Warning after the night before

Post-coital contraception can reduce unwanted pregnancies. But are there other health risks attached? By Heather Welford
Helen, from Newcastle, is 18 and currently in the middle of her A-levels. Two years ago, she had unprotected sex. "It was a mistake - I wouldn't let it happen these days. I knew I could get pills from the GP to prevent a pregnancy. He prescribed them, but he really glared at me and asked why on earth we hadn't used contraception. He made me feel like a little slapper."

It's experiences like these - not uncommon, according to health workers - that act as a disincentive to younger women seeking emergency contraception, "post-coital" contraception, or PC4 to give it its medical term.

Incorrectly tagged "the morning-after pill" by the media - in reality two lots of tablets are taken 12 hours apart, up to 72 hours after sex - the treatment is only available with a doctor's prescription. That could change if campaigners succeed in making it available over the pharmacy counter.

Currently, say the campaigners, a programme in operation in Washington State in the US demonstrates that pharmacists can be given the appropriate training. On Thursday, the Birth Control Trust hosts a meeting at the House of Commons opened by Dr Jenny Tongue, a LibDem MP who also has 30 years' work experience in family planning. "Anything that helps us reduce the appalling teenage pregnancy rate is worth considering," said Dr Tongue. She points out that with 9,000 pregnancies last year among under-16s, the UK has one of the highest rates in Europe.

Certainly, the pharmacists are in favour. Spokesperson for the Royal Pharmaceutical Society, Beverley Parkin, said the professional body could work on protocols for confidentiality, privacy, and GP referral. "Pharmacies are accessible when other sources of help aren't," Parkin said.

Yet Schering Health Care, manufacturers of the only product currently licensed for use as post-coital contraception, are reluctant to sanction its use off-prescription. "We've got no immediate plans to make an application for this," said Carole Graham, a spokesperson. "The issue is not as simple as some campaigners think. We have no data to support its safety outside medical control. The issue of liability - who is legally responsible if there is a claim for serious side- effects - has not been resolved."

However, the consensus among doctors is that PC4 is safe, said Ann Furedi of the Birth Control Trust. "Schering are dragging their heels about this. The main contra-indication is with women who have current focal migraine, as there's a risk of stroke, but there's no evidence of harm otherwise, and no evidence that when it doesn't work, the foetus is damaged. In fact, the biggest risk is it's not always effective, so it couldn't replace regular contraception."

According to figures from the Trust, 99 per cent of women who take emergency contraception won't become pregnant - but the figure drops to 75 per cent when sex has taken place mid-cycle, at or around ovulation. Anyone taking emergency contraception needs to know where they can discuss longer-term alternatives.

But teenagers complain that young people's advice centres - often preferred to the GP or the family planning clinic - are not open frequently enough. Newcastle's Streetwise, for example, has only one evening opening a week. "It's mainly open when we're at school," said Helen. "And a friend of mine was told to come back in a couple of days when the doctor would be there - but by then it would have been too late." Smaller towns and rural areas may have nothing at all.

It's not just teenagers who might need emergency contraception, either. Sarah Raynor, a senior nurse at London's Margaret Pyke Centre, says they have up to 60 women asking for emergency contraception on Monday mornings, and the majority of them are between 20 and 35. At Margaret Pyke, however, they don't have to be seen by a doctor. "Here, we've noticed a large increase in the uptake of PC4 in the last three years," says Sarah Raynor. "We have appropriately qualified and trained family planning nurses working to protocols validated by our local NHS Trust. So they can issue emergency contraception to clients within the guidelines, and ensure confidentiality and information on longer-term contraception methods."

Nurses are, say some experts, in an ideal position to issue PC4. Professor John Guillebaud of the Department of Family Planning and Reproductive Health at University College, London, would like to see school nurses, midwives and others given complete freedom to prescribe it. "There are 300,000 nurses in the UK, far more than doctors or pharmacists," he said. "Nurses can provide the necessary empathy, privacy and counselling more easily than pharmacists. I'd also support the idea of availability in pharmacies, as long as women had privacy, if there were protocols for the way PC4 is issued, if women had a user-friendly leaflet with the product, and there was adequate follow-up contraception." He's sceptical of the Royal Pharmaceutical Society's claim that 90 per cent of pharmacies can offer a "quiet area" for private consultation - "most of the chemist's shops I go into don't look suitable for this," he says. Leontia McLaughlan from Airdrie's peer training programme outside Glasgow, which trains young people to go into schools, clubs and colleges to teach sexual health, said teenagers are still embarrassed and under-confident about contraception. While she supports easier availability of contraception, she doesn't see it as the whole answer. "We still hear stories from embarrassed teens about going into the chemist's for condoms, and coming out with a pack of paper hankies instead." She felt it was important to raise confidence levels so girls and boys can make an informed choice about sex.

"Greater availability of PC4 would be a move forward," said Dr Diana Mansour, honorary secretary of the Royal College of Obstetricians and Gynaecologists' Faculty of Family Planning, "but it's only scratching the surface. There are lifestyle and health issues here. Some teenagers are risk-takers. You could have the contraceptives hanging from trees and they still wouldn't use them."

She says that it's not until the first pregnancy scare that some teens are propelled into considering contraception. "I'd like to see much more effective health education - girls still have a poor idea of their own fertility, and don't know when they're most likely to get pregnant. Social deprivation's a factor, too, and low self-esteem. Some girls want to get pregnant. It's what they feel they're born to."

Campaigning groups from the other end of the spectrum claim that extending the availability of emergency contraception will bring with it health risks and an increase in casual sex. "In our view, this isn't contraception, as it works by preventing implantation after fertilisation," said Josephine Quintavalle from the group Comment on Reproductive Ethics. "Women don't always understand this. We're also concerned that it may have as yet undetermined effects on women's health.

"They've got a right to their moral views," said Ann Furedi, "but we feel they're dressing up a moral argument inside an erroneous medical one. Emergency contraception is safe - a lot safer than many other things our society is quite happy to have on sale without a prescription."

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