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Prepared by Robert C. Blomberg, Dr.P.H., Consultant

Executive Summary

In 2002, in response to a challenge from Board Member Ann Compton Stephens, the Compton Foundation launched a major initiative to increase awareness of and access to emergency contraception worldwide, with an emphasis on domestic, Latin American and African efforts. Emergency contraceptive (EC) pills provide a low-tech, woman-controlled method of birth control that does not require the intervention of a clinician. It differs from other forms of contraception in that it empowers women with a "second chance" to prevent pregnancy. Although first reported on in 1967, emergency contraception had, until recently, been a well kept secret in the world of reproductive health.

Thanks to the noteworthy leadership of the Compton Foundation in partnership with a number of other foundations and many grantee organizations, emergency contraception is no longer the secret that it was. The initiative brought the foundation a new way of doing business, one in which a significant amount of money was committed over a significant period of time to keep an on-going focus on the goal of increasing awareness of and access to EC globally. While this approach is not new in the philanthropic community, achieving such a valuable return on investment resulted in the initiative being a success above and beyond the usual.

In the years of its operation, the initiative was at the forefront of funding, either directly or through leveraging of other resources, every major activity aligned with the goal of increasing awareness of and access to emergency contraception worldwide. The initiative became a nexus for work on EC and became recognized in the foundation community as a source of well-vetted grant making. In so doing, it earned the confidence and commitment of other funders, thereby leveraging its investment and expanding the range of work that could be undertaken.

Emergency contraception can now be considered mainstreamed as part of any high quality reproductive health service, and in fact can be considered an indicator of whether a program is high quality. But cost remains a major barrier to wider access in the US context, even as women in other countries enjoy greater choice and availability of dedicated EC products. Much work remains to be done to secure access to EC for low income women everywhere. And until mandates exist to assure that all women who are victims of sexual assault are informed about EC and given the option of receiving it, the mainstreaming work cannot be considered finished.

Background

A long-standing and passionate interest in population and reproductive health on the part of Compton Foundation board member Ann Compton Stephens led to her request that the Foundation provide major funding in this field prior to her retirement from the board in 2002. With the board's concurrence, several large grants were made for population and reproductive health activities. The largest such endeavor was the Foundation's five-year, $5 million initiative to expand awareness of and access to emergency contraception worldwide. The initiative was launched in 2001 with the first grants being made in 2002. With a subsequent grant to Compton of $2 million by the Packard Foundation, the period of the initiative was extended to six years, and the total funding rose to $7 million.

The Foundation had a significant history of grant related support for emergency contraception issues prior to this initiative. It provided early funding of the International Consortium for Emergency Contraception (ICEC) and made a program related investment in the Women's Capital Corporation, the organization responsible for bringing to the U.S. market Plan B(R) in 1999. Plan B(R) is the only dedicated emergency contraception pill currently available to American women. (Emergency contraceptive pills are made of a common progestin birth control hormone, levonorgestrel, taken in one or two pill formulations at doses higher than that found in the daily dose when used as a regular oral contraceptive. A single pill version is now marketed internationally in fourteen different brands, none of which is available in the U.S. Intrauterine devices (IUDs) also work as emergency contraceptives when inserted within four days of unprotected intercourse, but they have not been a programmatically significant factor in the provision of EC.)

The impassioned fervor felt by activists who sought to expand awareness of and access to emergency contraception revolved around its empowerment of women to make personal choices about their reproductive lives without having to depend on any healthcare provider; to paraphrase the late Felicia Stewart, M.D., it is a low-tech, woman-controlled method that should be well known and readily available. It differs from all other methods of family planning in that it gives women a "second chance" to prevent pregnancy.

As the concept of emergency contraception became known, a line of thinking developed that it could potentially have a major impact on the incidence of unwanted pregnancy, thereby resulting in a concurrent reduction in the need and demand for abortion. This was an especially significant and appealing prospect for the United States where nearly half of all pregnancies are unintended, and more than 40 percent of these result in early terminations.

