The Morning After Pill Health And Social Care Essay

The second method of the morning after pill is the combined oestrogen-pregesogen, also referred to as the Yuzpe method; it is no longer commonly used as emergency contraception as it is less affective with more side effects compared with the levonogestrel method. Two doses of 100ug ethinyl estadiol and 500ug levonorgestrel are taken 12 hours apart.

In addition, the morning after pill has to be taken within 72 hours and is most affective within the first 12 to 24 hours, although it can be taken up to 120 hours after intercourse, the earlier it is taken, the better it works.

There are several advantages and disadvantages concerning the morning after pill, these will be discussed in the body of the article.

Currently, the availability of the morning after pill depends on the country, and its legislation, regardless to the official policy of the country there is much controversy regarding the use of the morning after pill. Different social and religious groups oppose the use of the morning after pill for moral or ethical reasons. Whilst other groups with a different ethical and moral point of views support the use of this intervention. Since scientific research has provided us with both the negative and positive effect of using this intervention, each group chooses to support their claims with one side of the available research.

The Media, as a voice of the public, present the morning after pill intervention in different ways. Five sources from the media will be analysed and evaluated to represent the treatment of this intervention in the media.

Scientific Background

The history of the morning after pill is different around the world and therefore hard to summarise. The roots of modern emergency contraception date back to the 1920s, when researchers initially demonstrated that estrogenic ovarian extracts interfere with pregnancy in mammals (Ellertson, C, January 1996). Emergency contraception regime of a combination of oestrogen and progestogen was first developed in the 1970s by Dr. A. Albert Yuzpe at the University of Western Ontario in Canada(Family Health International, 2003) in 1974 and has been available in the United Kingdom since the 1970's(Family Planning Association, 2002). In 1984, the first licensed hormonal method, combining the hormones progestogen and oestrogen was launched (Family Planning Association, 2002).

The relatively high dose of oestrogen found in the Yuzpe regimen had fastidious side effects, particularly of gastrointestinal nature, such as vomiting and nausea. Research by the World Health Organisation (Family Planning Association, 2002), found that a regime based on the administration of only levonorgestrel, a synthetic progestogen used as an active ingredient in some hormonal contraceptives (Wikipedia, January 2010), appeared to be more effective with significantly less side effects. Subsequently a new progestogen only pill, or Levonelle 2, was launched. Levonelle became a pharmacy medicine in January 2001 (J>R).

The Morning After pill addresses the problem of unwanted pregnancies after unprotected intercourse, after birth control failed or after forced intercourse.

There are currently three types of the morning after pill intervention available, depending on the country. The first type of the emergency contraceptive pill, and proven to be the most effective, contains the hormone progestin or levonorgestrel, both being synthetic progestogens. The second type of emergency contraceptive pills uses both the hormones progestin and estrogen and therefore are called the 'combined morning after pill' (Princeton University, March 2010).

Currently, it is well established that both progestin-only and combined emergency contraceptive pills act through several distinct mechanisms (Bastianelli, Farris, and Benaiano, 2008). Studies show that the main mechanism (Princeton University, March 2010) is the inhabitation or delay of the ovulation process caused by an interference with the luteinizing hormone (LH) at mid menstrual cycle peak release(Bastianelli, C., Farris, M., and Benaiano, G. 2008). Several research groups have investigated how HEC can alter the ovulatory process and all studies conducted so far indicate that there are cases in which all measured restrictions were normal, whereas in other cases the LH peak is partially or totally suppressed, and follicle luteinization partially or totally abolished, depending on the time in the menstrual cycle at which HEC is administered (Bastianelli, Farris, and Benaiano, 2008). The administration of an oestrogen-progestin combination after the LH surge can act by altering physiologic mechanisms. With regard to the LNG method, its exact mode of action has not yet been elucidated. Studies indicates that the administration of the progestogen in the early follicular phase lengthens this phase, whereas treatment around ovulation may result in a wide spectrum of effects, ranging from anovulation or deficient luteal function in some women, to normal function in others(Bastianelli, C., Farris, M., and Benaiano, G. 2008). Administration during the luteal phase does not seem to elicit changes in cycle length or the size or shape of the endometrial morphology. Additional mechanisms involve impairment of sperm and ovum migration in the genital tract (Bastianelli, C., Farris, M., and Benaiano, G. 2008). Some studies reported that, following administration of LNG, there is a reduction in the number of sperm recovered from the uterine cavity, a pronounced alkalization of the uterine fluid (capable of immobilizing sperm), and an increased thickness of the cervical mucus(Bastianelli, C., Farris, M., and Benaiano, G. 2008). Moreover, it has not been clarified whether in the Yuzpe regimen endometrial changes have any impact on endometrial accessibility. With regard to LNG, a careful analysis of published data does not support the idea that its administration alters endometrial receptivity or impedes implantation. Moreover, two recent studies demonstrated that LNG does not interfere with postfertilization events (Bastianelli, C., Farris, M., and Benaiano, G. 2008).

