National Partnership for Women & Families

Monthly Women's Health Research Review

Review calls for community health workers to provide emergency contraception

Summary of "In support of community-based emergency contraception," Chin-Quee et al., Contraception, March 3, 2016.

"Community-based family planning is a proven, high-impact practice for extending reproductive health services to women, particularly those in hard-to-reach places," according to Dawn Chin-Quee of FHI 360's Division of Health Services Research and colleagues.

The researchers noted that as a result, "many community-based family planning programs facilitate and support the provision of condoms, oral contraceptive pills and even injectable contraceptives by community health workers." However, emergency contraceptive pills (ECPs) -- "a method for which there are no contraindications and the user herself can determine need -- are not routinely included among the contraceptive methods provided by community health workers," the researchers wrote. According to the researchers, this "is shortsighted, especially in light of the unique position that ECPs occupy in the method mix and [community health workers' (CHW's)] ability to meet the needs of potential clients in a way other providers often cannot or do not." They added that the link between the Zika virus and severe birth defects "that resulted in calls for women to avoid or delay pregnancy ... also serves to underscore the value of this proposition."

The researchers explained that emergency contraception (EC) "includes dedicated emergency contraceptive pill products, combined oral contraceptive pills ... and post-coital insertion of intrauterine devices (IUDs)." While "IUDs are the most effective form of EC, and with continued use, can provide long-term protection from pregnancy," they "require a clinical procedure by a higher-level provider than a CHW, which make IUDs less convenient and more difficult to obtain than [ECPs] within five days of unprotected sex," the researchers wrote.

Citing research showing that increased access to ECPs "had no public health impact" on rates of unintended pregnancy and abortion, the researchers acknowledged that a "call for CHW provision of ECPs may ... be called into question for lack of proven widespread effect." Nonetheless, the researchers contended that "it would be remiss to disavow CHW-provision of ECPs," given that ECPs have "proven effective for individual women who use [the method]" and that CHWs typically serve "'disadvantaged and marginalized populations,'" who according to the World Health Organization stand to benefit from comprehensive contraceptive information.

The researchers wrote, "We believe that now is the time for CHWs everywhere to provide ECPs in their communities," with a particular focus on trying "to achieve equity [in contraceptive access] between urban and rural women." The researchers outlined "the way forward" for community-based emergency contraception (CBEC), noting that CBEC "is an easily implemented public health initiative and would be timely given the need to help women avoid pregnancy in Zika-affected areas."

Reasons for community-based EC

The researchers outlined several reasons why CHWs are uniquely qualified to provide ECPs.

For example, CHW-provided ECPs "would increase access to this method for rural women who have relatively poor access to pharmacies and clinics compared to urban women." The researchers explained that rural women might be more likely to have unprotected sex because "the need to travel long distances" for care and a lack of "regular family planning methods" in such areas. However, if CHWs provided ECPs, in addition to other methods such as condoms and pills, such services "would be more readily and conveniently obtained," the researchers wrote, noting that such access is particularly important "in cases where the CHW may be the only representative of the health care system available to provide" care in instances of rape.

According to the researchers, CHWs also "may be less judgmental than clinicians and more willing to provide ECPs." The researchers cited research showing that clinic-based providers in Nigeria and Senegal "were reluctant to provide ECPs to young unmarried women" and tended to believe that "ECPs should be dispensed by prescription and by medically-trained personnel only." However, according to the researchers, people "may feel more comfortable requesting ECPs from a CHW who is a member of their community and has earned their trust." They pointed to another study that found patients in Rwanda seeking family planning services as well as those who were not seeking such services "much preferred to go to their CHW than the health clinic."

The researchers also noted that CHWs are better positioned than the private retail sector to provide ECPs because a private retail organization "may not be as willing to offer counseling and/or dedicate the time to provide education and instructions" about ECP. "Moreover, ECPs may more readily fulfill its role as a bridge to more effective methods in the hands of CHWs ... with whom client-provider interactions may prove more amenable to counseling and the provision or referral for regular, ongoing methods."