At the time the initiative was launched, branded emergency contraceptive pills were available in Europe and elsewhere1, and had been before they became available in the U.S., even achieving over-the-counter status in drugstores in some countries. However, they were not readily available in most countries of the world, and were not on the family planning commodities procurement lists of either the United States Agency for International Development (USAID) or the United Nations Fund for Population Activities (UNFPA). These two organizations are the largest providers of low-cost modern contraception to countries of the developing world. While EC had been known to the interested medical community for more than 30 years, it was virtually unknown to women of the world.

Emergency contraception had not been mainstreamed into reproductive health care practice by 2001. However, in years prior, the ICEC had undertaken major groundwork for mainstreaming by bringing together representatives of key organizations, including the World Health Organization, to develop uniform standards and guidelines, protocols and patient education materials to legitimize the method and establish it as an integral part of high quality reproductive health care. Of equal importance was the ICEC effort to promote the creation of a dedicated EC product, one that didn't require taking multiple regular birth control pills to achieve the effect. It was recognized that a dedicated EC product would be required if the method were to ever be mainstreamed in health care.

By 2001, funding for emergency contraception issues was no longer a high priority for the philanthropic community that had previously supported work on the topic. With the advent of Plan B, many donors believed that the private sector would now see to it that women would be informed and demand would assure access. Edith Eddy, executive director of the Compton Foundation, was not of that opinion. She felt that emergency contraception had not achieved a status that would guarantee rapid expansion of both awareness and access for women of the world. She brought this concern and suggestion for the initiative to Ann Stephens, and together they set the wheels in motion to develop the initiative.

The Initiative: Process

Both the size of the resource commitment to the emergency contraceptive initiative and its duration were unique in the Foundation's history. While the Foundation had an on-going history of support for work on emergency contraception, it had never dedicated such a large amount over such an extended period of time. The initiative would require an approach to grant-making different from anything it had done in the past, and would require someone to lead the process for its duration.

To lead the initiative, Ms. Eddy wanted a smart, passionate, committed, entrepreneurial individual who was well known in the field and who had extensive experience and credibility; she found that in Francine Coeytaux, a well-known and highly respected researcher and activist, whom she selected for the assignment. This decision consequently brought many outstanding additional benefits to the initiative. Ms. Coeytaux was asked to develop a process for: 1) identifying significant EC projects that merited funding; 2) making recommendations on these to the Foundation's staff and board; and 3) monitoring progress toward the initiative's goals.

Ms. Coeytaux suggested that a request for proposals (RFP) procedure be put in place that would assure transparency to the field about the grant making, and would provide for an open application process. She created a five-person team, including herself, whose members had decades of experience in the reproductive health field, including work on EC projects. The announcement of the initiative was widely publicized to organizations and individuals working in the reproductive health field; those receiving notice of the initiative were encouraged to forward the announcement to colleagues. Overtime, the initiative became well known in the field and the number of proposals grew.

The goal of the initiative remained constant throughout the six years, but the targets of each year's grant making were modified in each RFP to adjust to the evolution of the status of EC that was taking place. Experts and activists working to further awareness of and access to EC were consulted each year to learn what they felt were priority activities for the coming year.

Each member of the team independently rated proposals and then met to tally and discuss their ratings. There was a high degree of concurrence among raters as to which proposals deserved priority for funding, but there were always more meritorious proposals than there were funds to support them. This is one of the areas where the selection of Ms. Coeytaux brought significant secondary benefits to the initiative. She was able to broker many proposals to other foundations, either as partners in funding or sole funders, thereby expanding the number of projects that could be supported. The total value of brokered projects over the course of the initiative more than doubled the Compton Foundation's original commitment of $5 million. Appendix D provides a list of projects funded in this manner along with the funding source.

The Initiative: Grants Made

Over the six years of the emergency contraception initiative, the Foundation made 131 programmatic grants and seven more that were for administration and/or evaluation of the initiative, or for technical assistance to grantees. The table below shows the number of grants made each year.

Tables in Appendices B and C provide the names of organizations that were recipients of grants, by year, including dollar amounts. The graph below shows the percent of grant funds allocated by year to domestic or international programs. By the end of the initiative, a nearly equal amount of money had been granted to support domestic and international programs.

