Expanding Access to Emergency Contraception: The Case of Brazil and Colombia

Abstract

Emergency contraception was proven effective nearly 30 years ago yet remains greatly under-utilised. In the Latin American and Caribbean region, it would serve the goals of reducing unwanted pregnancy, unsafe abortion and related morbidity, and as a back-up to condom use and a bridge to longer-term contraceptive methods if made more widely known and available. The International Planned Parenthood Federation Western Hemisphere Region has developed a model for the integration of emergency contraception into sexual and reproductive health care services. This model is being tested in a two-year project with national affiliates in Brazil, Chile, Colombia, the Dominican Republic and Venezuela, and will contribute to the work of the Latin American Consortium for Emergency Contraception. Case studies of Brazil and Colombia describe how health sector reforms, e.g. decentralisation and managed competition among health insurers and service providers, have influenced promotion strategies. The experience of Profamilia Colombia with registration of a dedicated product and providing emergency contraception within its national network of clinics, with a focus on staff training and work with young people, is described. In Brazil, BEMFAM's study of different modalities for offering emergency contraception, e.g. through contractual agreements with municipalities and its own clinics, is highlighted.

Résumé

La contraception d'urgence, dont l'efficacité est prouvée depuis près de 30 ans, demeure sous-utilisée. Elle réduit les grossesses non désirées et les avortements à risque, sert de méthode d'appoint avec les préservatifs et de passerelle vers une contraception plus durable. Le bureau Hémisphère occidental de la Fédération internationale pour la planification familiale a défini un modèle d'intégration de la contraception d'urgence dans les services de planification familiale, les soins post-avortement, la prévention des IST/VIH et les programmes pour jeunes et sur la violence sexuelle. Ce modèle est testé dans un projet avec des associations membres au Brésil, au Chili, en Colombie, en République dominicaine et au Venezuela, et contribuera au travail du Consortium latino-américain pour la contraception d'urgence. Des études de cas au Brésil et en Colombie décrivent comment les réformes du secteur de la santé, p. ex. la décentralisation et la concurrence entre assureurs et prestataires de services, ont influencé la promotion de la contraception d'urgence des associations membres de l'IPPF. Profamilia Colombia a enregistré une pilule de contraception d'urgence et fournit ces services dans son réseau national de dispensaires, avec une priorité à la formation et au travail avec les jeunes. Au Brésil, le BEMFAM a étudié différentes modalités pour proposer une contraception d'urgence, p. ex. à tous ceux qui choisissent les préservatifs et autres méthodes barrières, et par des accords contractuels avec des municipalités.

Resumen

En América Latina y el Caribe, la anticoncepción de emergencia (AE) cumple con los objetivos de reducir el embarazo no deseado, el aborto inseguro y la morbilidad asociada. La Federación Internacional de Planificación de la Familia, Región del Hemisferio Occidental, ha creado un modelo para la integración de la anticoncepción de emergencia en los servicios de planificación familiar, atención post-aborto, y prevención de las ITS/VIH, y en programas dirigidos a jóvenes y programas contra la violencia de género. Las asociaciones miembro en Brasil, Chile, Colombia, Venezuela y la República Dominicana están probando el modelo en un proyecto de dos años. Se presentan estudios de caso de Brasil y Colombia que describen como las reformas del sector salud, tales como la descentralización y la competencia regulada entre los aseguradoras de salud y los prestadores de servicios, han incidido en las estrategias de promoción de AE desarrolladas por las asociaciones miembro de la IPPF. Se describe la experiencia de Profamilia Colombia con el registro de un producto dedicado y la provisión de AE en su red de clı́nicas, con un enfoque en la capacitación de proveedores y el trabajo con jóvenes. Se resalta también el estudio de BEMFAM sobre las distintas modalidades de ofrecer la AE en Brasil, por ejemplo, a todas las personas que optan por usar condones y otros métodos de barrera, y mediante acuerdos contractuales con las municipalidades.

