Emergency Contraception Knowledge Attitudes and Practices by alicejenny

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									Emergency Contraception: Knowledge, Attitudes and
Practices Among Brazilian Obstetrician-Gynecologists
By Loren Galvão, Juan Díaz, Margarita Díaz, Maria José Osis, Shelley Clark and Charlotte Ellertson




                                                                                                                regimen using regular oral contraceptives.
Context: In Brazil, where emergency contraception could play a critical role in reducing un-                    A number of pills potentially suitable for
wanted pregnancies, the government has included the method in its family planning guidelines.                   use as emergency contraception are avail-
Yet, little is known about its availability and provision.                                                      able on the market (Table 1). However, be-
                                                                                                                cause the various brands contain different
Methods: A nationally representative, randomly selected sample of 579 Brazilian obstetrician-
gynecologists responded to a 1997 mail-in survey on emergency contraception. The data yield
                                                                                                                dosages of active ingredients, they require
information on these providers’ knowledge about, attitudes toward and practices regarding emer-
                                                                                                                different numbers of tablets to create a com-
gency contraception.
                                                                                                                plete course of emergency contraception
                                                                                                                therapy, and this makes the method con-
Results: Nearly all respondents (98%) had heard of emergency contraception, but many lacked                     fusing for women. Furthermore, although
specific knowledge about the method. Some 30% incorrectly believed that emergency contra-                        pills are sold over the counter, obstetrician-
ception acts as an abortifacient, and 14% erroneously believed that it was illegal. However, 49%
                                                                                                                gynecologists play a critical role in inform-
of physicians who thought that the method induces abortion (which is largely illegal in Brazil)
                                                                                                                ing their clients about emergency contra-
and 46% of those who thought that emergency contraception was itself illegal have provided it
                                                                                                                ception and in educating the public about
to clients. Most surprisingly, while 61% of respondents report having provided emergency con-
                                                                                                                the proper regimens. Presumably, even with
traception, only 15% of these physicians could correctly list the brand name of a pill they pre-
                                                                                                                a dedicated product available over the
scribed, the dosage and regimen, and the timing of the first dose.
                                                                                                                counter, obstetrician-gynecologists will con-
Conclusions: Educational efforts that focus on specific prescription information and the intro-                  tinue to play a crucial role as educators.
duction of a dedicated product would greatly improve women’s access to this method in Brazil.                      Since obstetrician-gynecologists play a
                      International Family Planning Perspectives, 1999, 25(4):168–171 & 180                     pivotal role in disseminating information
                                                                                                                about new reproductive technologies and
                                                                                                                providing family planning methods, par-


E
       mergency contraceptives are meth-                       traception as part of their routine services.4   ticipants at the national meeting recom-
       ods that women can use after inter-                        In Brazil, where 26% of births in the early   mended conducting a survey to assess
       course to prevent an unwanted preg-                     1990s were unplanned and 22% were un-            their knowledge, attitudes and practices
nancy. Several methods of emergency                            wanted,5 emergency contraception could           regarding emergency contraception, and
contraception are safe and effective, in-                      play an important role by averting preg-         to define the best strategies to improve ac-
cluding combined hormonal contraceptives                       nancies attributable to contraceptive failure,   cess to this method.
