Emergency Contraception under Attack in Latin America: Response of the Medical Establishment and Civil Society

Abstract

The concept that it is possible to prevent a pregnancy after coitus is not new, but has gained prominence over the last 10–15 years. It provides a second chance to women who do not want to get pregnant and who, voluntarily or not, have had unprotected intercourse. Emergency contraception has been under strong attack by the Catholic church and anti-choice organisations in Latin America, who claim that the interference with implantation of the fertilised ovum is equivalent to an early abortion. The accumulation of evidence, however, is that the mechanism of action of emergency contraception is to prevent ovulation and that it does not interfere with implantation. This has been ignored by the anti-choice movement. The pattern of opposition to emergency contraception has been the same all over the Latin America region. The medical establishment and civil society, including the International Consortium for Emergency Contraception, have played a key role in defending access to emergency contraception throughout the region. A positive consequence of the public opposition of the Catholic church is that the concept and the method have become better known, and emergency contraception has become widely used. The cases of Peru, Brazil and Chile are described as examples.

Résumé

L'idée selon laquelle il est possible d'éviter une grossesse après l'acte sexuel n'est pas nouvelle, mais elle s'est fait mieux connaître ces 10–15 dernières années. Elle donne une deuxième chance aux femmes qui ne veulent pas être enceintes et qui, volontairement ou non, ont eu un rapport non protégé. En Amérique latine, l'Église catholique et les organisations anti-avortement ont violemment attaqué la contraception d'urgence en affirmant que l'interférence avec l'implantation de l'łuf fécondé équivalait à un avortement précoce. Pourtant, les données accumulées montrent que le mécanisme de la contraception d'urgence prévient l'ovulation et n'interfère pas avec l'implantation. Cela a été ignoré par le mouvement anti-avortement. Le mode d'opposition à la contraception d'urgence a été le même partout en Amérique latine. Le corps médical et la société civile, notamment le Consortium international pour la contraception d'urgence, ont joué un rôle clé pour défendre l'accès à cette méthode dans la région. Une conséquence positive de l'opposition de l'Église catholique est qu'elle a fait connaître le concept et la méthode, et qu'elle a élargi le recours à la contraception d'urgence. Les cas du Pérou, du Brésil et du Chili sont décrits à titre d'exemples.

Resumen

El concepto de que es posible evitar un embarazo después de tener relaciones sexuales no es nuevo, pero ha adquirido importancia en los últimos 10–15 años. Brinda una segunda oportunidad a las mujeres que no desean quedar embarazadas y que, voluntaria o involuntariamente, han tenido relaciones sexuales sin protección. La anticoncepción de emergencia ha sido atacada enfáticamente por la Iglesia católica y organizaciones contra el derecho a decidir en Latinoamérica, que sostienen que la interferencia con la implantación del huevo fertilizado equivale a un aborto temprano. Sin embargo, la acumulación de evidencia es que el mecanismo de acción de la anticoncepción de emergencia es impedir la ovulación y que ésta no interfiere con la implantación. El movimiento contra el derecho a decidir ha hecho caso omiso de esto. El patrón de oposición a la anticoncepción de emergencia ha sido el mismo en toda la región de Latinoamérica. La profesión médica y la sociedad civil, incluido el Consorcio Internacional sobre Anticoncepción de Emergencia, han desempeñado un papel importante en defensa del acceso a la anticoncepción de emergencia en toda la región. Una consecuencia positiva de la oposición pública de la Iglesia católica es que el concepto y el método ahora son más conocidos y el uso de la anticoncepción de emergencia es muy extendido. Los casos de Perú, Brasil y Chile se describen como ejemplos.

Key Words:

• emergency contraception
• advocacy and political process
• anti-abortion groups/movement
• Catholic church
• Latin America

The concept that the administration of sex hormones could prevent pregnancy when administered after coitus is far from new. In the first attempts to develop emergency contraception, relatively large amounts of oestrogen were administered to cause withdrawal bleeding after suspension of treatment. The effect of oestrogen is to cause the endometrium, the membrane that lines the interior of the uterus, to grow. The fall in the concentration of oestrogen in the blood then causes the endometrial lining to be sloughed off, with consequent bleeding.¹² The intended mechanism of action of such high doses of oestrogen was to cause endometrial changes that would be incompatible with implantation, as had been shown to occur in non-human primates.³ Increasing levels of progesterone, produced by the ovary after ovulation, transform the endometrium, making it receptive to the fertilised egg. This progesterone-induced effect was to be countered by the administration of a large amount of oestrogen, thus preventing implantation. However, the high amount of oestrogen that was used caused nausea and vomiting in almost every subject, leading to the abandonment of the idea.¹²