Key Words:

• emergency contraception
• strategic introduction
• sexual and reproductive health services
• health sector reforms
• Brazil
• Colombia

Emergency contraception (EC) has been described as the “best-kept secret in family planning”¹ since it was first proven effective nearly 30 years ago. Although emergency contraception has now found its way to the pharmacy shelf and into clinics in many countries, it remains under-utilised in much of the world.² Emergency contraception refers to several types of post-coital method that prevent unwanted pregnancy. All require prompt action: a woman must initiate use of emergency contraceptive pills within 72 hours of unprotected sex or have an intrauterine device (IUD) inserted up to five days post-coitally. When used correctly, the Yuzpe regimen of combined oestrogen−progestogen pills has an effectiveness of 75%, progestogen-only pills 85% and IUD insertion 99%. Recent studies suggest that the sooner EC pills are used, the more effective they are.^{3 4 5 6 7}

Emergency contraception plays a unique role in the contraceptive method mix in the Latin American region, serving the larger goal of reducing unwanted pregnancy and therefore unsafe abortion and abortion-related mortality. EC is critical for women who have experienced sexual violence as it can prevent pregnancy resulting from rape, and is a reason for developing links between legal and counselling services for women who have experienced sexual violence and the health sector. EC can also serve as a bridge to longer-term contraceptive methods or as a first level back-up to barrier methods, e.g. in the case of inconsistent or incorrect condom use, especially for adolescents or first-time method users, or in the case of no contraceptive use at all. Given its tremendous potential for decreasing the incidence of unwanted pregnancy, emergency contraception should be made available to all women who may need it. Oral contraceptives suitable for the Yuzpe regimen are readily available over the counter in most of Latin America;^{8 9 10} a medical prescription is required in theory alone.

Notwithstanding its unique role, controversy and confusion surround EC use. Anti-choice opponents (erroneously or deliberately) maintain that EC pills are abortifacient, and seek to equate it to early medical abortion as a way of condemning it.¹¹ Hence, a rights-based approach is needed to defend EC from those who would curb women's access to it on ill-informed legislative and normative grounds. However, studies in different countries have shown that the biggest obstacle to greater dissemination and use of emergency contraception is the lack of correct and timely information. Health care providers are unaware of or misinformed about EC and do not prescribe it, and women too are unaware of its existence and do not ask providers for it.^{12 13}

A strategic model for introducing emergency contraception in Latin America

The International Planned Parenthood Federation, Western Hemisphere Region (IPPF/WHR) has developed a strategic model to guide the introduction of emergency contraception into sexual and reproductive health programmes in Latin America and the Caribbean. This model identifies interventions for reaching out to potential providers and users, through the media and other communication channels, to foster favourable attitudes towards emergency contraception, improve the legal and political environment and increase its availability and visibility. It proposes that EC be integrated not only into family planning services, counselling services for women who have experienced sexual violence, youth-friendly services and post-abortion care, but also into other programmes and sectors, including legal and law enforcement services, schools, and youth and community programmes.

The introduction of EC must also take into account the health sector reforms sweeping the Latin American region, the socio-political climate, the structure of public health services and the role of IPPF affiliates and other NGO and private health services. In some countries, those promoting EC may choose to work intensely with policymakers and pharmaceutical companies/distributors; others with potential providers and women in the community.

In July 2002, IPPF/WHR embarked on a two-year project to test its model in conjunction with IPPF affiliates and other public and private sector organisations in five countries in Latin America and the Caribbean–Brazil, Chile, Colombia, the Dominican Republic and Venezuela. The common objectives of this study in all five countries are to:

• strengthen institutional capacity to integrate the provision of emergency contraception into sexual and reproductive health services,

• raise awareness of and access to emergency contraception, and

• increase knowledge about effective strategies for promoting emergency contraception.

This paper highlights the particular programmatic and political contexts for introducing emergency contraception in two of the five study countries, Brazil and Colombia. In each case, we explore the role of health sector reform and the strategies adopted in these two countries to expand EC use.

Integration of services and health sector reform

Integration of sexual and reproductive health services emerged as part of the shift away from traditional family planning programmes towards a larger constellation of services. To restructure and renovate more traditional service delivery, three main factors have been identified for facilitating change: (i) external factors (such as the extent of demand and donor support), (ii) catalytic actions (i.e. building consensus and offering new structures and services) and (iii) planned operational change (such as expanded partnerships with the public or private sector).^{14 15} These aspects need to converge rather than compete against one another in the broader context of health sector reform in order for a particular set of services to be integrated successfully.

