Author
Dr. Michelle C. Chan (biography and disclosures)
Disclosures: Received funding from the Society of Family Planning, Fellowship Research Grant, current research: Dispensing and Practice Patterns of Ulipristal Acetate 30 mg (Ella) as Emergency Contraception in British Columbia, Canada. Mitigating potential bias: Recommendations are consistent with current practice patterns, SOGC Contraceptive.
What I did before
In British Columbia, 2024 brings an opportunity to reflect on our family planning practice within medicine. BC started free universal contraception coverage for all residents under the BC Pharmacare program on April 1, 2023, and expanded prescribing to include pharmacists on June 1, 2023.1 There is evidence that universal, standardized screening for pregnancy intent supports preventing pregnancy and optimizing preconception care for best outcomes.2 In my practice I ask:
“Would you like to be pregnant in the next year?”2
Previously, for people at risk of becoming pregnant and who did not want to be, I reviewed contraception options with the patient including natural family planning (rhythm, calendar, withdraw), barrier, combined hormonal options (pill/patch/ring), progesterone-only options (depo/implant/pill), intrauterine devices (hormonal/non-hormonal), permanent irreversible fertility control (vasectomy/tubal). This is in addition to assessing whether there is contraceptive use (consistency and accuracy) and satisfaction with method choice.2
However, I did not use to include options for emergency contraception or abortion during counselling.
What changed my practice
Recent studies on emergency contraception and abortion as options in family planning have changed my practice:
- A recent provincial study found that there is low awareness of the more effective emergency contraceptive pill, ulipristal acetate.3 Ulipristal acetate is superior to levonorgestrel emergency contraception in preventing pregnancy.4 It is more effective up to 120 hours from intercourse, compared to 72 hours for levonorgestrel, and it is more effective for those who are overweight.5,6
- A primary care study reviewing patients’ attitudes toward discussing abortion during contraceptive counseling found that normalizing abortion as a family planning option can improve patient experience and decision-making.7 The study suggested that patients preferred to be presented with options routinely, and including abortion as an option, was found to be acceptable and least coercive.7 This destigmatized unwanted pregnancy and normalized abortion as an option in family planning.
What I do now
I now routinely take the opportunity when reviewing family planning options for people who are at risk of becoming pregnant and do not want to be pregnant to review emergency contraception and abortion as options in family planning. We will collectively recognize, given the abundance of options in family planning, that not all options may be available or acceptable to people in support of their comprehensive reproductive health.
The emergency contraception pill is a last-chance option to prevent pregnancy if a person does not wish to do so in the context of contraceptive failure or no use of contraception.8 The emergency contraceptive pill options delay ovulation to prevent a pregnancy.5 Ulipristal acetate 30 mg is currently available by prescription only.3 When patients choose a method, I will offer, in addition to their chosen contraception, a prescription for ulipristal acetate should they find themselves in a situation of contraceptive failure or non-use to still try and prevent pregnancy.
I phrase it as:
“We know no method of preventing pregnancy is 100%, sometimes people find themselves in a situation where despite best efforts contraception fails or is not used. There is a pill that one can take to still try and prevent pregnancy in such situations. Do you think this option can be helpful to you/Is this an option you are interested in?”
Abortion is an acceptable family planning option for some people who do not wish to be pregnant. I now routinely bring up abortion as part of family planning counselling.
I phrase it as:
“Sometimes people will experience an unintended or unwanted pregnancy. For people who do not want to be pregnant, there are various options for family planning and one of them is abortion. This is acceptable for some people and not for others. Some people find that learning about all options will help them understand and decide what are or are not acceptable options to them and this may be helpful in choosing family planning options.”
In collective solidarity for comprehensive reproductive health reflecting effectiveness of the method, and the values, needs, and preferences of the person, I call upon us to reflect on our practices and offer our patients, we have the privilege of caring for, all their options in family planning.
It’s what I talk about when I talk about family planning.
Handout
View and download the handout you can use in practice – Mechanisms of action and effectiveness of contraceptive methods.9 Download PDF.
Please note: A handout including information on emergency contraceptive pills is in development and will be shared here in due course.
Resources for patients
- Bedsider.org: I write this website on the backside of the prescription. It is an evidence-based up-to-date website that is very user friendly in the way information is organized. Particularly, troubleshooting contraception or starting/stopping contraception is helpful for patients to reference aside from calling up their friendly neighborhood pharmacist. I also explain that it is an American website so some features are not available in Canada. For example, the double rod implant is not an option, pricing is not relevant, and the service provider search functions are only for those in the United States.