Of the international grant funds, including grants made to consortia, nearly 55 percent went to projects in Latin America. Approximately a third went to projects in Africa, ten percent went to projects with a global reach, and two percent went for consortium work in Asia. This division of funds reflected both opportunities and the Foundation's geographic priorities.

The dollar value of the international grants made would not have been as high had it not been for the decision by the Packard Foundation to grant to Compton the $2 million return on investment it had received from the sale of Plan B(R) by Women's Capital Corporation to Barr Pharmaceutical, Inc. The Packard grant was allocated to domestic projects in 2005 and 2006, thereby freeing up more Compton Foundation funds for international grants.

It is worth noting the high regard other foundations had for the Compton Foundation initiative. The Packard Foundation and the John Merck Fund allocated their funds because they recognized the leadership of the Compton Foundation in this area, and had confidence in the process that had been established to solicit proposals from the field and the due diligence with which they were vetted. Staff of other foundations interviewed in the preparation of this report expressed similar sentiments. For some partnering foundations with limited staff resources, being offered the chance to fund a vetted proposal was a huge benefit.

Nineteen foundations participated in the emergency contraceptive initiative by inde- pendently funding 41 proposals and partnering in the funding of 15 other projects. The indispensable role played by Ms. Coeytaux in brokering these projects to other foundations cannot be overstated. The esteem, admiration and trust she enjoys among colleagues in the reproductive health community - activists, researchers and funders alike - allowed the Compton Foundation's initiative to accomplish far more than it could have absent her leadership.

The Initiative: Highlights of Accomplishments and Benefits

The Compton Foundation's emergency contraceptive initiative is considered a resounding success, both by those who have been its beneficiaries and those who have not. Its impact has been far in excess of the resources allocated to it; to put it in the vernacular, the foundation got a terrific bang for its buck. In the years of its operation, the initiative was at the forefront of funding, either directly or through leveraging of other resources, every major activity aligned with the goal of increasing awareness of and access to emergency contraception worldwide2. The grants were strategic, catalytic, or both. The initiative provided seed money to many projects and activities that were later picked up for funding by other foundations. The initiative was, in essence, the nexus for global emergency contraception activities and came to be a clearinghouse for ideas and the linking of people and organizations that had a common interest and purpose, to create new synergies among them.

To help them monitor the effectiveness of the initiative, Ms. Coeytaux and her team defined a set of indicators that would serve as a framework for determining if progress toward the initiative's goals was being achieved. In constructing this framework, the team was not suggesting that the Compton Foundation initiative should, could or would take credit for all the changes to be seen over its six-year period of operation. Rather, they wanted to challenge themselves to be thinking how projects they would recommend for funding would contribute to these ends. Some answers to their questions are found in the table below and the narrative which follows.

Domestic Projects

In April 2003, the Women's Capital Corporation first filed an application with the Food and Drug Administration to allow Plan B(R) to be sold over-the-counter. It was not until August 2006 that a partial victory was achieved when the drug became available OTC to women 18 and older3. This victory can be tied directly to the Compton Foundation's grants to such national organizations as the Reproductive Health Technologies Project and the National Women's Health Network, as well as grants to state level organizations, all of which focused on advocacy and mobilization of support from other interested groups. Their work included FDA hearing strategies, commissioner confirmation strategies, and press work.

The carefully planned work of these organizations constitutes a fascinating story of successful accomplishment in the face of adversity, political intrigue and partisan ideology. The Foundation's funding was cited as critical for its contribution to upholding the integrity of science in the process of getting EC approved for over-the-counter sale to people 18 and over. These groups, while hoping that the next administration will extend OTC status without age or identity restrictions, are not leaving anything to chance. They have filed a lawsuit arguing that the age restriction is arbitrary and capricious and not supported by scientific evidence.

The Compton initiative provided extensive support to the Pharmacy Access Partnership whose purpose was to change legislation in California to enable women to have direct access to emergency contraception at pharmacies without requiring a prior visit to a doctor or clinic. The Partnership was modeled on a similar ground-breaking demonstration project undertaken in Washington with support of the Packard Foundation, and subsequently replicated in California and elsewhere. In 2002, California became the first state in the nation to pass legislation specifically designed to ease and increase consumers' access to EC at pharmacies. As of June 2007, more than 1100 pharmacies in the state provide EC directly to consumers.