Figure 1 São Paulo, Brazil, 2002

It is the duty of research, service delivery and advocacy organisations to ensure that the sexual and reproductive health package is not excluded during reforms nor regresses to the demographically-driven family planning programmes of the past. Health sector reform can have a positive impact on IPPF affiliates and other private and NGO service providers, in that governments are being encouraged to contract private providers to fill the gaps in public services. On the other hand, the impact of reforms may be negative due to the resulting competition between private providers, or the failure to pursue opportunities in a timely fashion.¹⁶ One of IPPF's main strengths as a federation of voluntary and autonomous affiliates doing education and advocacy work and providing services is its ability to undertake multi-country projects such as the introduction of emergency contraception.¹⁷

Promotion of emergency contraception in the region

Now is an opportune moment to take advantage of the momentum built by regional and international support for emergency contraception through the International Consortium on Emergency Contraception and the Latin American Consortium on Emergency Contraception (LACEC). The latter, launched in 2001, is a network of governmental and non-governmental organisations (NGOs), that work in health, education and sexual and reproductive rights in the Western Hemisphere region. The goals of the Latin American Consortium are to:

• standardise the use of EC and include it in the relevant norms of Ministries of Health;

• disseminate information about and increase access to EC in its different forms to all socio-economic levels with a gender perspective; and

• expand social marketing initiatives for the commercialisation and distribution of a dedicated EC product, where feasible.

LACEC's main activities are to foster collaboration, lead advocacy strategies and campaigns and create a clearinghouse for articles and materials on emergency contraception. Stemming cutbacks in reproductive health care can only be done with this type of consensus participation from all levels of government and NGOs. IPPF/WHR is a founding member of LACEC and is on its steering committee, the Consortium coordinator participated in the planning of our multi-country initiative, and three of the five IPPF affiliates are members of LACEC.

The first annual LACEC conference was held in Quito, Ecuador, in collaboration with the Ecuadorian Consortium for Emergency Contraception in October 2002, attended by 235 participants from 20 countries in the region, including legislators, Ministry of Health officials, NGO representatives, researchers, clinic managers, activists and the media, as well the coordinators of the IPPF multi-country project. The objectives of the conference were to raise awareness about EC and motivate health authorities and legislators to incorporate EC into family planning, reproductive health and sexual violence programme norms within Ministries of Health in the region and to foster its provision through the public health services.¹⁸

This collective effort is critical in confronting the legal and political challenges posed in the last two years at national level in several countries to the detriment of EC, e.g. in Chile and Argentina. In August 2001 the Chilean Supreme Court banned the use of a dedicated EC product, Postinal, claiming that its abortifacient action was illegal under Chile's total ban on abortion. Against medical wisdom, the Chilean Court was persuaded by conservative religious arguments that pregnancy begins at fertilisation, and that any mechanism acting after fertilisation produces an abortion. Ironically, four months later the Chilean Ministry of Health was able to register another dedicated EC product with identical ingredients, though it is not accessible to many Chilean women today. The legal decision was a product of the battle between the government Institute of Public Health and women's groups on one side and Chile's Catholic bishops and the conservative right on the other. While women have won this battle by securing the right to EC in cases of rape, unprotected sex or contraceptive failure, EC is still not included in the Ministerial norms, nor is there a guarantee that other dedicated products will not be subjected to similar revisions. A newly formed Chilean Consortium on Emergency Contraception will concentrate efforts on the defence and promotion of EC.^{19 20}

In Argentina, in 1998, the National Drug Administration (ANMAT) approved the use of Inmediat, a dedicated combined EC product produced locally by Gador Laboratories. However, at the end of 2001 in the provinces of Mendoza and Rosario, complaints were filed against this EC pill and its distribution. In March 2002, the Supreme Court of Argentina prohibited the sale and use of Inmediat as a concession to the most conservative political sectors and the Catholic Church. Nevertheless, because the Supreme Court outlawed the brand name but not the chemical composition, two other brands (Inmediat N and Norgestrel Plus) remained on the market. While EC is not widely available in Argentina, these adverse events have publicised the method as never before and disseminated information about it to a larger audience.²⁰

