KARACHI, Pakistan, Mar 2 2010 (IPS) – The first time he and his wife had an ‘accident’, 40-year-old Kamran Rehman worried that they may have inadvertently paved the way for child number three. A chemist he consulted, however, recommended that his wife try the emergency contraceptive pill (ECP).
She did. Today, Rehman and his wife Aasia still have two daughters. Says Aasia Rehman: It was a big relief for both of us as we don’t plan to have another child.

It’s good to have a back-up in case of a mistake or an accident, she adds, confessing she has taken the drug when we were short of condoms at home and still had sex .

The ECP is essentially a high dose of female hormones – estrogen and progestin – that are normally in the daily-use oral contraceptive pills. Erroneously referred to as the ‘morning-after pill’, the drug prevents the implantation of a fertilised egg in the uterus if taken within a prescribed period after sex.

It has been around for years now in many countries, including mainly Muslim Pakistan. But it is only recently that the ECP seems to have attracted growing interest – and use – among couples in this South Asian country.

This development is welcomed by health professionals and population experts monitoring the country’s ballooning population, which is now about 180 million. Farid Midhet, a Pakistani who heads medical research at Qassim University College of Medicine, Saudi Arabia points out, Emergency contraception is essential in cases of contraceptive failure, the rate of which is very high in Pakistan.
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Its availability also means it quietly empowers women to make choices in this predominantly patriarchal society. Says international health consultant Rehana Ahmed, who sites on the board of Greenstar, a social marketing company that promotes ECP: I see this as an emergency measure that should be available to all married women of reproductive age. In our country we have men who are economic migrants and they become visiting husbands, so unprotected sex happens, she adds. This should not turn into a pregnancy if that is not desired. Yet Ahmed is among those who are concerned that ECP’s increasing popularity in Pakistan has not been matched by accurate information about it. It is being used as a regular contraceptive by couples who have infrequent sex, says Ahmed. This is not recommended.

Few couples are also apparently unaware that the efficacy of ECP is reduced when it is taken regularly and that it is not an abortifacient. It cannot terminate an established pregnancy, so this is an incorrect perception, says Ahmed.

In far too many cases, too, couples do not know when the ECP is most effective or when they are better off with another contraceptive or family planning method.

The efficacy of ECP to prevent pregnancy is less than regular pills and risk of pregnancy after ECP also depends on what stage of menstrual cycle it was taken at, says Sarah Saleem, head of the population and reproductive health programme at the Aga Khan University.

Saleem also warns that the ECP’s failure rate is higher in a year’s use compared to that of regular pills, even as she says that the drug should be an integral part of the family planning counselling .

Qassim University’s Midhet himself notes, If only women knew that they can use the normal daily-use oral contraceptive pill in cases of emergency, it would make their life very easy.

Let s say a woman had unprotected sex she can take four pills of the oral contraceptive pill the morning after, say within 12 hours, and another four pills about 12 hours after that, says Midhet, who laments that such information is often missing in the literature accompanying packages of daily-use oral contraceptives. Emergency contraception is most effective when pills are taken within 12 to 24 hours after unprotected sex, he explains. But it can still work if pills are taken later, even up to 120 hours after sex, in some cases. Protection rates vary but usually pregnancy is avoided if the correct dose is taken within prescribed time period. Midhet agrees with other health professionals that the information drive on ECP should be ramped up. Saleem, meanwhile, believes that healthcare providers should be providing the do’s and don’ts regarding ECP while the government should promote its use. Ahmed, for her part, cites the example of Kenya, where she is currently posted, where the drug has gained popularity by word of mouth. She stresses, The government and social marketing (there) have run communication campaigns to ensure that information is out that it is not a regular contraceptive. She concedes, however, that clerics may oppose the use of ECP if it were advertised if they are opposed to family planning altogether . But if they know that this is only to be used in an emergency, they may relent, says Ahmed. I think it has to be handled with sensitivity and correct information imparted.

A recent study, though, indicates that even healthcare providers may have limited knowledge about ECP, and may thus cause more harm than good should they be consulted about it.

The study, conducted in 2009 in a Karachi teaching hospital to assess the knowledge of family medicine providers and their attitudes towards emergency contraception, concluded that there were clear gaps in knowledge of ECP among healthcare providers .

Of the 45 physicians, nurses, pediatricians, family-planning service providers, and family doctors interviewed, for instance, only 33 percent replied that emergency contraception was not an abortifacient while 42 percent were unsure.

In addition, 44 percent of the respondents cited teratogenicity or the risk of producing foetal malformation as among the barriers to ECP use, while 31 percent said that it will promote promiscuity .

Thirty-eight percent also incorrectly chose menstrual ir¬regularity as the most common side effect of progestin-only emergency contraception pills .

Research shows that the most common side effect of this ECP variant is a feeling of being sick to the stomach, which is felt by one in four women. Those who take the combination pills complain of nausea.

Experts say that one possible impact of the informed use of ECP could be fewer women resorting to unsafe abortion in this country.

Abortion is used primarily as a family planning method, says Azra Ahsan, a lead author of a 2007 study conducted by the National Commission for Maternal and Neonatal Health in collaboration with the Society of Obstetricians and Gynecologists of Pakistan.

An earlier study by the Population Council of Pakistan showed that 29 of every 1,000 Pakistani women of reproductive age seek to terminate their pregnancies through unsafe means and that an estimated 890,000 such abortions were occurring in Pakistan annually.