increase Teens' Awareness of and Access to ECP

Studies show that, once informed about ECP, approximately three-quarters of young women report that they would be likely to take the pills if they needed them.² The following actions will strengthen professionals' ability to educate youth about ECP and ensure availability for them.

Health Care Providers Can Commit to Providing ECP.

• Register to be included in the directory of providers on the emergency contraception hotline or Web site—http://www.not-2-late.org.
• Make ECP available in various settings. Sexually active teens may not visit family planning clinics if they are using condoms. Provide ECP in both clinical (family planning clinics, school-based health centers, and physicians' offices) and non-clinical settings (pharmacies, community-based organizations, and local health departments).
• Make ECP available through a variety of providers. Depending on local regulations, doctors, nurses, midwives, pharmacists, school nurses, and community health workers, among others, may provide ECP.
• Prominently post information about Plan B^®'s nonprescription status; provide information about which local pharmacies carry Plan B^®.

Health Care Providers Can Improve Service Delivery.

• Create "teen-friendly" office policies and/or procedures that welcome youth.
• Ensure clients receive information about and access to ECP. Educate all staff, including receptionists, volunteers, and medical assistants, on the office policies and/or procedures.
• Simplify the response for times when young women under age 18 call and report having had unprotected sexual intercourse. Take a medical history over the phone, assess the young woman for ECP, and call in a prescription to her pharmacy.
• Accommodate walk-in appointments, especially for pregnancy testing. Use this as an opportunity to counsel the young woman about ECP and, if she wishes, provide her with ECP for future use.
• Provide telephone referral to another ECP provider that may be more financially and/or logistically convenient for a teen.
• Develop formal referral networks among family planning clinics, hospitals, health maintenance organizations, school-based health centers, physicians' offices, community-based organizations, pharmacies, and local health departments. These networks can provide women with round-the-clock access to ECP.
• Provide specific instructions on the office's voice mail and a sign on the door on how to access ECP whenever the office/clinic is closed.

Health Care Providers Can Educate Teens about ECP—Before They Need It!

• Provide teens with information about where to obtain and how to use ECP. Posters and patient education pamphlets should be noticeable in waiting areas. Provide teens with the specific language in which they can request ECP over the telephone, for example, "I need to speak to someone about emergency contraceptive pills."
• Counsel female and male youth about ECP during routine visits, including sports physicals, annual check-ups, and vaccinations.
• Invite a young woman's male partner into counseling sessions and educate the couple together about ECP. Increase young men's comfort by providing magazines and posters that target men in the waiting room.
• Provide young women under age 18 with a prescription for ECP during routine visits. Better yet, provide young women with ECP. Anticipatory provision ensures that young women can use ECP as soon as possible after unprotected sexual intercourse. Young women who have ECP in advance may begin treatment sooner than those with a prescription that will have to be filled.

Health Care Providers Can Provide Teens with ECP—When They Need It.

• Assure teens that all ECP services are confidential, whether the services occur face-to-face or over the telephone. Prominently display the confidentiality policy on posters and on the client intake forms. Warn teens if using their parents' medical insurance may result in the health plan sending parents any forms for billing or services rendered.
• Use a system of sliding-scale fees to provide low-cost or free access to ECP. The cost of ECP and related services may deter many teens from obtaining ECP.
• Provide ECP without a pelvic examination or pregnancy test, reducing financial and psychological barriers. Experts assert that neither is necessary prior to dispensing ECP.
• Phone prescriptions into a pharmacy for ECP when young women under the age of 18 call. Inform women ages 18 and over that they can obtain EC without a prescription at their pharmacy. Schedule a follow-up appointment with them for a later date.
• Encourage teens seeking ECP to adopt a regular contraceptive method in the future. Providing ECP can create a bridge to regular reproductive health care for sexually active teens. If the teen is at also risk for HIV and other sexually transmitted infections (STI), use the opportunity to counsel the teen about using dual methods—condoms to prevent HIV/STD and another form of effective contraception to prevent pregnancy.
• Ensure that teens who have been forced or coerced into genital sexual activity receive ECP, HIV/STI testing and counseling, contraceptive counseling, and referral to important social services, as mandated by law.

Educators Can Make Certain that Teens Know about ECP.

• Commit to learning about ECP.
• Include accurate information on ECP in sexuality education curricula.
• Provide students with information about the emergency contraception hotline and Web site.
• Write about ECP for high school, college, and local newspapers.

Everyone Can …

• Learn about what other communities, states, and nations have done.
• Mobilize the community. Present information on ECP to youth activist groups, public health officials, school boards, PTAs, community clubs, professional associations, and community-based organizations.
• Start a public education campaign to raise awareness and increase support for ECP. Ensure that the campaigns are culturally appropriate for the target audience.
• Develop ECP materials that target specific adolescent populations, including teen parents, males, young women of color, runaway and homeless youth, and gay, lesbian, and bisexual teens.
• Distribute ECP materials, such as posters, postcards, and brochures, in community centers, restaurants, retail establishments, arenas, nightclubs, teen centers, and other places that youth frequent.
• Develop ECP materials targeting parents. Distribute the materials in businesses, restaurants, retail establishments, health clubs, community centers, religious institutions, and places that parents frequent.
• Write a letter to the editor of local newspapers urging providers to improve teen access to ECP.
• Support progressive legislation to allow collaborative drug therapy agreements—pharmacist and physician protocols that authorize pharmacists to deliver ECP in specific situations. Pharmacists can contact the American Pharmaceutical Association to ascertain if collaborative drug therapy agreements are permitted in their states and can work with the Association to implement procedures in their pharmacies.
• Advocate for funding for research on emergency contraception, including biomedical, programmatic, social science, and service delivery research.

Other Sources of Information and Materials

* The American College of Obstetricians and Gynecologists and the American Medical Women's Association define pregnancy as beginning after the egg has completed implantion (attached to the wall of the uterus).

References

1. Trussell J et al. Emergency contraceptive pills: a simple proposal to reduce unintended pregnancies. Fam Plann Perspect 1992;24:269-73.
2. Delbanco SF et al. Missed opportunities: teenagers and emergency contraception. Arch Pediatr Adolesc Med 1998;152:727-33.
3. Cohall AT et al. Inner-city adolescents' awareness of emergency contraception. JAMWA 1998;53 (5,Supp 2):258-61.
4. Hoff T et al. Sex Education in America: A Series of National Surveys of Students, Parents, Teachers, and Principals. Menlo Park, CA: Henry J. Kaiser Family Foundation, 2000.
5. Sills et al. Associations among pediatricians' knowledge, attitudes, and practices regarding emergency contraception. Pediatrics 2000;105:954-6.
6. The ProChoice Resource Center. EC Does It. Port Chester, NY: PCRC, 2000. Retrieved from http://www.prochoiceresource.org/html/training/ecdoesit.htm on July 31, 2000.
7. Consortium for Emergency Contraception. Medical and Service Delivery Guidelines. Seattle, WA: Program for Appropriate Technology in Health, [n.d.].
8. The Reproductive Health Technologies Project. The Emergency Contraception Campaign: Expanding Our Audience in Philadelphia. Washington, DC: The Project, 1999.

This publication was supported by a grant from the Program on Reproductive Health and Rights of the Open Society Institute.

Written by Ammie N. Feijoo and Susan Pagliaro
Revised edition, August 2001, 2007 © Advocates for Youth