Brazil

Brazil underwent health sector reform 15 years ago. The 1988 Federal Constitution of Brazil legislated the decentralisation of health services to the municipalities, created a sharper division between financing and provision of health services, and authorised the establishment of the (SUS, Sistema Único de Saúde, or Integrated Health System). Though the reforms have created a positive atmosphere of experimentation and innovation, they have also exposed inherent weaknesses in the system, and introduced confusion in roles and responsibilities. All levels of government continue to be involved in the financing and delivery of care, though the municipalities in theory now have more control, authority and autonomy. The larger municipalities (over 1 million population) have benefited greatly due to economies of scale and stronger, more accountable management. The smaller municipalities (5,000 to 30,000 inhabitants) have neither the managerial expertise nor the resources to manage and deliver services efficiently and effectively.²¹ Even though the individual states have the potential to be the most important actors in the health system, the SUS has actually weakened state control by making the municipalities dependent on federal rather than state funds.

Emergency contraception was included in the Ministry of Health norms in 1997 with little resistance. Currently four dedicated EC products are registered in Brazil: Postinor-2, Norlevo, Pilem and Pozato. In the Brazilian health system, assuring access to emergency contraception hinges upon its successful introduction in both the weaker, government-run public services and the larger private sector, navigating the multi-tiered patchwork of coverage and reaching the large population excluded historically from health insurance coverage. Health sector reforms in Brazil have shifted the financing of health services from almost complete dependence on social security revenues to the general funds of federal, state, and municipal budgets.²² Hence, the decision to include or expand the provision of emergency contraception depends on a favourable cost–benefit ratio at municipality level.

BEMFAM (Sociedad Civil Bem-estar Familiar no Brasil), Brazil's IPPF affiliate, has capitalised on the decentralisation of the health system in Brazil by directly contracting with municipalities for the provision of sexual and reproductive health services, primarily in the areas of training, monitoring and evaluation, educational and communications materials and information systems. BEMFAM has been active in the area of sexual and reproductive health for the past 35 years. BEMFAM is a national-level organisation active in 14 of Brazil's 27 states and the Federal District. Its strength lies in its long-standing provision of services which are complementary to those of the public sector. It operates six clinics and four laboratories of its own located primarily in the Northeast, Brazil's poorest region. In addition, BEMFAM has over 1,100 agreements with more than 950 municipalities. Through these agreements, BEMFAM provides both contraceptives and technical assistance to the public health sector.²³

Only about 5% of BEMFAM's contracts are for the direct provision of services.¹⁶ However, if BEMFAM were able to negotiate reasonable prices for a dedicated EC product and market and distribute the complete EC package in such a way as to promote integration and cost–savings, this percentage could increase. As part of the two-year multi-country EC project, BEMFAM will test three different strategies of EC distribution in its six clinics:

• EC provided only upon request,

• EC provided upon request and to all condom, spermicide and other barrier method users, and

• EC provided upon request in conjunction with an IEC/advocacy campaign.

At the end of the two years, an analysis of the cost-effectiveness, access, and success or failure of these strategies will be carried out.

Emergency contraception has already been available for many years in Brazil, but needs to be made more available to youth and adolescents, although the debate about parental consent continues. At an adolescent hotline of the São Paulo State Secretariat of Health, 15% of all calls (or some 30 calls daily) are about emergency contraception.²⁴ In one study in which adolescents were informed of the efficacy and mechanism of action of EC pills, 82% said that it should be made available to all women, and more than 80% said they would use emergency contraception if a condom broke.²⁵

Albertina Takeuti, coordinator of the Women and Youth Programme, São Paulo State Secretariat of Health, has estimated that 5% of all adolescents in the state will use emergency contraception each year, although many more may need the method, but no actual figures are available on current use. According to the Director of Adolescent Services at the Clinical Hospital in São Paulo, it is not unusual for some young women to have used emergency contraception twice, though more than twice is rare. After an abortion, partners often disappear, but with emergency contraception, women's partners actually participate by purchasing the pills.²⁶ On the other hand, the issue of male involvement in EC delivery is complicated by concerns that male partners will put pressure on women to use EC in lieu of condoms. Hence, part of the challenge of providing EC is the need to stress to both women and their partners that unlike condoms, EC does not protect against sexually transmitted infections.