taken in a dose higher than is used for reg-                   nonuse of contraceptives, lack of knowledge
ular contraception (the Yuzpe method*) and                     about or access to methods, or coercive sex.     Methodology
insertion of a copper IUD.1 Another hor-                       It also could reduce levels of unsafe abor-      In August 1997, we conducted a mail-in sur-
monal emergency contraceptive method,                          tion. In 1991, an estimated 1.4 million          vey of members of the Brazilian Federation
the levonorgestrel-only regimen, has been                      women in Brazil had an abortion, and many        of Societies of Gynecology and Obstetrics
widely tested, with excellent results.2 In ad-                 of these procedures were unsafe.6                (FEBRASGO). More than two-thirds of the
dition to preventing pregnancy, emergency                         Recognizing the potential contribution of     nation’s obstetrician-gynecologists belong
contraception can serve as a bridge into the                   emergency contraceptive methods, in March        to FEBRASGO, so this study provides a fair-
health care system and a way to obtain an                      1996, Brazil’s Ministry of Health convened
ongoing contraceptive method for women                         a national meeting, in collaboration with the    Loren Galvão is program associate, and Juan Díaz is se-
                                                                                                                nior program associate, Population Council, Campinas,
who do not have one.3 The World Health                         Population Council, to discuss this issue.       Brazil; Margarita Díaz is director of the Department of
Organization recommends that reproduc-                         The main conclusions were that emergency         Education and Communication in Sexual and Repro-
tive health services offer emergency con-                      contraception should be included in the          ductive Health, and Maria José Osis is director of so-
                                                               ministry’s official family planning program       ciomedical research, Center for Research and Control of
*The Yuzpe method consists of 200 mcg of ethinyl estra-                                                         Maternal and Child Diseases, Campinas, Brazil; Shelley
                                                               guidelines; that educational and dissemi-
diol and 1.0 mg of levonorgestrel (or 2.0 mg of norgestrel),                                                    Clark is staff program associate, Population Council, New
usually dispensed as four combined estrogen-progestin
                                                               nation activities should be developed for the    York; and Charlotte Ellertson is director of reproductive
oral contraceptive tablets; two pills are taken within 72      general public and health providers; and         health for Latin America and the Caribbean, Population
hours of unprotected intercourse, and the remaining two        that additional research was needed about        Council, Mexico City. This study was conducted with the
are taken 12 hours later. (Source: Ellertson C, History and    emergency contraception in the context of        support of the U.S. Agency for International Develop-
efficacy of emergency contraception: beyond Coca-Cola,                                                           ment, the William and Flora Hewlett Foundation and the
International Family Planning Perspectives, 1996, 22(2):
                                                               Brazil.7 In March 1997, the Yuzpe regimen        Robert H. Ebert Program. The authors thank the Brazil-
52–56.) When the exact types of pills to make the Yuzpe        of emergency contraception was included          ian Federation of Societies of Gynecology and Obstet-
regimen are not available, providers may substitute            in the family planning program guidelines.8      rics for its logistical support in the study implementa-
tablets containing 240 mcg of ethinyl estradiol and 1.2           Although a levonorgestrel-only dedi-          tion; Schering/Brazil for providing the prize that was
mg of levonorgestrel, administered in two doses of four                                                         used as an incentive to participate in the survey; Bever-
pills each, taken 12 hours apart. (Source: Hatcher R et al.,
                                                               cated emergency contraceptive became             ly Winikoff and Martha Brady for technical support dur-
eds., Contraceptive Technology, 17th ed., New York: Ar-        available in Brazil in July 1999, at the time    ing the planning stages of the study; and the survey par-
dent Media, 1998.)                                             of the survey, women had to make up the          ticipants.


168                                                                                                                  International Family Planning Perspectives
                                                                                           (96% reported their gen-    spondents (4%) mentioned other methods,
Table 1. Characteristics of selected brands of oral contraceptives
available in Brazil that can be used for emergency contraception
                                                                                           der, and at least 98% all   such as mifepristone and danazol, which
                                                                                           other characteristics).     are less widely available.
Brand (and manufacturer)            Pills per Hormonal content per dose                    Among those who re-            The vast majority of respondents (66%)
                                    dose
                                                Ethinyl        Levonor-      dl-           ported their gender, 63%    correctly indicated that emergency con-
                                                estradiol      gestrel       norgestrel    were male. Sixty-four       traception prevents pregnancy. Howev-
                                                (µg)           (µg)          (µg)
                                                                                           percent of respondents      er, 15% incorrectly thought that it induces
Anfertil (Wyeth-Ayerst)             2           100            0.0           1.0           lived in the country’s      abortion. Notably, respondents could in-
Primovlar (Schering AG)             2           100            0.0           1.0           southeastern      region,   dicate more than one mechanism of ac-
Evanor (Wyeth-Ayerst)               2           100            0.5           0.0
Neovlar (Schering AG)               2           100            0.5           0.0           which is the most highly    tion, and 15% believed that emergency
Microvlar (Schering AG)             4           120            0.6           0.0           developed and populat-      contraception both prevents pregnancy
Nordette (Wyeth-Ayerst)             4           120            0.6           0.0           ed region and includes      and induces abortion. Only 3% said that
Note: The complete emergency contraception regimen consists of two doses taken 12 hours
                                                                                           the largest cities, São     they did not know how the method
apart, and started as soon as possible, but within 72 hours after unprotected intercourse. Paulo and Rio de Janeiro.   works. (Although several possible mech-
Source: International Planned Parenthood Federation (IPPF), Directory of Hormonal Con-
traceptives, third ed., London: IPPF, 1996.