This early research was the origin of the concept that any post-coital pill for pregnancy prevention that is taken after sexual intercourse acts by preventing implantation. The fact is, however, that the current dedicated emergency contraception pill is a progestogen, a hormone that induces changes in the endometrium necessary for the maintenance of pregnancy. This fact has not changed the popular belief that the mechanism of action of all emergency contraceptive pills is to block implantation. That mistaken belief is coupled with the lack of understanding that the female oocyte is not fertilised immediately after intercourse; fertilisation may occur from 24 hours to five days later, giving time to interfere with the process before fertilisation. This misconception may be irrelevant in most of the world, but it has been a key element on which a concerted attack against free access to emergency contraception pills in Latin America has been based. The lack of awareness of the political implications of the belief that emergency contraception prevents implantation may be the reason why so little care has been taken to correct this misconception.

Emergency contraceptive pill and its mechanism of action

Widespread knowledge of emergency contraception is relatively new, but the first clinical trials showing it was possible to control human fertility by the administration of steroidal hormones after coitus were published 40 years ago.¹ Several options were tried, from high doses of oestrogen alone, as described above, to high doses of combined oral pills containing ethinyl-oestradiol and levonorgestrel, known as the Yuzpe regime.^4–6 In 1974, these authors gave the name “morning-after pill' to this method, intended to be used following rape or unexpected and unprotected sexual intercourse.

One year earlier Kesseru et al had proposed the use of levonorgestrel alone as a post-coital pill, to be taken after every sexual intercourse during the cycle, a scheme with the theoretical advantage of not requiring a daily pill.⁷ The effectiveness of this method was much lower than that of the combined pill, so its use was discouraged. In fact, there is an almost total lack of reference to it even in some of the most comprehensive books on contraception published before the mid-1990s. It was not until 1993 that a single study, conducted in Hong Kong, demonstrated that the use of levonorgestrel alone was as effective as the Yuzpe regimen in preventing pregnancy, with a reduced frequency of adverse events.⁸

In April 1995, the International Planned Parenthood Federation (IPPF), Family Health International (FHI), Population Council and World Health Organization met at Bellagio for a meeting hosted by South-to-South Cooperation in Reproductive Health, supported by the Rockefeller Foundation. This meeting developed a consensus statement calling for the need to make access to emergency contraception a practical reality.⁹ Shortly afterwards, the Consortium for Emergency Contraception, an international collaboration of seven organisations, was created. The promotion of the concept of emergency contraception by this Consortium gave a totally new life to this method.

Initially, efforts to make emergency contraception accessible to women were focused on the Yuzpe regimen, since it used four tablets of the standard contraceptive pill, which contained 250 mcg of levonorgestrel and 50 mcg of ethinyl oestradiol, which was readily available in many countries. The woman had to take two of these pills as soon as possible and no later than 72 hours after unprotected sexual intercourse, and another two pills 12 hours later. In theory, access to the Yuzpe regimen was relatively easy. In practice, its use was minimal because knowledge of it was limited among both the public and gynaecologists.¹⁰¹¹

Promotion of the Yuzpe method became more complicated when the pharmaceutical companies launched a new, lower-dose generation of pills, which meant that the number of pills to be taken to obtain the right dose increased to eight, four as soon as possible and four 12 hours later. As the general public were not aware of the different doses of hormones in different brands of pills, they had difficulty in knowing how many pills to take post-coitally. In the absence of a dedicated product, that became an obstacle to more widespread use of this kind of contraception.

Greater attention to emergency contraception was raised by a large, comparative clinical study coordinated by the World Health Organization, which showed that levonorgestrel alone was significantly more effective than the Yuzpe regimen and was associated with fewer side effects.¹² It was the broad dissemination of these findings that created an environment of greater trust in the effectiveness of emergency contraception.