Traditionally, contraceptive promotion has been aimed at women and STI prevention directed at men,²⁷ reflecting gendered stereotypes. The promotion of the use of condoms with emergency contraception as a back-up method, as a form of dual protection, is one strategy used by IPPF/WHR and others to integrate these two areas of concern, and to invest women with more control over both contraception and STI prevention. BEMFAM is integrating EC service provision into its existing STI/HIV screening, prevention and treatment services and ensuring that an STI/HIV prevention message is always incorporated with EC promotion. The protocol for service delivery in both instances should include EC method provision and post-exposure prophylaxis against HIV if indicated, screening for STIs, initial HIV counselling and scheduled follow-up visits. The IPPF/WHR has developed several tools, including a gender sensitivity continuum and a services checklist for STI/HIV integration, that can be adapted and applied to expanding EC service delivery and quality of care.^{28 29 30}

A study in 1997 among a random sample of 579 Brazilian obstetrician−gynaecologists indicated that nearly all respondents had heard of EC, but many lacked more specific knowledge of the method, and nearly one-third believed that EC was abortifacient. The study concluded that concerted educational efforts and the distribution of a dedicated product would improve women's access to EC in Brazil.¹² A smaller study among 120 women in a São Paulo favela showed that half of the women thought more information could motivate use, and at least 80% claimed they would use EC in case of condom failure or unprotected sex.³¹ From 2000 to 2002, training for hundreds of professionals (health care providers, women's groups, AIDS and gender-based violence activists, academicians and others) has taken place in at least 16 Brazilian states by diverse organisations like BEMFAM, NEPAIDS (Núcleo de Estudos para a Prevenção de AIDS) of the University of São Paulo, and the Pacific Institute for Women's Health. BEMFAM personnel have taken part in a larger IEC and advocacy campaign spearheaded by NEPAIDS and the Pacific Institute for Women's Health to reach close to 300 relevant organisations interested in EC provision and information dissemination.^{32 33} Emergency contraception is now being offered by the Ministry of Health in partnership with the states and municipalities. For example, the government has trained 800 professionals in major urban areas in 18 service delivery points in São Paulo and are training personnel at 12 more locations in the interior of the state.³²

BEMFAM has also attempted to address some of the misconceptions and knowledge gaps identified in studies by informing the providers in their own clinics, hundreds of providers in the public sector and other relevant civil society groups in 14 states. BEMFAM has services for gender-based violence, and their programme, Atitude, incorporates EC as a routine measure and a right for all women attending. By embedding its emergency contraception activities within a quality of care and reproductive rights framework, BEMFAM is strengthening existing ties to other non-governmental organisations, feminist groups, rights activists and the university sector, all of which favour expanded access to EC. BEMFAM plans to play a pivotal role in expanding access to EC throughout Brazil by building a local referral network with allied organisations, coordinating national advocacy and education efforts, and through public–private partnerships. At a later stage, BEMFAM will develop and apply social marketing and access strategies to expand EC in the public sector and to a broader national audience and integrate EC provision into other programme areas.

Colombia

Colombia began to carry out health sector reform in 1993 with its Law 100, which provides universal health care coverage and authorised managed competition among public and private health insurers and health service providers. The Colombian Ministry of Health saw this as a cost-effective means of boosting coverage and quality of services. Virtually all sexual and reproductive health services are now covered under the basic health plan and its supplement, including contraceptives, counselling, clinical consultations and treatment. With the reformation of the social security system under Law 100, competition to provide services was established among various health organisations: the EPS (Entidades Promotoras de Salud—so-called health-promotion companies that can provide services directly or contract out to others), the IPS (Instituciones Prestadoras de Salud—health service providers, such as Profamilia, the IPPF/WHR affiliate in Colombia) and other subsidised entities.²³

Because of cutbacks in international donor support to Profamilia and other NGOs delivering health services, the only means of survival was to compete with all providers of sexual and reproductive health services for contracts with private and public health plans. Since 1995, Profamilia (Asociación Pro-Bienestar de la Familia Colombiana) has contracted with numerous public and private health agencies to broaden its revenue base and improve the diversity and quality of its services. They have had to learn about local health service “markets”, carry out research on the needs of service users and work to gain “market” awareness and visibility.^{34 35} is currently providing 50% of the family planning services in Colombia in 35 clinics, all of which have programmes for youth, and six of which also offer legal services in family law and sexual and reproductive rights. Profamilia also provides services to the internally displaced population in the country and their receptor communities in 23 departments, in a context of worsening civil conflict and dwindling funds to subsidise these services.³⁶