                                                                                           An additional 16% lived     anisms of action are being investigated,
                                                                                           in the southern region,     research shows that emergency contra-
                                                                                           which is characterized by   ception acts by preventing pregnancy and
ly representative sample of all obstetrician- a large European immigrant population                                    cannot interrupt an established pregnan-
gynecologists in Brazil.                                            and small-scale industry and farms. Only           cy, which the National Institutes of
    A structured questionnaire, including 20% came from the poorer and less-popu-                                      Health10 and the American College of Ob-
closed- and open-ended questions, asked lated northeastern and center-northern re-                                     stetricians and Gynecologists11 define as
physicians about their knowledge, atti- gions. The sample is unbiased with respect                                     beginning with implantation. The
tudes and practices regarding emergency to sex, but there are significant regional dif-
contraception. Population Council staff in ferences between respondents and nonre-                                     Table 2. Among obstetrician-gynecologists
Brazil, in collaboration with the Center of spondents. Physicians who did not return                                   who have heard of emergency contraception,
Maternal and Child Health of Campinas the survey were less likely than respon-                                         percentage who know about various aspects
                                                                                                                       of the method, Brazil, 1997 (N=567)
(CEMICAMP), prepared and pretested the dents to live in the southeast (54%) and
questionnaire. Results from the pretest are more likely to live in the northeastern and                                Aspect                                                     %
not included in the analysis.                                       center-northern regions (30%).                     Methods used for emergency contraception
    We randomly selected 10% of FEBRAS-                                One-fifth (21%) of respondents had fewer         Combined pill                                              87.6
GO’s members (1,003 health care providers) than 10 years of professional work experi-                                  IUD                                                        25.9
                                                                                                                       Estrogen-only pill                                         19.2
to participate in the survey. FEBRASGO ence, while nearly half (47%) had 11–20                                         Progestogen-only pill                                      15.3
mailed these physicians a questionnaire, years; 24% had 20–30 years, and 9% had                                        Monthly injectable*                                         3.7
                                                                                                                       Three-month injectable*                                     1.8
along with a letter explaining the objectives more than 30 years. Some 56% of respon-                                  Other                                                       4.4
of the research and guaranteeing anonymi- dents worked in state capitals, 37% worked                                   None                                                        3.9
ty, and a prepaid return envelope addressed in other cities or rural areas, and 7% worked
                                                                                                                       Mechanism of action
to FEBRASGO. Because mailed question- in both state capitals and other cities.                                         Prevents pregnancy                                         66.2
naires have inherent limitations, to boost the                         Respondents who replied to the initial          Induces abortion                                           14.8
                                                                                                                       Prevents pregnancy and induces abortion                    15.3
response rate, we applied the total design round of surveys were slightly but sig-                                     Don’t know                                                  3.0
method:9 We sent a second and, if necessary, nificantly more likely to have heard of
third mailing to nonrespondents; after the emergency contraception than were those                                     Legal status
                                                                                                                       Legal, not included in government
third mailing, we attempted to reach non- who needed to be prompted by a third                                            family planning guidelines                              37.0
respondents by telephone. As an incentive round of surveys (98% vs. 92%; p=.02).                                       Illegal                                                    14.1
to participate, we informed potential re- This finding suggests that our results may                                    Legal, included in government
                                                                                                                          family planning guidelines                              11.6
spondents that at the end of the study, one overestimate obstetrician-gynecologists’                                   Don’t know                                                 37.3
respondent would be randomly selected to knowledge of this method.