The fact that HEC is administered as soon as possible after coitus and the existing experimental and clinical evidence seem to exclude that post-coital hormonal contraception could dislodge the embryo after implantation has occurred. However there is no proof that HEC always acts before fertilisation occurs (Bastianelli, C., Farris, M., and Benaiano, G. 2008).

The third type of emergency contraceptive pill contains ulipristal acetate (also known as CDB-2914), and is available only in Europe, sold as ellaOne. It has been found to be highly effective and well-tolerated (Faculty of Sexual & Reproductive Healthcare, October 2009). Ulipristal's primary mechanism of action is thought to be inhibition or delay of ovulation. A single midfollicular dose has been shown to hold back growth of lead follicles. Administration just before, or in some cases just after, the luteinising hormone surge can hold back follicular rupture. Endometrial changes may also play a role(Faculty of Sexual & Reproductive Healthcare, October 2009). Early luteal administration of ulipristal results in delayed endometrial maturation and alterations in progesterone-dependent markers of implantation (Faculty of Sexual & Reproductive Healthcare, October 2009). A mid-luteal dose has been shown to induce early endometrial bleeding in a dose-dependent manner. It has been assumed that alterations to the endometrium may inhibit implantation by rendering the uterus less receptive to the trophoblast (Faculty of Sexual & Reproductive Healthcare, October 2009). However, it is not known if ulipristal has a direct endometrial effect or if the observed changes are a result of an ovarian effect. (Faculty of Sexual & Reproductive Healthcare, October 2009).

Fig 1. The Menstrual Cycle

There are both advantages and disadvantages to the morning after pill. The chief advantage of The Morning after pill is that it can be used after unprotected or forced intercourse to prevent unwanted pregnancy. In addition, this emergency contraception is easy to use and easily available from the majority of pharmacies, this depending on the country regulating the availability. Another advantage is the fact that woman can purchase the morning after pill ahead of time, therefore if the pill is needed, it is already available for them at home (BBC Health, July 2007).

The morning after pill is an effective form of backup birth control; however it is less affective then using a combination of ongoing birth control. In addition, the morning after pill has to be taken within 72 hours and is most affective within the first 24 hours, although it can be taken up to 120 hours after intercourse, the earlier it is taken, the better it works (BBC Health, July 2007).

Another disadvantage of the morning after pill are the short term side affects which some women may feel, these include filling sick, tired, get headaches, breast tenderness and or dizziness. However these symptoms are not common and usually don't last long (BBC Health, July 2007). Also the female's period may be disrupted for a short time (BBC Health, July 2007). Lastly, the morning after pill offers no protection against sexually transmitted diseases or infections, therefore it is recommended for women to have STD testing after unprotected intercourse (Planned Parenthood Federation of America. 2010).

Many ethical, social and religious issues have been raised by different groups concerning the morning after pill. These arguments were raised by groups for and against some aspects, or use, of the Morning After pill. The groups opposing this intervention raise a number of arguments. The most significant argument against the morning after pill is one of ethical beliefs. Some believe that human life starts at syngamy, once fertilisation has taken place(Bastianelli, C., Farris, M., and Benaiano, G. 2008), and as the activity of the intervention may include affects after conception, it can be classified as abortion(Williams, A. May 2005).Therefore religious groups consider emergency contraception an abortifacient -- a drug that causes a very early abortion. For example the catholic church views emergency contraception as a "dark and deadly pill" and " chemical weapons that can be destroyers of children"( Bartels, F.K. 2010). Another argument against the morning after pill is that it can lead to women having a "false sense of security" and encourage a more casual attitude to sex (Devlin, 2010).