The pharmacy access model has been replicated, with some variations, in nine states (AK, CA, HI, MA, ME, MT, NH, NM, VT) and a number of states have introduced legislation or pursued changes in pharmacy practice that would allow them to adopt similar policies. The initiative funded a number of these successful state efforts as well as efforts in other states that have not yet been successful.

The pharmacy access movement was instrumental in obtaining FDA over-the-counter approval of EC because it could contribute evidence that the product could safely be dispensed without clinician intervention. The movement substantiated the claim that EC was safe, with years of evidence that could be used in testimony at FDA hearings.

The fact that EC is now available over-the-counter for people 18 and older would seem to diminish the importance of the pharmacy access movement. However, until the over-the-counter status of EC applies to people under 18 as well as undocumented people, there will be a continuing need to use this mechanism to assure that younger clients and people who are not citizens are able to access the method at pharmacies without a prior visit to a clinician. Unfortunately, many pharmacists have construed the OTC rule of "18 and older" to supplant the pharmacy access legislation for all women. This has created a problem requiring continuing education of both consumers and pharmacy providers.

Ironically, now that EC is available over-the-counter, it may be less available to low-income women who qualify for Medicaid services because Federal funds may not be used to pay for drugs available over-the-counter. Eight states have chosen to continue to cover EC for Medicaid eligible women by using state general funds to cover the cost. However, these states limit the number of Medicaid-subsidized EC doses a woman can receive in a year, ranging from two to twelve units, a restriction that may not be responsive to the needs of all consumers. In most other states, women on Medicaid can still get coverage for EC, but need to take the added and time consuming step of getting a prescription, even if they meet the OTC age requirement.

The initiative made several grants aimed at assuring, through legislative and regulatory advocacy, that emergency contraception is available in hospital emergency rooms for women who have been sexually assaulted. Currently, 16 states have passed laws or regulations requiring hospital emergency rooms to provide information about emergency contraception, but only 15 of these include the requirement that EC be dispensed to the victim on request. While this represents progress over conditions in 2001, activists recognize that there is much more work to be done.

The legislative climate for expanding access to EC varies among states, and in some it is quite negative. Only two states have laws in effect requiring that all valid prescriptions be filled by pharmacies (CA, NJ) and only one requires any pharmacy dispensing birth control methods to also dispense EC (IL). Four states have laws allowing individual pharmacists to refuse to dispense emergency contraception (AR, GA, MS, SD) and one of these (MS) extends refusal coverage to pharmacies as well.

International Projects

Today, dedicated emergency contraception products are available in over 140 countries, and are available without a prescription in more than 30 of them. As of April 2008, Canada joins the group of countries providing EC without a prescription.

Through its funding of the International Consortium for Emergency Contraception and that organization's affiliated regional consortia, the initiative has sped the rate of diffusion of information about emergency contraception, and provided a structured way in which information, ideas and strategies could be shared among advocates. The consortia have been a resource for distributing the latest scientific findings, spreading news of the latest policy developments across the globe, creating talking points on hot button issues, and providing technical assistance to activists in disparate countries and regions of the world. These functions are enormous timesavers and eliminate vast duplication of effort that would be required if the consortia did not exist.

The consortia have played a key role in defending access to emergency contraception in regions where it has come under attack, such as in Latin America where the Catholic Church has actively campaigned against it. It has been noted with some irony that a positive consequence of the public opposition of the Catholic Church is that the concept and method have become better known and more widely used.

The Latin American Consortium is now well established, with a large, growing and diverse membership composed of over 100 governmental and non-governmental organizations, family planning agencies, academics, women's groups, activists, social marketing specialists, youth organizations and pharmaceutical companies. It holds elections for the two-year consortium coordinator job (a part-time, paid position) and has conducted internal reviews of organizational performance aimed at improving its services to members. The coordinator position was first staffed by the Pacific Institute for Women's Health in Los Angeles, but then rotated to organizations in Chile, then Bolivia, and now Peru.