                                                                                                                       Best candidates
receive a prize (a computer and printer).                                                                              Any women who have had
    Research staff reviewed each question- Knowledge and Attitudes                                                       unprotected intercourse                                  71.3
naire, coded the open-ended questions Awareness of the concept of emergency                                            Adolescents                                                46.4
                                                                                                                       Women who have infrequent intercourse                      35.7
and assessed if the questionnaire had been contraception was virtually universal; only                                 Inconsistent method users                                  26.1
answered seriously. Fewer than 1% of 2% of respondents had never heard of it.                                          Women with multiple partners                                9.2
completed questionnaires were rejected. All respondents who were familiar with                                         Perimenopausal women                                        9.1
                                                                                                                       Other                                                      15.5
Data from accepted questionnaires were emergency contraception were queried as
entered twice, using a data entry program to their knowledge about the method and                                      Situations appropriate for use
                                                                                                                       Rape                                                       91.2
based on SPSSPC-DE. The data were an- their attitudes toward its use (Table 2).                                        Condom breakage                                            82.1
alyzed using SPSSPC.                                                   Of those who knew of emergency con-             Unprotected intercourse                                    75.9
                                                                    traception, 88% were aware that combined           Missed pills                                               38.0
                                                                                                                       Infrequent sexual activity                                 24.8
Results                                                             pills could be used for this purpose, and          Other                                                       7.4
Sample                                                              26% knew that insertion of an IUD after            None                                                        3.7
A total of 579 valid questionnaires were re- intercourse could prevent pregnancy. Es-                                  *Effectiveness is unsubstantiated. Notes: Ns varied negligibly be-
ceived, yielding a response rate of 58%. Vir- trogen-only and progestogen-only pills                                   cause not all respondents who were familiar with emergency con-
                                                                                                                       traception answered all questions. For some questions, respon-
tually all respondents provided informa- were also mentioned often (19% and 15%,                                       dents could indicate more than one answer.
tion about their background characteristics respectively). A small proportion of re-

Volume 25, Number 4, December 1999                                                                                                                                                  169
Emergency Contraception in Brazil

                                                                       Three-quarters of respondents (76%) be-      Yuzpe regimen (Table 3). Almost half (43%)
Table 3. Among obstetrician-gynecologists
who have prescribed emergency contracep-
                                                                    lieved that emergency contraception is ap-      gave the correct name of a pill but failed
tion, percentage who have prescribed the                            propriate after any act of unprotected in-      to give the correct dosage and timing of the
method in certain situations, and percentage                        tercourse. Nearly all respondents (91%)         first dose. About one-third (36%) provid-
distribution, by accuracy in describing the reg-                    felt that this method should be used in         ed the correct name and regimen but gave
imen (N=353)                                                        cases of rape, and 82% believed that it         an inaccurate answer for the timing of the
Measure                                                  %          should be used if a condom breaks.              initial dose. The majority of providers in-
Situations in which physician has prescribed
                                                                       To further examine knowledge and atti-       correctly thought that emergency contra-
Unprotected intercourse                                    75.4     tudes about the prescription of emergency       ception must be given within 24 hours
Condom breakage                                            60.9     contraception, the survey asked physicians      after intercourse. This confusion may stem
Rape                                                       22.7
Missed pills                                               15.6     how they would respond to the following         from the common usage of the term
Other                                                       4.8     hypothetical situation: An adolescent arrives   “morning-after pill,” which implies that
Don’t remember                                              1.4
                                                                    for an appointment, saying that she had un-     the method should be taken the next morn-
Description of regimen                                              protected intercourse two days ago; she does    ing. A scant 2% gave completely incorrect
Only name of pill was correct                   42.8                not want to become pregnant and asks the        answers, while 4% did not answer the
Name and dose were correct                      36.3
Name, dose and timing of first dose were correct 14.7                doctor for guidance about how to prevent        question or mentioned only the IUD.
Not mentioned                                    4.0                a pregnancy. Providers were given a list of        In general, physicians’ knowledge, at-
Completely wrong                                 2.3
Total                                          100.0                alternatives and were asked to select one or    titudes and practices did not differ sig-
                                                                    more ways to advise this young woman.           nificantly by their sex, region or residence.
Note: Respondents could indicate more than one situation in which
they have prescribed emergency contraception.