The groups which support this intervention also raise a number of arguments. One argument is that the use of the morning after pill to prevent unwanted pregnancies reduces the number of abortions which may cause medical and physiological issues to the woman. Even some pro life activists claim that the morning after pill should be used as it reduces the need for abortions (Chapman, November 2005). The supporters of this intervention oppose the argument of the opposing groups that this emergency contraception is an abortifacient. They argue that the morning after pill it is the same as the regular contraception pill, however with an increased level of hormones (Heartbeat International, Unknown Date). In addition recent studies show that the primary mechanism of the intervention interferes at an early stage to prevent ovulation, and therefore the pill is not interfering with reproduction, as fertilisation hasn't taken place yet (Dyer, Feibelman, Loening, Neuhauser, Pham, Unknown Date).

Other groups, which encourage the use of the morning after pill, argue that women should be free to make their own decisions regarding their bodies, sexuality and reproduction and therefore have the right to prevent an unwanted pregnancy (Feminist Women's Health Centre, 2010).

Another social argument for the use of this intervention is that the pill is a solution against the high rates of teen pregnancy around the world, and as teen pregnancies are very expensive for their countries, if teen pregnancy is reduced, so will the costs(Devlin, 2010).

Another big issue raised in association with the morning after pill is whether it should be available over-the-counter. The opposing arguments are that the easy availability of the intervention would jeopardize the health of women with medical conditions. This means that because it is easily accessible a woman does not need a prescription from a doctor and therefore does not learn of the risks she is putting herself in by taking the morning after pill. Another argument against it being available over-the-counter is that it increases the potential for the emergency contraception to be slipped to women without their knowledge or consent. In addition, some believe that easy access to emergency contraception may increase risk taking behaviours and promiscuity. As the morning after pill has been promoted as a back-up in a case of unprotected intercourse, which may lead to a message that casual sexual involvement is without adverse consequences if one has access to this backup contraception. Therefore this will have an increase of sexually transmitted diseases (Heartbeat International, Unknown Date). On the other hand, evidence suggests that access to emergency contraception may encourage women to use regular birth control. For example, a study conducted by the Population Council, based on focus groups with women from France, Sweden, Portugal and Norway found that the use of an over-the-counter morning after pill acted as a wake-up call for women and encouraged them to take responsibility and to use regular contraception (Flora, 2004). Another argument from supporters of the over-the-counter availability of the morning after pill claim that if it's not easily and quickly available for women, as the morning after pill is most effective during the first 24 hours, by the time women receive the emergency contraception it may be too late, and consequently they may have to go through an abortion, which would have a larger physiological impact on them (Planned Parenthood Federation of America, 2010).

An alternative form of emergency contraception which can be used is the Copper-T, an intrauterine device (IUD) which some women use for regular birth control. The regular birth control IUD are placed in the uterus (Family Doctor.org, 2009) and act primarily by immobilising sperm or preventing their migration to the Fallopian tubes, thus preventing fertilization (Bastianelli, Farris, and Benaiano,2008). However, it has been utilized for emergency contraception where a doctor or other trained clinician insert it up to five days after unprotected intercourse to prevent pregnancy. As emergency contraception, the Copper-T IUD is much more effective than either type of the morning after pill reducing the chance of pregnancy by more than 99% (Princeton University, March 2010). In the case of emergency contraception, post-coital insertion of an IUD could not inhabit sperm migration or capacitating and therefore it is more likely that it acts by preventing implantation. It is not yet clear whether C-IUDs act because copper is a toxic agent to the early embryo or because the sterile inflammation of the endometrium creates an environment unsuitable for implantation, or whether both mechanisms are involved (Bastianelli, Farris, and Benaiano,2008). However, infectious complications may follow shortly after insertion if there is already a lower genital tract infection and in addition, the risk of infection increases in the following 21 days following IUD insertion. Therefore women are often advised how to recognise the symptoms of pelvic infection following the insertion. Lastly this method is only used as an emergency contraception is no longer effective as more than 72 hours have passed since the unprotected intercourse. The alternative form of emergency contraception which can be used is the IUD. It is a much higher chance of reducing pregnancy and can be inserted to prevent pregnancy up to five days after unprotected intercourse. However this alternative does have a high risk of infection and therefore has to be monitored frequently (Family Doctor.org, 2009).

Media Portrayal, Analysis and Evaluation

The media represents the morning after pill or emergency contraception in different ways, and from different points of view. The following five sources from the media need to be analysed and evaluated to work out the overall treatment of this intervention in the media.

