Emergency Contraception: In Law, In Practice

EllaOne: An available form of UPA in Italy

            Timely and convenient access to healthcare and pharmaceuticals is always important, and is especially vital to emergency contraception (EC) usage rates and efficacy. Intrauterine EC is available in the form of the copper-T IUD inserted up to 5 days after estimated date of ovulation, but despite this method’s higher efficacy, it is less convenient because it requires placement by a skilled healthcare provider (Cameron, 2017). This leaves oral EC (either levonorgestrel [LNG] or ulipristal acetate [UPA]) the obvious choice for quick and convenient access, a must in an emergency situation following unprotected sex. The European Medicines Authority believed so as well, and in 2015 recommended both forms of oral EC be made available without a prescription throughout Europe (ECEC, 2015). Italy obliged, and currently one brand of LNG and all brands of UPA are available over the counter for women over the age of 18, costing approximately 15 to 30 euro (ECEC, 2015), in some cases cheaper than the 30 to 65 dollar price tag in the United States (Kaiser Family Foundation, 2015). On paper, the drug appears accessible.

Logo of Obiezione Respinta
(Rejected Objection).
Text below: Map the objectors!

Unfortunately, translating emergency contraception policy to practice tells a different story. Widespread misunderstanding of the mechanism by which these pills prevent pregnancy has led women, their family and friends, and even some doctors to believe that EC has an abortive rather than preventative effect, which does not play well with the strong Catholic influence on Italy’s culture and policies (Bo, Casagranda, Charrier, & Gianino, 2012; Bo, Casagranda, Galzerano, Charrier, & Gianino, 2011; Nappi, Lobo Abascal, Mansour, Rabe, & Shojai, 2014). In one study, 19% of Italian women reported not using emergency contraception because they considered it to be like an abortion (Nappi et al., 2014). Pharmacists and doctors may not see prescribing emergency contraception as being within the scope of their job or would prefer not to on moral grounds, and thus sometimes choose not to dispense EC to women who ask for it (Bo et al., 2012, 2011). In fact, this has become such a common experience for women that networks have emerged to help women find which locations will actually dispense EC. An example is Obiezione Respinta (https://obiezionerespinta.info/), which offers an interactive map where women can report both successful and unsuccessful attempts to obtain EC throughout Italy.

Unfortunately, the barriers do not stop here. In a 2017 news report on research conducted by the SWG-Health Communication of over 500 Italian women, 79% were not aware of the 2015 law change removing the requirement of a prescription for EC (“Pillola 5 giorni dopo senza ricetta, ma solo 1 su 5 lo sa,” 2017). This simple but massive marketing error has likely led many women on wild goose chases for unnecessary prescriptions, which is especially concerning considering many sexual encounters occur around the weekend when fewer healthcare providers may be available to prescribe the drug (and that is, of course, if you can even find one who approves of its use).

Yes, it is legal to purchase EC over the counter in Italy without a prescription if you are over 18 years old, but the truth is more complicated than that. Women may feel it is morally wrong, or that they may be judged by friends and family for taking it. Lack of accurate and accessible information regarding safe usage may lead to women not knowing when or how to safely use EC. Finally, even once the decision has been made to obtain EC, barriers remain despite the deregulation of prescriptions. Some women do not know they do not need a prescription, and even those who do know may be denied access at pharmacies or hospitals, increasing the inconvenience and time taken to locate the pill, and running the risk of missing the vital 5-day window for pregnancy prevention. Opportunities abound for improved public health messaging to provide accurate, accessible information to women and their healthcare providers to ensure that emergency contraception is safely and effectively utilized.

This post was written by Sydney Rivera, a Master of Public Health 4+1 student from Indianapolis, Indiana. Her research interests include contraception, pregnancy, and patient-provider relationships, as she intends to go to medical school to become an OB-GYN.

Bo, M., Casagranda, I., Charrier, L., & Gianino, M. M. (2012). Availability of emergency contraception: A survey of hospital emergency department gynaecologists and emergency physicians in Piedmont, Italy. The European Journal of Contraception & Reproductive Health Care, 17(5), 373–382. https://doi.org/10.3109/13625187.2012.692410

Bo, M., Casagranda, I., Galzerano, M., Charrier, L., & Gianino, M. M. (2011). Emergency Contraception: a survey of Hospital Emergency Departments Staffs. Emergency Care Journal, 7(1), 10–15.

Cameron, S. (2017). Emergency Contraception. In Frontiers in Gynecological Endocrinology (pp. 189–198). Springer, Cham. https://doi.org/10.1007/978-3-319-41433-1_13

ECEC. (2015, November). Italy. Retrieved July 30, 2017, from http://www.ec-ec.org/emergency-contraception-in-europe/country-by-country-information-2/italy/

Kaiser Family Foundation. (2015, August 5). Emergency Contraception. Retrieved July 30, 2017, from http://www.kff.org/womens-health-policy/fact-sheet/emergency-contraception/

Nappi, R. E., Lobo Abascal, P., Mansour, D., Rabe, T., & Shojai, R. (2014). Use of and attitudes towards emergency contraception: A survey of women in five European countries. The European Journal of Contraception & Reproductive Health Care, 19(2), 93–101. https://doi.org/10.3109/13625187.2013.865164

Pillola 5 giorni dopo senza ricetta, ma solo 1 su 5 lo sa. (2017, May 24). AdnKronos. Retrieved from http://www.adnkronos.com/salute/farmaceutica/2017/05/24/pillola-giorni-dopo-senza-ricetta-solo_cEuQcONmolBIqWzFUhe3RL.html