                                                                       The majority would give advice on how        However, women were significantly more
                                                                    to use emergency contraception. About           likely than men to give a completely cor-
                                                                    one-third (36%) identified the two correct       rect prescription for hormonal emergency
method’s ability to inhibit or delay ovu-                           descriptions of the Yuzpe regimen listed,       contraception (20% vs. 11%; p<.05).
lation has been demonstrated in several                             and 22% selected one of the two correct sin-       Considerable discrepancies exist between
clinical trials12 and is an important mech-                         gle-hormone regimens described; 8% in-          beliefs about emergency contraception and
anism of action if emergency contracep-                             dicated that they would insert an IUD. Ex-      actual practices. For example, not under-
tion is used during the first half of the                           pressions of negative attitudes toward          standing the correct mechanism of action
menstrual cycle, before ovulation has oc-                           giving emergency contraception to this          does not imply an unwillingness to pre-
curred. Some clinical studies suggest that                          adolescent were rare: Seven percent of          scribe emergency contraception: Forty-nine
emergency contraception may make the                                physicians agreed with the statement “I         percent of doctors who believe that emer-
endometrium less receptive to the im-                               would not do anything because I am              gency contraception acts as a means of abor-
plantation of a fertilized egg,13 although                          against abortion,” and 3% indicated that        tion provide it, even though abortion is
others have not found any effect on the en-                         they would “give [her] a serious reprimand      legally restricted in Brazil. Either these doc-
dometrium.14 In addition, emergency con-                            and would tell her to come back for con-        tors disregard the Brazilian abortion law
traception may prevent pregnancy by in-                             traceptives, if she did not get pregnant.”      and provide what they incorrectly consid-
terfering with corpus luteum function;                                                                              er abortions, or they draw a distinction be-
thickening the cervical mucus; altering the                         Prescribing Emergency Contraception             tween emergency contraception and abor-
tubal transport of sperm, egg or embryo;                            Despite providers’ largely favorable atti-      tions. Moreover, only 16% of physicians
or directly inhibiting fertilization.15)                            tudes toward emergency contraception,           who think that emergency contraception in-
   Many respondents (37%) did not know                              they seldom inform their clients about this     duces abortion stated that they would never
the legal status of emergency contracep-                            method or prescribe it. Of all physicians       provide it for that reason. Similarly, nearly
tion in Brazil. An additional 37% believed                          who responded to the survey, only 11%           half (46%) of physicians who believe that
that it was legal but not included in the na-                       said that they inform all their female          the method is illegal have prescribed it—a
tional family planning guidelines, and 14%                          clients. Some 43% give information about        considerable proportion, albeit much lower
answered that the method was illegal.                               emergency contraception only when               than the proportion among providers who
Only 12% correctly answered that emer-                              clients request it, and 41% do not usually      know that it is legal (71%).
gency contraception was legal and in-                               inform their clients. More than half (61%)
cluded in the family planning guidelines.                           have prescribed emergency contraception,        Discussion
   When asked to identify all appropriate                           mostly hormonal methods; fewer than 1%          Our survey followed on the heels of sev-
candidates for emergency contraception,                             mentioned IUDs. In the last year, 75% of        eral major initiatives to inform health care
71% of physicians who had heard of the                              these providers had prescribed emergency        providers about emergency contraception.
method declared that it should be offered                           contraception for women who had had             A few months before the survey, the pro-
to any woman who had had unprotected                                unprotected intercourse, and 61% for            ceedings from a national meeting on
intercourse; 46% specifically mentioned                              women who reported condom breakage              emergency contraception were published
adolescents. Providers noted that women                             (Table 3). Rape was also a common reason        in FEBRASGO’s official journal,16 which
who engage in intercourse infrequently or                           for prescribing it (23%).                       is distributed free to all its members, and
who use contraceptives inconsistently (for                             Physicians who have provided emer-           another highly circulated scientific jour-
example, women who forget to take oral                              gency contraception were asked the com-         nal.17 In addition, many physicians and in-
contraceptives) would be likely candi-                              mercial name of the hormonal contracep-         stitutions throughout Brazil received the
dates for emergency contraception. Re-                              tive they have prescribed, the dose and         government’s family planning guidelines,
spondents also had the option to describe                           regimen prescribed, and the timing of the       which included guidelines on emergency
“other” candidates and most frequently                              first dose after intercourse. Only 15% gave      contraception.