In addition, five basic research studies were published with increasingly convincing evidence that in contrast with the high-dose oestrogen regimens originally studied, the administration of levonorgestrel alone does not prevent implantation but acts earlier, interfering with ovulation.^13–17 Two other studies found no alteration in the endometrium that would support the hypothesis that levonorgestrel could interfere with implantation.¹⁴¹⁵ In a more recent study, three contraceptive failures occurred among 99 women who used emergency contraceptive pills; all three pregnancies were in women who had taken the pills shortly after ovulation, at a time when fertilisation would have occurred, thus indicating that there was no effect on the fertilised egg, while no pregnancies occurred in the women who took the pills before or on the day of ovulation.¹⁸ Only one study has reported hystochemical changes in the endometrium that may have an inhibitory effect on implantation, but only if administered before ovulation and not if given on the day of ovulation or after it.¹⁹ Furthermore, studies in rats and monkeys have shown that emergency contraception does not prevent pregnancy if administered after fertilization.²⁰²¹

Thus, all the evidence confirms that levonorgestrel emergency contraceptive pills cannot prevent pregnancy if the pills are not taken early enough in the cycle so as to interfere with or postpone ovulation. This limitation explains their relatively low contraceptive capacity, which reduces the chances of pregnancy by 65–85%.^12,22–24 However, the problem remains that the old concept of emergency contraception interfering with implantation still appears in a number of specialist books and internet sites, including newsletters of the Pan American Health Organization. Many usually well-informed people and media sources continue to repeat this outdated and incorrect information. As recently as 30 January 2007, the BBC announced that Chilean President Bachelet had signed a decree so that the morning-after pill can be given to adolescent girls without their parents' consent and ended the report by saying that “It works by stopping or delaying ovulation, or by stopping an egg settling in the womb”.²⁵

Emergency contraception in Latin America

Latin America, where the daily oral contraceptive pill is quite popular and has a high prevalence of use, was one of the regions where a high level of acceptance of emergency contraception was expected. It is a region where a large power imbalance between the sexes still exists and it is not uncommon for women to be exposed to unexpected, undesired and unprotected intercourse, which is when the greatest benefit of emergency contraception is obtainable. It is also a region with very restrictive abortion laws, where women only exceptionally have access to safe, legal abortion, even if they fulfill the legal conditions, and where most of those with unwanted pregnancies end up having unsafe abortions.

The need for emergency contraception exists worldwide. The logical conclusion is therefore that women should have access to such a product. However, in spite of the potential market for levonorgestrel emergency contraceptive pills, none of the large pharmaceutical companies has shown any interest in producing and distributing it, apparently to avoid the political opposition to emergency contraception that has been observed for the last decade.

Confronted with this resistance, the Consortium for Emergency Contraception played a key role in Latin America by working with local and international NGOs to motivate smaller pharmaceutical firms to produce a dedicated product in practically every country in the region. The best known and first to be marketed was Postinor-2, distributed with that brand name in several countries in the region.

The pattern of opposition

Shortly after efforts to disseminate information more widely about emergency contraception started, and when dedicated products began to appear from 1997 on, strong opposition from the Catholic church hierarchy emerged. Their opposition is posited on the belief that emergency contraception prevents implantation of the fertilised egg and that the fertilised egg has the same rights as a living person. Consequently, using emergency contraception is equivalent to killing a human being or, at the least, the same as an abortion. Since abortion is totally or partially illegal in Latin America (with the exception of Cuba), they argue that emergency contraception should also be legally prohibited.

Such statements come mainly from two sources: physicians and professors of universities associated with the Catholic Church or certain radical Protestant denominations. They generally ignore any evidence that undermines their position on this subject. Quoting “authoritative sources”, bishops, archbishops, cardinals and sometimes national Councils of Bishops make public statements, widely publicised in the press, advising governments that allowing the marketing of emergency contraceptive pills would violate the Constitution and is against the law.²⁶²⁷

A number of long-standing conservative groups and some new NGOs closely associated with the Catholic church have recently emerged claiming to represent civil society by defending the people from the dangers of emergency contraception. Some of these groups appear to be connected with the US pro-life movement and use the same or a very similar name (Pro-vida or Sí vida). In addition, the Catholic hierarchy has a direct influence on politicians in the executive branch, legislative and justice systems, and directs them to propose bills, support juridical claims of unconstitutionality and executive orders to reduce or eliminate access to emergency contraception.