A rights-based approach to health was introduced after Colombian delegates participated in the International Conference on Population and Development in 1994, and the Ministry of Health adopted an expanded reproductive health policy that included sexual health. Official norms were established in February 2000 to set service delivery standards, clarify providers' responsibilities for sexual and reproductive health services at all levels, and identify patients' rights. National networks of active women's groups and advocacy organisations reinforce the commitment to uphold these rights and expose violations and inconsistencies.³⁷

However, Profamilia's experience of the reform process has been mixed. Benefits include a broadening of its revenue base and improvements in quality of care. The major drawback is that contracts with public agencies expose Profamilia and other NGOs to ever-present financial risk. Reimbursement for services depends largely on Profamilia's administrative capacity to invoice correctly under a broad range of health coverage plans, the corresponding levels of subsidies and the overall viability and/or quality of patients' insurers. Profamilia's revenues also depend on government agencies paying their bills promptly and in accordance with invoices. Unlike most NGOs, Profamilia has been able to accommodate persistent delays thanks to its size, diversified financial base and careful resource allocation.¹⁶ Smaller and less financially diverse and solvent NGOs would be likely to find this near impossible to manage.

In Colombia dedicated EC products are widely available in the public and private sectors. Colombia was selected by IPPF/WHR to serve as a model for EC introduction in the Latin American region because of the extensive work Profamilia has carried out in this area.³⁸ In 1995, Profamilia staff at a clinic in Bogotá were trained in the Yuzpe regimen of EC and informational flyers were produced. Two years later, Profamilia extended training and services to its other centres in the country, investing significant time and energy on internal information and education to address providers' biases and misconceptions about EC before it was made available in the clinics. They also stimulated accurate media coverage and carried out social marketing.

In 1998, Profamilia entered into negotiations with Gedeon Richter, manufacturer of Postinor-2, a levonorgestrel-only dedicated EC product, and a year later was awarded exclusive distribution rights in Colombia. After some debate, the appropriate national health authorities included EC in the technical norms for family planning in February of 2000. In April 2000, Gedeon Richter applied to INVIMA, the Colombian drug regulatory body, for product approval and registration, and Profamilia began an advertising campaign on radio and with educational materials to inform potential users of the method. This included the dissemination of scientific evidence about its mode of use and mechanism of action, and carefully crafted educational messages emphasising sexual and reproductive rights and the high rate of unwanted pregnancy in the country.

Profamilia generally does not engage directly with anti-choice organisations or the Catholic Church in the media, but rather responds to attacks by presenting solid medical evidence and reproductive rights arguments whenever it is invited to speak on these issues. Other feminist groups often assume the challenge of directly rebutting conservative attacks on sexual and reproductive rights, and together they form a broad coalition of like-minded groups in civil society.

In September 2000, INVIMA registered Postinor-2, for which Profamilia had the distribution rights. Profamilia celebrated the decision as an accomplishment for women's rights. Two weeks later, the US Food and Drug Administration approved mifepristone for early medical abortion in the United States, and the media asked Profamilia to comment on this. Profamilia's executive director declared the decision a victory for women's reproductive rights in the US and took the opportunity to announce that Postinor-2 had just been approved in Colombia, taking care to distinguish emergency contraception from early abortion. The press took great interest in this news item and a flurry of articles followed. The Ministry of Health reiterated that this new EC product could not induce an abortion. Still, the juxtaposition of the “French abortion pill” and the “EC pill” was perhaps unfortunate. The Catholic Church has consistently opposed modern contraception, and the pressure came from the regional and local powers of the Church, as well as Vatican policy. The Catholic Church in Colombia claimed that EC was an abortifacient, contrary to the medical evidence, and put pressure on INVIMA to review its approval of the new method.

In January 2001, Profamilia began to distribute Postinor-2, generating more than 30 media reports. Due to high demand, six weeks later, the warehouses had exhausted their supplies. Nonetheless, the constant pressure of the Catholic Church forced INVIMA to review the entire registration process again. For nine months, Profamilia operated under the threat that their distribution licence for Postinor-2 could be revoked and that they would have to go back to the Yuzpe regimen. Finally in November 2001, 18 months after initial approval, INVIMA issued a statement declaring that EC was an appropriate contraceptive alternative and reaffirmed Postinor-2 registration. Since then, Postinor-2 sales have been increasing steadily, mostly via pharmacies and Profamilia clinics.