The initiative supported a large number of small grant projects in Mexico and Central America. In the first years of the initiative, these started as direct grants to organizations in the region; later initiative funds were distributed through a re-granting program managed under the Emergency Contraception Leadership Initiative of International Health Programs, a center of the Public Health Institute. Some of these projects aimed at increasing awareness of EC in indigenous communities while others focused on educating health care providers about EC. Still other projects focused on advocacy that attempted to create a more favorable environment for the promotion of EC access. The cumulative and long-term impact of these small grants cannot be assessed by methods available in the current review.

Emergency contraception is now widely available in the private sector throughout Latin America. The same cannot be said for public health services. With few exceptions, public sector clinics in Latin America do not provide dedicated EC products to clients; if they do, it is usually the so-called Yuzpe4 Regimen. Most recently, as a result of a decision in April of this year by Chile's Constitutional Court, free emergency contraception is banned from public health centers in that country; in the opinion of the justices, it is an abortifacient. This argument flies in the face of overwhelming scientific evidence that the method works primarily and maybe entirely through delaying or preventing ovulation. More than 10,000 people took to the streets to decry the court's decision. EC remains available in the private sector in Chile for $25 US.

Many Latin American countries have multiple brands of EC available; women in Brazil have 10 to choose from, and women in Peru have 21. While most Latin American countries have incorporated emergency contraception into their norms for family planning and reproductive health care, according to data on the consortium website, very few have incorporated them into their norms for care of victims of sexual assault.

In Africa, efforts to expand access to emergency contraception have moved more slowly. However, once again, the Compton initiative has played an essential role in the progress to date. By introducing to the Hewlett Foundation the initial proposal from the Population Council to establish an African consortium, modeled on the Latin American Consortium, the initiative served as the midwife for the birth of ECafrique. The Hewlett Foundation has now provided or committed multi-year funding in excess of $1.2 million for ECafrique programs.

The consortium in Africa has a smaller and less diverse membership base than the one in Latin America. It works to promote EC access in both English and French speaking countries, however rather than being membership operated, the consortium is managed by the Population Council through its office in Nairobi.

ECafrique has evolved since its inception in 2003. At that time, it had a re-granting program that provided support to large international non-governmental organizations (NGOs) working to bring emergency contraception, and reproductive health services generally, to African countries. Now, it focuses its re-granting program on smaller, local NGOs, and provides them with substantial amounts of technical assistance to develop their proposals and to execute their projects once funded.

Efforts to broaden awareness of and access to EC in Africa suffer from the endemic weaknesses in the health service infrastructure. In addition, where it is influential, the Catholic Church has attacked EC in some countries such as Uganda. In other countries, the media have editorialized on the potential of EC to contribute to promiscuity among young women, another fear that is not substantiated by the research evidence. Nonetheless, their stories have slowed progress in making EC available in public health clinics. In countries such as Kenya where, until recent election violence, there was observable economic growth and a burgeoning middle class, the cost of EC at the pharmacy is within the reach of young women in urban areas who have salaried jobs.

Because of the large number of both internal and international refugees in many African countries, there has been concern for women in refugee camps who have been victims of sexual assault in these settings. Sexual violence as a form of political terror is also on the increase in some areas, creating the need for heightened awareness on the part of caregivers for addressing the needs of women (often young women) subjected to these atrocities. Providers and policy makers overwhelmingly recognize EC as necessary in cases of rape, even if they are reluctant to make it available for women generally. The UNFPA has created "rape kits" to address this sad circumstance. Among other things, the kits contain both emergency contraceptive pills and anti-retroviral drugs, targeting the prevention of HIV.

Status of Emergency Contraception at End of Initiative

In 2008, emergency contraception is considered and integral part of high quality reproductive health care. While EC may not yet have achieved full mainstream status globally, it is well on the way to achieving it. There has been expanded awareness and availability worldwide. There are now an estimated 30 manufacturers marketing 68 different brands of EC, most based on the levonorgestrel formulation, in over 140 countries. In 44 of these countries, EC is readily available. Unfortunately, most of these products still do not have any quality assurance built into their manufacture.