These attacks have been made at every stage of the process of approval and marketing and have aimed to restrict access to approved products in pharmacies and prevent free distribution of emergency contraception through the public health system. Successful registration and marketing of dedicated products, which has already taken place in at least 23 Latin American countries, is never the end of the story. If its opponents lose the battle against registration and approval of the method, then they try to ban its distribution or limit sales by requiring a physician's prescription. If the government decides to make it accessible to everyone through the public clinics, by including it alongside the other available contraceptive methods, initiatives to ban its availability are immediately begun. Their allies at all levels of service provision are urged to limit access to it, both nationally and locally, with any success depending on the extent of their political influence.

This has been an apparently endless struggle that has at least temporarily limited access to emergency contraception in several countries, including Chile, Peru, Argentina and Colombia.²⁸ Yet there is practically no opposition to the Yuzpe regimen, which is the only emergency contraception available in Panama, Costa Rica and Honduras. In countries where no dedicated emergency contraceptive pill is registered, the Catholic church has not acted to prevent access to the combined pill being used also as emergency contraception in the public health service, maybe because it is never as widely used as when a dedicated product exists.

Defending emergency contraception: strategies

As could be expected, the defenders of access to emergency contraception are the same institutions, groups and individuals who defend sexual and reproductive rights in general: women's groups, human rights advocates, public health and human rights-minded physicians. Several institutions have played a crucial role regionally in addition to the Emergency Contraception Consortium: the Feminist Network for Sexual and Reproductive Rights in Chile, FLASOG (Latin American Federation of Obstetrics and Gynecology Societies), IPPF Western Hemisphere Region and, more recently, the Pan American Health Organization. While feminist organisations at the national and local level provide grassroots support for emergency contraception, the regional bodies give scientific and professional credibility to the arguments.

A very important role has also been played by the research institutions and individual researchers who have provided the scientific evidence that emergency contraception does not cause abortions. Many of them have gone beyond presenting their results in meetings and publishing in scientific journals; they have also played an important political role in the defence of access to emergency contraception.

Three main points are being made in defence of universal access to emergency contraception. First, there is no evidence to support the assertion that the current dedicated levonorgestrel pills are abortifacient. No effort has been made to contest the argument that a fertilised egg is equivalent to a person. Those beliefs, shared or not, should be respected. In any case, however, such a dispute is unnecessary, because the scientific evidence is so clear that emergency contraception is not effective after fertilisation.

Secondly, access to the means to prevent an unwanted pregnancy is supported by the universally accepted right to decide whether and when to bear children, the human right to non-discrimination based on sex and age and the right of access to essential medicines and to benefit from the fruits of scientific progress. Thirdly, it is argued that as many as eight out of every ten women who have timely access to emergency contraception after unprotected intercourse will have prevented an unwanted pregnancy and possibly an abortion, an outcome which should be supported by those who attack emergency contraception, as well as everybody else.

FIGO (the International Federation of Obstetrics and Gynecology) and the FIGO Committee on Women's Sexual and Reproductive Rights were instrumental in organising the defence of emergency contraception by the gynaecology and obstetrics establishment in countries. FLASOG (the Latin American Federation of Obstetrics and Gynecology Societies) acts mostly through its Committee on Women's Sexual and Reproductive Rights, similar to the FIGO Committee. The FLASOG Committee organises workshops on different aspects of women's rights, which make recommendations to national obstetrics and gynaecological societies and individuals. Recommendations to protect and promote women's sexual and reproductive rights were confirmed by the FLASOG General Assembly in 2002 and ratified in 2005. Those recommendations have become an important instrument to motivate national societies to go public in defence of the scientific facts and of access to emergency contraception. The Committee also acts by sending letters of encouragement or congratulations to national societies and governmental health offices, where appropriate, to urge them to maintain a firm stance of defence of the right to access emergency contraception.

Country case studies

The following brief histories of the struggle (or lack thereof) to ensure that women have access to emergency contraception in Peru, Brazil and Chile in the past few years are described below from the personal experience of the authors from Peru and Brazil and a colleague from Chile.

Peru

In July 2001, the Peruvian Minister of Health, Dr Eduardo Pretell, signed Ministerial Resolution 399-2001, which included emergency contraception among the other contraceptive methods distributed by the Ministry of Health. A few days later, with a change of government, Dr Luis Solari was made Minister af Health. Not only did Dr Solari not implement the Resolution, he also dismantled the government Family Planning Programme. Although a further change of Health Minister occurred at the beginning of 2002, the distribution of emergency contraception remained on hold based on the claim that it could interfere with implantation of the fertilised egg and consequently was abortifacient.