Resources for providers
Free eLearning modules:
- We All Have a Role to Play: Increasing Access to Abortion Care in Canada (aussi disponible en français)
- Emergency Contraception Update
References
- College of Physicians and Surgeons of British Columbia. BC patients get free access to many contraceptives. College Connector. Published April 2023. Accessed April 21, 2023. https://www.cpsbc.ca/news/publications/college-connector/2023-V11-02/04 (View)
- Allen D, Hunter MS, Wood S, Beeson T. One Key Question®: first things first in reproductive health. Matern Child Health J. 2017;21(3):387-392. doi:10.1007/s10995-017-2283-2 (View with UBC)
- Chan MC, Munro S, Schummers L, et al. Dispensing and practice use patterns, facilitators and barriers for uptake of ulipristal acetate emergency contraception in British Columbia: a mixed-methods study. CMAJ Open. 2021;9(4):1097-1104. doi:10.9778/cmajo.202001933 (View)
- Shen J, Che Y, Showell E, Chen K, Cheng L. Interventions for emergency contraception. Cochrane Database Syst Rev. 2019;2019(1). doi:10.1002/14651858.CD001324.pub6 (View)
- Canadian contraception consensus chapter 3: emergency contraception. J Obstet Gynaecol Can. 2015;37(10):S20-S28. doi:10.1016/S1701-2163(16)39372-0 (View)
- Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555-562. doi:10.1016/S0140-6736(10)60101-8 (View or View with UBC)
- Dianat S, Silverstein IA, Holt K, Steinauer J, Dehlendorf C. Breaking the silence in the primary care office: patients’ attitudes toward discussing abortion during contraceptive counseling. Contracept X. 2020;2:100029. doi:10.1016/J.CONX.2020.100029 (View)
- Trussell J, Raymond EG, Cleland K. Emergency contraception: a last chance to prevent unintended pregnancy. Contemp Readings in Law Soc Justice. 2014;6:7-38. https://heinonline.org/HOL/Page?handle=hein.journals/conreadlsj6&id=813&div=100&collection=journals. Accessed April 22, 2020. (View with UBC)
- World Health Organization Department of Sexual and Reproductive Health and Research (WHO/SRH), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP). Family planning: a global handbook for providers (2022 update). https://fphandbook.org/. Published 2022. Accessed October 9, 2024. (View or View PDF)
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Please redact as there is significant risk in some of these recommendations.
Ulipristal acetate effects the progestin component of hormonal contraception therefore if someone is taking a hormonal contraceptive and then also uses ulipristal acetate it can cause their regular contraceptive to become ineffective for the next 5 – 7 days – this is a serious missed step in these recommendations.
The referenced websites are American. The clinic locations does not include Canadian options. Why not use the Canadian SOGC website instead: http://www.sexandu.ca or the BC Options for Sexual Health: http://www.optionsforsexualhealth.org
Also, it’s great to “normalize” abortion, except that providers then must also integrate mifgymiso prescribing into their practice if they are going to offer abortion as a “contraceptive” option. It is irresponsible to not offer this yourself if you want to promote termination as a birth control method. Abortion is not in fact a “contraceptive” in the true sense since the word “contraceptive” means prevention of pregnancy…not termination of pregnancy. Downloading abortion services to already busy clinics who do offer this is not ideal practice and not accessible or affordable for many women in the province who live rurally or remotely.
Response to Hannah Varto:
Please redact as there is significant risk in some of these recommendations.
I welcome an evidence-based discussion surrounding risks, in this offering of an evidence-based approach.
Ulipristal acetate effects the progestin component of hormonal contraception therefore if someone is taking a hormonal contraceptive and then also uses ulipristal acetate it can cause their regular contraceptive to become ineffective for the next 5 – 7 days – this is a serious missed step in these recommendations.
Ulipristal acetate (UPA) is a serum progestin receptor modulator, it does not primarily work by effecting the progestin component of hormonal contraception. It is important to advise against continued non-contracepted intercourse after taking any oral emergency contraception. Thank you for pointing out it is also important to counsel restarting of progestin containing contraceptives 5 days after taking UPA but not due to the mechanism proposed in the comment. Apologies for this oversight, as we have only so many words to get a take home message across.
