At the dawn of the 21st century, responsibility for contraception continues to fall, for the most part, to women. However, recent decades have seen striking changes in customs and couples' sexual behaviors. Contraceptive methods are few, and none of them is 100% effective. Thus throughout her sexually active lifespan a woman runs the risk of unprotected sex at any time, with the consequent possibility of accidental or undesired pregnancy.
Emergency Contraception
Some of these pregnancies could be prevented with the postcoital pill (PCP). This treatment, which only recently came on the market in Spain, consists of high doses of levonorgestrel (750 µg) in 2 tablets that should be taken within 72 hours of unprotected complete sexual relations. The first pill should be taken as soon after unprotected sex as possible, and the second should be taken 12 hours after the first.
The PCP is marketed in Spain under the brand names Postinor, Postfemin, and Norlevo. Until now, the Yuzpe regimen (100 µg ethinylestradiol and 500 µg levonorgestrel) has been used.
Currently available treatment containing only gestagens is more expensive but avoids the side effects of the Yuzpe method (vomiting, headache, abdominal pain, dizziness, etc). Its effectiveness is very high and inversely proportional to the number of hours elapsed since high-risk intercourse.
The mechanism of action of levonorgestrel, a synthetic hormone, works at a number of levels: the hormone inhibits ovulation if it has not yet occurred at the time of intercourse, impeding fertilization of the egg by the sperm. If ovulation has already occurred, the hormone prevents implantation of the fertilized egg in the uterus.
In the general population and among some health professionals, there is some confusion between the PCP and RU 486 or mifepristone, an abortive treatment dispensed only at clinics authorized for this type of intervention in accordance with the current Voluntary Interruption of Pregnancy Law passed in 1985.
Obviously, the PCP is an emergency solution that should not be considered or used as a routine method of contraception. Its authorization, distribution and private use
--like many other issues that touch on sexuality and human reproduction--have been the subject of biomedical and religious debate, although the core issues remain difficult to resolve. The Episcopal Conference considers the PCP an abortifacient as in certain cases it would prevent the implantation of a fertilized egg. The WHO, on the other hand, considers gestation to begin when the fertilized egg is implanted in the endometrium, and thus does not consider the PCP a method of abortion.
Another technique for preventing undesired pregnancies after unprotected sex--insertion of an intrauterine device--has never been widely used in Spain for medical and organizational reasons.
In recent years family physicians have faced a growing number of requests for health care related with sexuality and reproduction. Men and women value their sex lives as an important aspect of health, and many citizens no longer hide problems that were considered taboo until recently.
The right of women and men to sexual health and birth control is exercised more freely by an increasingly well-informed population.
In 50% of the cases the woman who requests the PCP is younger than 20 years of age. Many are minors, and physicians must judge the woman´s degree of maturity in deciding whether to prescribe this treatment, just as they must also weigh the risks of undesired pregnancy in this type of patient.
The Situation in Spain
Access to this treatment remains unequal in different parts of Spain. Marketing of the PCP was authorized by the Ministry of Health and Consumer Affairs but its cost is not covered by the public health service in most autonomous communities. Each treatment costs slightly more than e19.
The only region that dispenses PCP through public health care centers is Andalusia, where this treatment is provided according to structured protocols for health care professionals. The protocols include interviewing the woman who requests the PCP, and providing information about health centers that can offer appropriate contraception. As a result, in this autonomous community the rate of increase in voluntary interruptions of pregnancy was reduced by 3.42% from 2001 to 2002, a reduction that appeared when dispensation in public centers was started. In the rest of Spain during the same period, the rate of voluntary interruptions of pregnancy continued to rise steadily.
A look at developments in other autonomous communities reveals a variety of situations. On one extreme, some emergency services at large hospitals do not keep records of visits by women who seek help after high-risk intercourse, but only provide women with the telephone number of a planned parenthood center that is naturally closed on weekends--which is precisely when most requests for the PCP occur. Conscientious objection by some family physicians and misinformation by others do the rest. Postcoital contraception for unwanted pregnancy, listed in the services such centers are obliged, in theory, to provide
throughout the country, is not provided under the same conditions to the whole population everywhere in Spain. In a country where the official abortion rate is approximately 50 000 per year, experts estimate that up to 75% of these interventions could be avoided if women had access to appropriate medical treatment.
The original article published in this issue of Atención Primaria by Vergara Cano, López-Guerrero, and López López describes the user profile of women who requested emergency contraception in urban health care centers that form part of the system of continuing primary care. The data these authors report confirm that women seek this treatment most often on weekends, and that most requests for this medical service came from young women. Postcoital contraceptive treatment was perceived as an emergency. In most cases the women indicated that the couple had had problems with condom failure.
It is noteworthy that information and education services for women who had previously used this treatment seemed to be inadequate, as women who had used the PCP on a previous occasion more often took longer than 24 h to come to the health center.
For those of us familiar with the conditions most primary health care teams work under in Spain, the efforts of this group of professionals to undertake research are praiseworthy. Also deserving of note are their efforts to provide this emergency care, whose availability at continuous care services or hospital emergency rooms cannot be taken for granted.
It is to be hoped that this service will soon be offered appropriately as part of health care services provided throughout the country, and that information will be provided for couples so that they can optimize their use of all available methods and thus minimize failures.
Health authorities in each autonomous community in Spain should be urged to deal with this high-priority
issue. Decided action will prevent unwanted pregnancies and avoidable abortions, and will have the further benefit of endowing citizens with less angst- and guilt-ridden sex lives.