Also in 2002, women's organisations went to court to seek to oblige the Ministry of Health to provide emergency contraception to women who require it. They had the public support of the Peruvian Society of Obstetrics and Gynecology, the Medical College of Peru and even the People's Attorneys (Defensoría del Pueblo), a governmental office, that made a pronouncement in favour of emergency contraception.

In spite of those efforts the situation remained unchanged until in June 2003, when a new Minister got Presidential approval to create a High-Level Commission to make a scientific, technical and legal pronouncement on emergency contraception. The High-Level Commission sat from September to December 2003, with the participation of 14 public and private institutions. During the deliberations it became increasingly clear that its final decision would be in favor of distributing emergency contraception. This disturbed the hierarchy of the Catholic church. The bishops tried hard but unsuccessfully to influence the Minister of Health, and in December 2003 the Commission approved, with 11 of 14 votes in favour, a recommendation of broad access to emergency contraception. In June 2004, the National Guidelines on Integrated Sexual and Reproductive Health Care, and one month later the National Strategy for Sexual and Reproductive Health, which included emergency contraception, were approved by the Ministry of Health.

From 2004 on, a public opinion and legal battle over emergency contraception was launched, with the Catholic church and organisations associated with it trying to ban emergency contraception and women's and medical organisations defending it.

Following the court case in 2002, a counter-demand to ban emergency contraception was placed before the court. After many appeals of both litigations, in December 2006, the Constitutional Court confirmed the verdict in favour of the women's organisations' demand to oblige the Ministry of Health to provide emergency contraception, giving full legal support to its distribution through government clinics.

The struggle is not over, however. Anti-choice organisations under the leadership of the Catholic church maintain a web page dedicated to discrediting emergency contraception and its proponents. At the same time, they use the media to feed the public with articles opposing emergency contraception, still based on its supposedly abortive effect. In response, an intense campaign in favour of emergency contraception was launched nationally. Civil society, including scientific and academic institutions, support the Ministry of Health with public statements, inclusion of the subject in congresses and courses, and support the travel around the country of key scientific leaders to inform the public and provide training to health professionals, in close collaboration with the Ministry. The media have also played an important role in educating the public with information predominantly in favour of emergency contraception.

In spite of all this turbulence, since 2005, emergency contraception has been distributed in all outpatients clinics across the country. It is hoped that being already so well established as just another contraceptive method within the system, it will be more difficult to halt its access to the public.

Brazil

This history is totally different from that of Peru. The Ministry of Health of Brazil was involved from the very beginning, with the support of FEBRASGO (the Brazilian Federation of Obstetrics and Gynaecology Societies), and leading obstetricians and gynaecologists. The Ministry of Health included emergency contraception among the range of contraceptive methods in the National Family Planning Guidelines issued in March 1997, when only the Yuzpe regimen was available. The first dedicated product was speedily registered in 1998, and incorporated in the national programme.

Although there were a few public statements from the hierarchy of the Catholic church against emergency contraception, one leading liberal bishop declared to the press that it was better to use emergency contraception after coercive unprotected sex than having an unwanted pregnancy that would be aborted. Feminist groups did not play an important role, probably because it was not required, but also because they showed a certain mistrust of emergency contraception at that early period. Currently, emergency contraception is sold widely over the counter in pharmacies and distributed throughout the public health system, although logistic problems prevent it always being available.

Chile*

Probably the most furious struggle to make emergency contraception available occurred in Chile, where several of the most important studies on its mechanism of action were carried out by the ICMER (Chilean Institute of Reproductive Medicine). This same institution motivated the national pharmaceutical industry to produce and market a dedicated product in March 2001, with the brand name Postinal. A claim of unconstitutionality (that it caused abortions) was presented to the High Court of Justice, which led to prohibition of the sale of Postinal in October 2001. However, another product was registered immediately afterwards and remained on the market until March 2006.

In 2003, the Ministry of Health purchased a large stock of emergency contraceptive pills for distribution through the public health system, but only for women who had been raped. Even so, in some municipalities, the mayors rejected its distribution on the grounds of conscientious objection, claiming that it caused abortion. In 2006, under the new government of President Bachelet, the Minister of Health signed a new National Guideline on Fertility Regulation, which included access to emergency contraception for every woman aged 14 and older, without requiring parental consent. A group of 33 parliamentarians presented a claim of unconstitutionality to the Court, alleging the Guidelines included methods with abortifacient effects, such as emergency contraception, thus violating the human right to life of the fertilised egg. The Constitutional Court decided not to consider the issue of whether emergency contraception was abortifacient but ruled that the Minister did not have authority to decide to make it available by decree, only the President. Soon after, President Bachelet signed a decree with the full support of the scientific and academic community, as well as from women's groups, supporting provision of emergency contraception.