mentioned women who have been raped.                                a completely correct prescription for the          These dissemination efforts may partly

170                                                                                                                     International Family Planning Perspectives
explain the high proportions of respondents     who may offer emergency contraception.                     6. Alan Guttmacher Institute (AGI), An overview of clan-
                                                                                                           destine abortion in Latin America, Issues in Brief, New
to our survey who had heard of emergency        Also, since women in Brazil are often able
                                                                                                           York: AGI, 1996, pp. 1–6.
contraception and who knew how it works.        to buy oral contraceptives over the
                                                                                                           7. Lebardone A et al., A anticoncepção de emergência:
Nonetheless, many physicians held inac-         counter without consulting a physician or
                                                                                                           um grupo de consulta para o seu uso no Brasil, Femina,
curate beliefs about the method and its legal   other health care provider, studies that                   1996, 24(6):567–570.
status, and lacked specific knowledge about      evaluate the knowledge and attitudes of
                                                                                                           8. Ministério da Saúde, Normas para a Assistência ao Plane-
the correct prescription.                       pharmacists, as well as pilot studies of                   jamento Familiar, Brasília: Ministério da Saúde, 1996, pp.
   Although this survey did not ask             clear and adequate instructions for con-                   121–125.
providers about their awareness and recall      sumers, could greatly enhance awareness                    9. Dillman DA, Mail and other self-administered ques-
of recent publications on emergency con-        of and access to emergency contraception.                  tionnaires, in: Rossi PH, Wright JD and Anderson AB,
traception, the abundance of misinforma-           Finally, given the scant knowledge about                eds., Handbook of Survey Research, Orlando, FL, USA: Aca-
                                                                                                           demic Press, 1983, pp. 359–377; Dillman DA, Mail and
tion evident in their responses calls into      the correct prescription of the currently
                                                                                                           Telephone Surveys: The Total Design Method, New York:
question the adequacy of traditional in-        available pills, the recent introduction of a              Wiley-Interscience, 1978; and Dillman DA et al., In-
formation dissemination systems to change       dedicated product in Brazil could greatly                  creasing mail questionnaire response: a four state com-
attitudes and ensure high-quality practices.    improve women’s access to safe and effec-                  parison, American Sociological Review, 1974, 39(5):744–756.
Obstetrician-gynecologists clearly require      tive emergency contraception. Although the                 10. 45 CFR 46.203.
additional education on several aspects re-     ultimate impact of this dediated product is                11. Hughes EC, ed., Obstetric-Gynecologic Terminology,
lated to emergency contraception in Brazil.     yet to be determined, such a product may                   Philadelphia, PA, USA: F.A. Davis Co., 1972.
These interventions should also aim to de-      also help decrease the number of unwant-                   12. Swahn ML et al., Effect of post-coital contraceptive
bunk myths and allay concerns about the         ed or unplanned pregnancies and subse-                     methods on the endometrium and the menstrual cycle, Acta
method. For example, studies from other         quent abortions, reduce the hospital costs                 Obstetrica et Gynecologica Scandinavica,1996,75(8):738–744;
countries clearly indicate that women are       associated with abortion complications and                 Ling WY et al., Mode of action of dl-norgestrel and
                                                                                                           ethinylestradiol combination in postcoital contraception,
not likely to “misuse” emergency contra-        act as a bridge to reproductive health ser-                Fertility and Sterility, 1979, 32(3):297–302; and Rowlands S
ception or substitute it for their regular      vices. International experience suggests that              et al., A possible mechanism of action of danazol and an
method; a landmark study revealed that          approval of specially packaged and labeled                 ethinylestradiol/norgestrel combination used as postcoital
Scottish women who were given the ther-         emergency contraceptive pills with clear in-               contraceptive agents, Contraception, 1986, 33(6):539–545.