Please see this study for further details on the impact of CHC OCP on UPA: Edelman AB, Jensen JT, McCrimmon S, Messerle-Forbes M, O’Donnell A, Hennebold JD. Combined oral contraceptive interference with the ability of ulipristal acetate to delay ovulation: A prospective cohort study. Contraception. 2018 Dec;98(6):463-466. doi: 10.1016/j.contraception.2018.08.003. Epub 2018 Aug 14. PMID: 30118684; PMCID: PMC6204102 (View).
UPA use and thorough counselling is more than the scope of this article. You can complete this online learning course on Emergency Contraception for more information.
The referenced websites are American. The clinic locations does not include Canadian options. Why not use the Canadian SOGC website instead: http://www.sexandu.ca or the BC Options for Sexual Health: http://www.optionsforsexualhealth.org
Thank you for the comment. These websites are both excellent resources.
Bedsider was shared particularly for the troubleshooting aspect that is excellent for patient health information access. For example, within the FAQs there are “what should I do if my patch falls off” evidence-based troubleshooting guidances which patients have found helpful. For example: https://www.bedsider.org/questions/2090-will-the-patch-fall-off
Also, it’s great to “normalize” abortion, except that providers then must also integrate mifgymiso prescribing into their practice if they are going to offer abortion as a “contraceptive” option. It is irresponsible to not offer this yourself if you want to promote termination as a birth control method. Abortion is not in fact a “contraceptive” in the true sense since the word “contraceptive” means prevention of pregnancy…not termination of pregnancy. Downloading abortion services to already busy clinics who do offer this is not ideal practice and not accessible or affordable for many women in the province who live rurally or remotely.
Thank you for this comment. Please note, I am not offering termination as a “birth control method”, rather this piece was about “family planning options”. Mifepristone is available as emergency contraception in countries outside of Canada. At the moment, Mifepristone is not indicated for emergency contraception in Canada.
I am not proposing offering abortion as contraception, nor trying to conflate. The change in practice article is attempting to move us from “contraception-only” to “family planning” discussions.
Thank you for the excellent point, this practice is not being offered as ideal, however some food for thought given review of evidence, changes in access. As you have pointed out, it may be even more important to review all family planning options in rural and remote areas to assist with decision making given the context of access in remote and rural areas.
I appreciate you taking the time to read and share your thoughts.
Excellent info and comments. Thank you.
This was beautiful to read, thank you for taking the time to share.
On the topic at the beginning, when the question of “Would you like to be pregnant in the next year?” I have been more and more preparing young families for the idea of budgetting for assessment of tethered oral tissues, as it is unfortunately mostly private care at this time. HealthlinkBC has an updated multidisciplinary document about Tethered oral Tissues and would be a great piece to share with them as they plan for their infant’s care needs following birth.
Please find the new link attached.
https://www.healthlinkbc.ca/pregnancy-parenting/parenting-babies-0-12-months/baby-health/tongue-tie-and-tethered-oral-tissues
I appreciate Dr. Chan’s thoughtful, democratic, and considerate approach to family planning, especially after seeing with alarm what has happened in this field in the United States. Having an escape mechanism, when required, would also be appealing in other areas of health care – were that available.
Note that after performing a systematic review and critical appraisal of randomized trials that compared ulipristal acetate with levonorgestrel, we were unable to conclude that ulipristal has been proven superior. (https://www.ti.ubc.ca/2024/07/29/150-emergency-contraceptives/)
Levonorgestrel, which is widely available to British Columbians at no charge and without a prescription, also remains a good option for emergency contraception.
Tom Perry MD, FRCPC
Editor, Therapeutics Letter
UBC Therapeutics Initiative
Response to Thomas L Perry:
Thanks for sharing this wonderful information and the work TI does. This TCMP utilized SOGC guidelines to mitigate any bias and thus the comment about weight and what the provincial study was based on back when it was performed in 2019.
After this article I will provide prescription for Ulipristal as “stand by ” for patients; the “talking tip” is very useful in this article. In the past I relied on patients going to Pharmacists and asking for Plan B.
Talking to patients about their options at all points of care when related to Birth control or sexual health makes a difference in my experience.
Thanks for the added confidence to add abortion to the conversation, this article will change my practice in this regard.
Hi Michelle, do you know if Ulipristal is covered for free? I dont believe so based on this: https://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/what-we-cover/prescription-contraceptives#morning
it seems like other emergency contraceptive options are covered for free though… cost may be a barrier for some eg. youth. thanks, Claire
Response to Claire Young:
Hi Claire – thanks for sharing this important point, it adds to the fact we need to collectively work for contraception advocacy and access. Some would argue that the costs of pregnancy and parenting are even higher than the cost of contraception.