Comparing alternative products in the provision of emergency contraception

This report is the third in a series of summaries produced in connection with the operations research project, Enhancing Access to Family Planning Services through the Introduction of Emergency Contraception. The project was launched in September 1997 to explore a broad range of issues surrounding the introduction and delivery of emergency contraception services in a developing country context. The study described in this report compares the introduction of two different emergency contraception pills: the combined oral contraceptive PC-4, introduced into Zambia in 1997, and the progestin-only contraceptive, Postinor-2, which was introduced by this study in the following year. The impetus for the study evolved out of two concerns expressed at a 1998 national workshop on emergency contraception. The first was that Schering AG, the manufacturer of PC-4, might block moves to broaden the range of facilities providing the product, despite indications that doing so would make emergency contraception more accessible to thousands of Zambian women. Elsewhere, the manufacturer had prevented the registration of PC-4 on similar grounds, and it was feared that they might do so again in Zambia. The second impetus for comparing the two products was the growing body of evidence to suggest that progestin-only pills might actually be a better product than the combined oral regimen, both in terms of reducing side-effects and limiting the number of unwanted pregnancies. Service providers, therefore, were eager to see for themselves what impact, if any, a progestin-only alternative might have on improving overall quality of care. Because Zambia’s experience with emergency contraception had been, prior to this study, based solely on the delivery of PC-4, the objective of this research was to explore whether the lessons learned in connection with that product would still be applicable should circumstances necessitate the registration of an alternative emergency contraception pill. The goal of this exercise, therefore, was to provide an empirical basis for generalizing the lessons learned to date through the introduction of PC-4. To accomplish this, the study compared 1) differences in the service delivery requirements associated with the provision of the two methods; 2) variations in the range, frequency and/or severity of side effects attributable to the two methods; and 3) any discrepancies in client attitudes and behavior that might be method-related. The research design entailed replicating activities previously undertaken to introduce PC-4, but among a different group of public-sector health care facilities in Lusaka. The study entailed three major sets of activities: provider training; the delivery of emergency contraception services; and the collection of service statistics and other data on potential and actual users of emergency contraception services. Results were then compared across the two groups of health care facilities. Study results revealed that despite the earlier introduction of PC-4, clients at the two groups of facilities evidenced few differences in knowledge or attitudes. Both groups, for example, were equally likely to claim they knew ways of preventing a pregnancy after unprotected intercourse and equally unlikely to identify a correct response. Clients at the Postinor-2 clinics were no more likely than those at the PC-4 clinics either to recognize the name “emergency contraception”, or to be aware that oral contraceptives could be used for emergency purposes. Given this lack of familiarity, the study recommended that a more systematic dissemination of information on the method be undertaken. Acceptance rates of the two products followed similar trajectories. Both began gradually, peaked at around 4-6 months, and then leveled off. Although the volume of PC-4 distributed exceeded that of Postinor-2, the disparity was attributable to differences in the sizes of the two catchment areas, to provider concerns over the long-term availability of Postinor-2, and even to provider-preferences for PC-4 itself. Not only did many providers believe Postinor-2 to be “more experimental” than PC-4 but, in contrast to their clients, most providers were already familiar with PC-4 by the time the study had begun. Given the potential impact of such provider preferences, the study recommended that until Zambia’s regulatory authorities selected an emergency contraception product for approval, IEC efforts should remain brand-neutral and focus more on the possibilities of preventing unwanted pregnancies, than on the technical or commercial attributes of any particular emergency contraception pill. The second issue to be addressed in this study concerned the impact of reduced levels of side effects associated with use of Postinor-2 on client behavior and services. Of particular concern was the fear that a “more tolerable” emergency contraceptive method might remove incentives for women to shift to routine family planning methods. Overall, the results of this study suggest only a weak relationship between side effects and the