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Many biomedical aspects of emergency contraception have been investigated and documented for >30 years now. A large number of social science questions, however, remain to be answered. In this article, we review the rapidly growing but geographically lopsided literature on this topic. Using computer database searches supplemented by reference reviews and professional correspondence with those active in the field, we gathered literature on the social science and service delivery aspects of emergency contraception published in English up through December 1998, as well as a few unpublished papers from the same time and slightly later, representing regions where published material is practically nonexistent. Methodologically acceptable papers are summarized in our tables and text, and form the basis for suggested improvements in existing emergency contraceptive services. The review also offers ideas for designing new emergency contraception services where they do not yet exist. We conclude by proposing an agenda for further social science research in this area.

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PIP: Emergency contraception (EC) refers to methods usually based on standard contraceptives for use within a few days of unprotected intercourse to prevent pregnancy. The most common, used in many countries for over 2 decades, is based on high doses of combined oral contraceptives (OCs) taken within 72 hours of unprotected coitus, followed by a second dose 12 hours later. Copper IUDs inserted within 5 days also provide protection. The "morning-after pills" have no effect on a pregnancy that is already established, do not cause abortion, and have not been shown to cause congenital malformations in case of failure. Emergency OCs entail no risk for most women, and occasional use is not believed to carry the same risks as regular OC use for women at cardiovascular risk, although progestin-only EC may be indicated. Only about 2% of women who use EC become pregnant. EC is useful in case of method failure, unexpected sexual relations, or rape. EC may reduce recourse to abortion by preventing unwanted pregnancy. There is no evidence that availability of EC increases sexual activity among young people. Women are not likely to replace their regular methods with emergency OCs because of the side effects, greater expense, and lower efficacy. Adding EC to existing reproductive health services is not costly in itself and offers savings in care for unwanted pregnancy and abortion.^ieng

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Emergency contraception promises to reduce Mexico's high unwanted pregnancy and unsafe abortion rates. Because oral contraceptives are sold over-the-counter, several emergency contraceptive regimens are already potentially available to those women who know about the method. Soon, specially packaged emergency contraceptives may also arrive in Mexico. To initiate campaigns promoting emergency contraception, we interviewed health care providers and clients at health clinics in Mexico City, ascertaining knowledge, attitudes, and practices concerning the method. We found limited knowledge, but nevertheless cautious support for emergency contraception in Mexico. Health care providers and clients greatly overestimated the negative health effects of emergency contraception, although clients overwhelmingly reported that they would use or recommend it if needed. Although providers typically advocated medically controlled distribution, clients believed emergency contraception should be more widely available, including in schools and vending machines with information prevalent in the mass media and elsewhere.

PIP: An interview was conducted to ascertain knowledge, attitudes, and practices concerning emergency contraception (EC) among health care providers and potential EC users in metropolitan Mexico. Findings showed that there was a limited knowledge about EC per se and its method, but nevertheless, most of the participants were cautious to support EC in Mexico. Health care providers and clients greatly overestimated the negative health effects of EC, although clients overwhelmingly reported that they would use or recommend it if needed. Although providers typically advocated medically controlled distribution, clients believe EC should be more widely available, including in schools and vending machines, with information prevalent in the mass media and elsewhere.

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PIP: The new life of a human being begins at the moment of fertilization, i.e. when an ovum and a sperm join together. From this moment on the fertilized egg has the capacity to achieve its complete development whether or not nidation takes place. Abortion means interruption of pregnancy through death of the fetus. Postcoital contraceptive agents are not contraceptive agents but abortifacient agents, since they intervene on an already fertilized egg. Spontaneous abortions have usually pathological reasons, as do early deliveries. The majority of the so called therapeutic abortions are really induced abortions disguised under another name; the cases in which a new pregnancy can really be detrimental to the mother are, these days, extremely rare, and psychiatric indications for abortion are mostly excuses to free a woman from an unwanted pregnancy. Moreover, it is precisely the mothers who have sought an abortion who often become affected by serious psychological problems. Contraceptive agents must be distinguished according to their mechanism of action; those which are really anovulatory agents, and those which are antiimplantation agents, and, as such, abortifacient agents. The mechanism of action of OCs (oral contraceptives) does inhibit ovulation; at times, however, it inhibits implantation either by modifying tubal or uterine contractility, or by causing endometrial changes. In this case even OCs are abortifacient agents. The mechanism of action of all types of IUDs always leads to inhibition of nidation by modification of endometrial functions; as such, any IUD is an abortifacient agent. As international statistics can demonstrate the widespread use of contraception has not diminished the number of abortions; on the contrary the number has increased enormously. Obviously the step from contraception to abortion in case of contraception failure is a very short one.^ieng

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PIP: The results of 2 studies on the use of high doses of progestins as postcoitum contraceptives are reported. 1 of the studies was carried out in Peru and involved 4632 women, treated for 41,802 months with single doses of 150, 250, 300, 350, and 400 mcg of D-Norgestrel, administered within 3 hours postcoitum (the doses were administered to 28, 699, 544, 559, and 2801 women, respectively). 165 unwanted pregnancies were reported; their incidence was higher among women treated with the smaller doses. The most important side effects were changes in the duration of the cycle; spotting was present in 10% of the cases and independent of the dose; liver disorders, thromboembolic accidents and breast pains were absent; treatment had to be suspended because of side effects in 5-8% of the cases. The 2nd study was carried out in Chile and involved 136 fertile women for 184 months, treated with 3 different progestins. A total of 5 pregnancies were reported and the treatment was well tolerated by all patients. Generally, it is concluded that these 1st studies suggest that high doses of progestins are effective and well tolerated postcoitum contraceptives, and side effects are less frequent and serious than those produced by estrogen preparations.^ieng

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PIP: The observation that estrogens in sufficient dosage given postcoitally may prevent implantation of the ovum have led to studies regarding practical clinical application. Estrogens that appear effective in humans include stilbestrol and ethinyl estradiol orally and estrone parenterally. Mestranol should also be effective as well as ORF-3858. Any estrongenic substance in sufficient dosage would probably prevent implantation. Effective period of administration is only between time of fertilization and implantation or 4 to 6 days following coitus. Test dosages have been 25-50 mg stilbestrol or .5-2 mg esthinyl estradiol daily for 5 days. It is now considered that 2-5 mg ethinyl estradiol would be more effective. In over 100 midcycle exposures there have been no pregnancies. Others have reported failures with inadequate dosage. Injectable estrone, 2-20 mg on alternate days for 3 doses, has also been reported effective. The process of implantation is discussed. Endometrial biopsies have usually revealed a "retarded endometrium," a possible mode of action. Side effects have been those usually associated with estrogens: nausea, vomiting, breast soreness, prolonged menses.^ieng

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