apy to keep on hand in case of need were        structions for providers and clients helps le-             13. Ling WY et al., 1979, op. cit. (see reference 12); Kubba
no more likely to use it repeatedly than        gitimize the method; makes existing regi-                  AA et al., The biochemistry of human endometrium after
                                                                                                           two regimens of postcoital contraception: a dl-
women who had to go to the clinic to get        mens much easier to administer and use;                    norgestrel/ethinylestradiol combination or danazol, Fer-
the pills when they were needed.18              and promotes safe, effective and appropri-                 tility and Sterility, 1986, 45(4):512–516; Ling WY et al.,
   Educational campaigns should em-             ate use.19 Furthermore, by widely advertis-                Mode of action of dl-norgestrel and ethinylestradiol com-
phasize that no evidence indicates that this    ing their commercial products, companies                   bination in postcoital contraception. II. Effect of pos-
                                                                                                           tovulatory administration on ovarian function and en-
method is unsafe even when women use            can help inform the public about this con-                 dometrium, Fertility and Sterility, 1983, 39(3):292–297; and
it repeatedly. Emergency contraception          traceptive option.                                         Yuzpe AA et al., Post coital contraception—a pilot study,
pills have a very short duration of expo-          Educational interventions that reach all                Journal of Reproductive Medicine, 1974, 13(2):53–58.
sure, and their total hormone content is far    health professionals, further studies on the               14. Swahn ML et al., 1996, op. cit. (see reference 12); and
lower than the estrogen levels experienced      provision of emergency contraception and                   Taskin O et al., High doses of oral contraceptives do not alter
during pregnancy. Physicians should also        the widespread availability of a dedicated                 endometrial α1 and αν-β3 integrins in the late implanta-
                                                                                                           tion window, Fertility and Sterility, 1994, 61(5):850–855.
be encouraged to inform all potential           product would significantly improve the
users about emergency contraception and         quality of reproductive health services by                 15. Glasier A, Emergency postcoital contraception, New
                                                                                                           England Journal of Medicine, 1997, 337(15):1058–1064; and
be willing to prescribe the method to all       offering this method in the context of free                Ling WY et al., Mode of action of dl-norgestrel and
women, including adolescents, in need of        and informed choice. Our study shows that                  ethinylestradiol combination in postcoital contraception.
a postcoital contraceptive. Finally, edu-       obstetrician-gynecologists in Brazil are pre-              III. Effect of preovulatory administration following the
cational interventions should be evaluat-       pared to support expanded access to emer-                  luteinizing hormone surge on ovarian steroidogenesis,
                                                                                                           Fertility and Sterility, 1983, 40(5):631–636.
ed after their implementation to help           gency contraception, but will need further
identify effective ways to disseminate in-      information to do this well.                               16. Lebardone A et al., 1996, op. cit. (see reference 7).
formation to obstetrician-gynecologists on                                                                 17. Lebardone A et al., Relatório final da I oficina
the use of the Yuzpe regimen with the cur-      References                                                 Brasileira sobre a anticoncepçaõ de emergência: um
                                                1. Berer M et al., Consensus statement on emergency con-   grupo de consulta para o seu uso no Brasil, Reprodução
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                                                                                                           18. Glasier A and Baird D, The effects of self-adminis-
traception would aid the development of         2. World Health Organization Task Force on Postovu-
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these educational interventions. The re-                                                                   Medicine, 1998, 339(1):1–4.
                                                trolled trial of levonorgestrel versus the Yuzpe regimen
sults of this study suggest a couple of areas   of combined oral contraceptives for emergency contra-      19. Senanayake P, Emergency contraception: the Inter-
that require further investigation. For ex-     ception, Lancet, 1998, 352(9126):428–433.                  national Planned Parenthood Federation’s experience,
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                                                3. Grossman RA and Grossman BD, How frequently is
cantly more likely than their male coun-        emergency contraception prescribed? Family Planning
                                                                                                           69–70.
terparts to prescribe the Yuzpe regimen         Perspectives, 1994, 26(6):270–271.