Who can provide CBEC

According to the researchers, "any community health worker can be trained to safely provide ECPs, as they have no contraindications and women themselves are aware of when they may need ECPs." The researchers noted that the training is "simple" -- requiring "minimum investments in time and resources" -- particularly when compared with alternative methods that require training about "health screening, counseling for side effects, and techniques such as safe injection and waste disposal."

Types of EC that should be provided

The researchers outlined three ECP options, noting that one method in particular, 1.5 mg of levonorgestrel, might be the best option for CBEC because:

  • It has a lower cost compared with other methods;
  • It is developed and distributed by several companies globally, it is available over-the-counter in several developing countries, and multiple generic formulations are sold;
  • Research has found that it is not less effective than ulipristal acetate (UPA) -- another ECP -- among women who weigh more than 165 lbs.; and
  • Alternative ECP UPA is less accessible in low-income countries and requires a prescription outside of the European Union.

Where community-based EC should be offered

The researchers called for "the international community [to] work together to increase women's access globally to emergency contraception through public and private sector programs that include community-based distribution, facility provision, social marketing programs, and private providers and clinics." Moreover, because "ECPs do not require special handling or refrigeration," they can be sent "in advance of need" and stored "in very remote areas, or areas that periodically become inaccessible," the researchers wrote.

How CBEC should be provided

The researchers wrote that because "ECPs have no contraindications, and they are more effective if used as soon as possible after unprotected sex," trained community health workers "can provide the product and, more importantly, the necessary counseling." However, the researchers noted that since ECPs are "not intended for routine use" community health workers should work to identify cases in which women should be "counseled about methods intended for ongoing use, including more effective [methods]," such as long-acting reversible contraceptives. Community health workers are "trained to provide referrals" for such methods, according to the researchers.

The demand for ECPs is difficult to assess because the "product [is] not intended for routine use and -- even now -- poorly known among providers and potential clients," the researchers wrote. However, they noted that "as ECPs are mainstreamed into public sector family planning programs ... [through] supportive policies, greater awareness of the method, integration into routine logistics data and procurement, supply can be tailored to approximate demand."

Challenges to CBEC

The researchers addressed several possible challenges to the CHW provision of ECPs. They cited research debunking concerns that CBEC would spur "promiscuity and unprotected sex ... as well as a concomitant increase in sexually transmitted [infections]" (STIs). According to the researchers, studies also show that women who access ECPs without a prescription know that there are more effective contraceptives available and that ECPs do not protect against STIs. Moreover, the researchers noted that ECPs are "not harmful to the woman nor to the fetus should the woman become pregnant."

The researchers acknowledged that adding ECPs to a CHW's "basket of services" could potentially divert resources by "overburdening the CHW and/or taxing the health system." However, there is no research yet to substantiate such concerns, according to the researchers, who noted that "adding ECP provision to community-based family planning [likely] would prove much less disruptive than other methods already provided by CHWs ... that require more training in counseling, administration, and logistics."

The researchers also cited a feasibility assessment of the CHW-provision of ECPs in Uganda, which found that national and regional health leaders thought that "any negative aspects associated with increased access and availability of ECPs via CHWs would be outweighed by the positive (avoidance of unintended ... pregnancy and abortion)."

Conclusion

Based on this analysis, the researchers concluded that there is "ample justification for adding emergency contraception to community-based family planning programs." They noted that the current "family planning agenda, with the added importance of a rights-based focus, underscores health and ethical obligations."

The researchers wrote, "Community-based emergency contraception should be considered an integral part of community-based family planning services, because unintended pregnancy is generally higher in rural than urban settings, as is unmet need for contraception more broadly." Pointing to regions affected by the Zika virus, the researchers noted that CBEC "would help individual women in largely marginalized, underserved areas to decrease their chances of having unintended pregnancies."

Further, according to the researchers, "CBEC should also be considered ethical, because the provision of comprehensive contraceptive information and services is a human right." The researchers concluded, "As a practice that can be readily implemented, CHW-provision of ECPs is low-hanging fruit for preventing unintended pregnancy, increasing access to family planning, expanding the method mix and advancing equity in reproductive health."