Although this is an important success, the situation is far from resolved. Since October 2006, all pharmaceutical companies registered in Chile to sell emergency contraception stopped marketing the product. The Ministry of Health is now looking for a pharmaceutical firm willing to produce emergency contraception. The only one to date that agreed to do so changed its mind under pressure from a pro-life consumer group. Thus, the only product available comes from APROFA, the national family planning association and an IPPF affiliate, that sells one brand at a relatively low price, and the remaining stock of the Ministry of Health.

Throughout this period the strongest defender of emergency contraception was ICMER. The Ministry of Health was supportive most of the time. APROFA and the women's Network for Sexual and Reproductive Health and Rights also played an important role.

At the present time, conservative groups remain very active and have considerable financial support. The down side is that there is no emergency contraception product sold in pharmacies. On the positive side, there is finally unanimity among scientific and academic institutions in publicly defending the notion that emergency contraception is not abortifacient and should be available to everyone, to help to ensure the right of women to decide about their own fertility.

Current situation in Latin America

A dedicated emergency contraceptive product is registered and marketed in almost every country in the Latin American region except Panama, Costa Rica, Honduras and Guatemala. Although in Mexico and Argentina a medical prescription is in theory required, in most pharmacies women can get a packet without a prescription.

Most governments have included emergency contraceptive pills among the methods recommended in their family planning guidelines and several have made emergency contraception available through the public health system, including Mexico, Peru, Chile, Uruguay, Nicaragua and Brazil. The actual availability of the method at basic health posts is a different matter, more dependent on the logistic capacity of the local government health management than of an intended policy, at least in the countries just mentioned. In some countries, emergency contraception is not freely distributed to everyone who requests it through the public health system, but is limited to cases of rape, such as in Guatemala.

A positive consequence of the publicity provided by the public opposition of the Catholic Church is that awareness of the concept and the actual method of emergency contraception has grown, and emergency contraception has become widely used. In Mexico, for example, it is estimated that about 1.5 million doses of emergency contraceptive pills were sold in 2006 (Schiavon R. Personal communication, 2007).

The cost of one packet of emergency contraceptive pills is US$ 5–7 in most countries in the region. This is barely affordable for most women, and probably not affordable at all for poorer and younger women, thus creating a serious barrier to access. That is why its free distribution as part of national family planning and reproductive health programmes is so important and also why the opposition is so determined to block this happening. For the time being, we are very far from universal access to emergency contraception, which is a shameful example of the violation of the rights of women in the Latin American region.

The future

It is impossible to predict the future, but it is always possible to have hope and a goal. The conviction of the rightness of defending emergency contraception will increase with technical and scientific support for the fact that emergency contraception is not abortifacient on the part of FLASOG, IPPF affiliates in the region and the Pan American Health Organization. These organisations offer formidable scientific credentials to governments, who also know that most people favour access to emergency contraception.²⁹

The conservative religious forces behind the opposition to emergency contraception are self-defeating in their declared aim of combating abortion when they seek to place barriers to a method with the potential to prevent unwanted pregnancies and abortions. While it is true that there is not yet any evidence that emergency contraception has been able to reduce the number of abortions in a population,³⁰ at the individual level it has been shown that up to eight in ten women who have unprotected intercourse and use emergency contraception will avoid an unwanted pregnancy.

Although there are fanatics who will never accept facts and reason, there are also many intelligent and rational religious people in the world. The same church that finally recognised that Galileo was right when he showed that the earth revolves around the sun, should also finally accept that emergency contraception does not cause abortion. It may take time and the struggle may last for years, and it will cause suffering and pain to many women, but we are confident that the opposition to emergency contraception will progressively weaken. The final outcome should be that emergency contraception will become more accessible in a timely way for most women and will help to protect younger and poorer women from unwanted pregnancy, as an integral part of the right to practise family planning, recognised by practically every nation in the world.

Notes

* We acknowledge information about Chile from Verónica Schiappacasse, a midwife, who was the former director of the Latin American Consortium on Emergency Contraception.