accurately. This issue deserves further ex-     4. Van Look P and Von Hertzen H, Emergency contra-
                                                                                                           Resumen
ploration and special attention when ed-        ception, British Medical Bulletin, 1993, 49(1):158–170.    Contexto: En Brasil, donde la anticoncepción
ucational strategies are being designed.                                                                   de emergencia podría jugar un importante
                                                5. Sociedade Civil Bem-Estar no Brasil (BEMFAM) and
Furthermore, it would be advisable to ex-       Macro International, Pesquisa Nacional Sobre Demografia     papel en la reducción de los embarazos no de-
amine the knowledge and practices of            e Saúde, 1996, Rio de Janeiro, Brazil: BEMFAM; and         seados, el gobierno ha incluido este método en
other health providers, such as nurses,         Calverton, MD, USA: Macro International, 1997.                                               (continued on page 180)

Volume 25, Number 4, December 1999                                                                                                                                   171
Emergency Contraception in Brazil

Emergency Contraception…                           gal. Más sorprendente aún, resultó que en            tion d’urgence. Les données recueillies ren-
(continued from page 171)                          tanto que el 61% de todos los entrevistados in-      seignent sur les connaissances, les attitudes
                                                   dicaron que habían recetado la anticoncepción        et les pratiques de ces prestataires à l’égard de
sus normas sobre planificación familiar. Sin        de emergencia, solamente el 15% de ellos po-         ce type de contraception.
embargo, se sabe muy poco acerca de la dispo-      dían indicar en forma correcta la marca de la        Résultats: Presque tous les répondants (98%)
nibilidad y provisión de este método.              píldora que habían recetado, la dosis, el régi-      avaient entendu parler de la contraception
Métodos: Una muestra representativa a nivel        men y el momento en que las pacientes debí-          d’urgence, mais beaucoup n’en possédaient pas
nacional que fue seleccionada en forma alea-       an tomar la primera dosis.                           une connaissance spécifique. Environ 30%
toria constó de 579 obstetras y ginecólogos bra-   Conclusiones: Podría mejorar en gran forma           croyaient, à tort, qu’il s’agissait d’une méthode
sileños; dichos médicos respondieron a una en-     el acceso de la mujer al considerado método en       abortive, et 14% pensaient, à tort aussi, qu’elle
cuesta sobre anticoncepción de emergencia,         el Brasil si se introduce en el país un produc-      était illégale. Quarante-neuf pour cent des mé-
realizada por correo en 1997. Los datos apor-      to determinado para fines de anticoncepción           decins selon lesquels la méthode provoquait un
taron información acerca de su conocimiento,       de emergencia, y se realizaran trabajos de edu-      avortement (généralement illégal au Brésil) et
sus actitudes y sus prácticas relacionadas con     cación para informar a los profesionales sobre       46% de ceux selon lesquels la contraception
la anticoncepción de emergencia.                   cómo recetar el método.                              d’urgence était en soi illégale l’avaient toute-
Resultados: Casi todos los entrevistados                                                                fois prescrite à leurs clientes. Plus étonnant
(98%) habían oído hablar de la anticoncepción      Résumé                                               encore, alors que 61% des répondants décla-
de emergencia, pero muchos no tenían un co-        Contexte: Au Brésil, où la contraception d’ur-       raient avoir presté des services de contracep-
nocimiento específico de este método. Aproxi-       gence pourrait jouer un rôle critique dans la ré-    tion d’urgence, 15% seulement pouvaient citer
madamente el 30% creía erróneamente que la         duction des grossesses non désirées, le gouver-      correctement la marque, la dose, le régime et
anticoncepción de emergencia funciona como         nement a inclus la méthode dans ses normes de        le moment de la première dose d’une pilule
un abortivo y el 14%, también en forma erró-       planification familiale. L’on en sait toutefois peu   prescrite.
nea, creía que este método era ilegal. Sin em-     sur la disponibilité et la prestation du service.    Conclusions: Les efforts de sensibilisation axés
bargo, lo ofreció a sus pacientes el 49% de los    Méthodes: Un échantillon national aléa-              sur une information de prescription spécifique
médicos que pensaban que el método induce el       toire de 579 obstétriciens-gynécologues brési-       et l’introduction d’un produit spécial permet-
aborto (el cual es ilegal en el Brasil) y el 46%   liens a répondu à une enquête menée par cour-        traient d’améliorer grandement l’accès des
de ellos pensando que el método mismo era ile-     rier en 1997 sur la question de la contracep-        femmes à la contraception d’urgence au Brésil.




180                                                                                                         International Family Planning Perspectives

								
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