The actions pursued in defence of Postinor-2 against a regulatory injunction were determined through a participatory process involving the entire staff and all the clinics of Profamilia. Profamilia defended emergency contraception as a reproductive right, which helped to ensure that they were not undermined by accusations of commercial incentives, and took the lead to mobilise public opinion in favour of EC.³⁸

The next challenge for Profamilia is to get the word out to those most in need of emergency contraception, namely youth, especially in the more rural, disadvantaged areas of the country. Youth are an underserved but primary target group for EC information and use, and youth-friendly and peer education programmes are an ideal mode of EC information dissemination. During the two-year IPPF/WHR project, Profamilia Colombia is focusing on training staff in its stand-alone youth centres and increasing access to EC among its younger clients in the other 32 centres across the country. Profamilia staff and adolescent peer promoters are being sensitised to the challenges of providing EC to young people, and trained to incorporate EC information and provision into their programmes and outreach services.

Lastly, Profamilia will carry out an external advocacy and information campaign, including plans to distribute pamphlets on EC and use radio spots and jingles to advertise a toll-free telephone hotline that provides free and confidential information to callers country-wide (though activities may vary). In addition, Profamilia will be carrying out training in EC advocacy and service delivery for Bolivia, Colombia, Ecuador, Peru and Venezuela.

Discussion

Almost everyone makes mistakes with contraception, but young people are among the most in need of emergency contraception because they are the least experienced with contraception and condom use. Even so, work with youth often raises special concerns among programme planners and service providers, who say such things as “EC is too easy”, it will “promote promiscuous, irresponsible behaviour” among adolescents and will be used repeatedly.³⁹ Such comments beg the question of whether repeat use of emergency contraception is not “a good thing” and should be discouraged, or whether EC use should in fact be encouraged as a legitimate form of responsible and appropriate contraceptive use. We believe the latter is the case.

In some Latin American countries, like Brazil, Colombia, Mexico, and Venezuela where EC hotlines and other youth EC services exist, young people have asked about health risks, about effects of EC use on fertility, breakthrough bleeding and menstruation, and how frequently EC pills can be used. As regards EC use changing behaviour, a recent study in England found that even a single lesson by secondary school teachers on emergency contraception significantly improved students' understanding of EC use, e.g. appropriate time intervals for use, but it did not influence their sexual activity.⁴⁰

High and rising rates of unwanted pregnancy and STI/HIV infection among adolescents in Latin American and Caribbean countries and the considerable morbidity and mortality due to unsafe abortion call for more effective prevention strategies. Women who have been raped, pressured or coerced into having sex benefit enormously from a method that averts a pregnancy they will have had no choice and little or no say in causing. Emergency contraception affords precisely this. Furthermore, emergency contraception has the potential to avert higher costs associated with unwanted pregnancy, induced abortion, and treatment for complications of unsafe abortion, and when used as a back-up to consistent and correct condom use, to reduce and prevent STI/HIV infection rates and related costs.

Given the ongoing health sector reforms taking place in the region, the increased emphasis on integration and cost-benefit ratios, and the now globally accepted discourse on the right of couples to determine the number and spacing of their children, it would appear not only ethically justifiable, but economically and socially responsible to support the integration of emergency contraception into sexual and reproductive health and other relevant programmes.

Acknowledgements

The authors would like to thank the Erik and Edith Bergstrom Foundation, Summit Foundation, Open Society Institute, Wolford Fund and West Wind Foundation for their financial support for this project in progress. We are grateful to current and former IPPF colleagues for their comments and contributions to earlier drafts: Eva Bazant, Judith Helzner, Alejandra Meglioli and Lara Tabac. A special note of appreciation goes to Angeles Cabria, the coordinator of the Latin American Consortium on Emergency Contraception, for collegial support and information. Our thanks also to the executive directors and project coordinators of the IPPF/WHR affiliates in this five-country project, especially BEMFAM and Profamilia Colombia, for undertaking and supervising this EC initiative.