The 'Is Emergency Contraception Safe' article, taken from the morningafterpill.org website, expresses the view that the morning after pill is dangerous to a woman's health. This article presents the side effects of hormonal contraceptives in relation to Head/Brain, Eyes and Heart/Blood. This article was written by the American Life League, who openly states their objection to emergency contraception and so their reliability has to be questioned and there is a high chance that the information they provide is largely biased. To support its arguments, the American Life League provides statements from various studies and health professionals. Although the information provided seems scientific, the writers fail to describe the extent of the studies, whilst also only representing one side of the results. In addition this article uses largely emotive and biased language, for example "EC kill a tiny preborn life in its earliest stages", "very dangerous" and "mega-dose".

The second article examined from the media is 'Emergency Contraception Information for Health Professionals Fact Sheet' provided by Family Planning Queensland. This fact sheet provides overall information regarding various emergency contraception, their mechanism of action, their effectiveness and expected side effects. This source is reliable in the sense that it is neutral and does not take any side. In addition, it is also reliable as it provides further readings and as it is written for health professionals, the scientific information in it would assumingly be accurate. The only problem with this source is that it was written in 2002, and therefore it does not include any present studies which may have been conducted in the past 8 years and can influence the decision of whether to use this intervention.

The third article is an extensive review of emergency contraception written by Carlo Bastianelli, Manuela Farris and G.Benagiano and published by The European Journal of Contraception and Reproductive Health Care in March 2008. This article discusses Hormonal methods, miferpristone and Intrauterine methods of emergency contraception. Providing information on the mechanism of action, adverse effects, indications, and contradictions, for each method, as well as an overview on access to emergency contraception. All the information provided is largely scientific and well researched, with an extensive reference list, adding to the reliability of the article. The information in this article is backed up by a large amount of statistics. All statistical information is referenced and therefore the reader can explore the information further, which assumingly means that the scientific information has to be accurate. Another aim of this article is to advocate the use of the mass media to provide women with accurate unbiased information regarding emergency contraception.

The fourth source from the media is an Emergency Contraception informative article published by the Children by Choice Association in 2004. It is a short article concerning the availability of emergency contraception over the counter at pharmacies in Australia. The article focuses on the importance of access to emergency contraception and provides some basic information regarding the use of the morning after pill. This source is biased since it emphasizes the importance of emergency contraception but fails to portray a broad picture of emergency contraception. The reader of this information may get the impression that the morning after pill has not side effects or possible risks and therefore the decision to take emergency contraception may be done without due consideration. The reliability of this source can be further questioned as it fails to provide any evidence or scientific information from other reliable sources.

The fifth source from the media is the 'Contraception and Chance' written by Carlin Flora and published on January 01, 2004- last reviewed on February 22, 2006 in the Psychology Today magazine in the US. This article focuses on the effects of the decision to allow over-the-counter sales of the morning after pill. They relay on the experience of several European countries where the morning after pill is already available over-the-counter. So that the article would not seem biased, the author discusses the fear that the easy access to the morning after pill will encourage people to engage in risky sexual behaviour. However, for the rest of the article, the author provides information on the positive influence of the use of the morning after pill, for example that emergency contraception is perceived as a "wake-up call" to take more responsibility in the future.

The fact that this article was written in 'Psychology Today' may mislead readers into believing that the information received is highly accurate, where as it is a magazine, and in the case of this article, the reliability and expertise of the author is unknown and therefore over all, the reliability of the article is questioned.

The five sources investigated from the media all represent a different view on Emergency Contraception and or the morning after pill. In the media, this intervention is treated differently by the different views and believes of the authors. Some sources, such as pro-life supports, in the media represent the morning after pill as something unethical, where as other sources largely advocate the positive use of the morning after pill. Other sources represent the intervention on a scientific basis and investigate all scientific and social points of view using research. Overall, all sources taken from the media have to be analysed and evaluated to work out how reliable the information they give is.

Conclusion

The morning after pill, also known as 'emergency contraception' (EC), is a backup contraception method taken by women to prevent pregnancy after having unprotected intercourse, when contraception failed to work, or after forced intercourse. Although the mechanism of action for emergency contraception is not completely understood, hormonal methods are believed to prevent or delay ovulation. The morning after pills may also interfere with ovum and sperm transport, fertilisation and possibly implantation. The media is a tool used by the public, therefore different publications select scientific research that supports their purpose. On the other hand, scientific or academic journals usually portray the morning after pill in a more neutral and unbiased way. From a scientific and medical point of view, the morning after pill has a large success rate in preventing unwanted pregnancies, therefore there is no question in society of whether this intervention is successful, but rather there are social and ethical issues of whether the morning after pill should be used and or easily available.