It is estimated that emergency contraception can be found in 90% of the countries in sub-Saharan Africa. The same is true for countries in Latin America, where it is available with only a few exceptions. However, having EC present in a country does not guarantee either awareness or availability for all, or even average, residents. Private sector pricing continues to be a barrier to access in many places including the U.S., and distribution systems may have regional weaknesses that limit access, such as in rural areas. Recently published findings from surveys on contraceptive knowledge and use in 35 developing and transitional countries found that emergency contraception was still among the least known methods of avoiding unwanted pregnancy.

It is probably safe to say that the private sector (including private, non-profits) leads the public sector in making EC available in most countries. Domestically, for example, sales of EC pills at Planned Parenthood affiliates nationwide increased by an average of 25% a year between 2001 to 2006, going from fewer than 500,000 units in 2001 to nearly 1.5 million in 2006, the latest year for which figures are available. While many Planned Parenthood clients qualify for subsidized EC, those that don't are able to purchase it on a sliding price schedule. For example, Planned Parenthood Mar Monte sells Plan B(R) for between $20 and $40 per unit, depending on a client's income. In a personal communication, the CEO of the affiliate reported that since EC went over-the-counter they now have men, as well as parents and grandparents, buying it; the latter are not buying it just for their daughters and granddaughters but also for their sons and grandsons.

When Plan B(R) went over-the-counter for consumers 18 and over in August 2006, sales surged in the following year according to an article in The Washington Post. The Post reported that Barr Pharmaceutical expected sales to total about $80 million in 2007, almost double the total for 2006 and up eightfold from 2004 when it acquired the product as a prescription-only drug.

During the six years of the initiative, there has been a greater understanding of emergency contraception's mode of action and its efficacy. It is now known that EC prevents ovulation and has its highest effectiveness when used up to five days prior to ovulation. It is not effective after fertilization and therefore cannot be considered an abortifacient. Because there is no routine way to know when ovulation will occur or is occurring, much EC is consumed when it is not required or providing benefit.

Research completed or compiled to date on the potential role of EC in reducing unintended pregnancy has not met earlier heightened expectations; no "population" effect has been found. EC advocates have been pro-active in asking questions about efficacy. Possible reasons for the outcomes to date include the likelihood that EC is not being taken after every act of unprotected intercourse in the studied populations; the efficacy of the method is less than originally calculated; and that the sample sizes of the study populations are too small to accurately measure the effect. Not much is known about the characteristics of the consumers and their motivation, e.g., why don't they take it after every act of unprotected intercourse? Have they tried it once and found the experience too uncomfortable to repeat? Many providers also believe that EC has not achieved utilization levels that would produce a noticeable public health effect; they believe that as use increases, an effect will be achieved. When we understand more about what women think regarding EC and what those who have used it tell their friends, we may gain insights into how messaging about appropriate use of EC can be enhanced.

Irrespective of the absence of a measurable effect on the incidence of unintended pregnancy, promoting access to emergency contraception is justified from a human rights perspective for the benefit it provides to individual women; it gives women a second chance to prevent pregnancy. One interviewee offered an analogy: many people benefited from seatbelt use before seatbelt use became widespread enough to produce a statistical reduction in morbidity and mortality. Those early adopters of seatbelt use were the beneficiaries of seatbelt availability. Women today who chose to use EC are those early adopter beneficiaries. When women everywhere have ready access to affordable emergency contraception, the public health benefits will be seen.

Future Directions and Continuing Work

As reported above, much progress has been made in mainstreaming emergency contraception in reproductive health care, but there are continuing challenges and much work remains to be done.

The price, combined with age restrictions on its OTC status in US pharmacies, continues to be a major barrier to adequate EC access for low-income women and teens. US pharmacies typically charge between $35 and $50 for a packet of EC pills; in other countries, the drugstore price of EC is dramatically lower, and the public sector price is even lower. For example, in Bangladesh, EC pill sell for 2 cents, the subsidized price in the public sector, without restriction on the number of doses a woman can obtain.

It is essential that the price of EC be brought down for American women if it is to be accessible to everyone whenever it is needed. To address these issues, policy advocates recognize the need for a larger advocacy mix and a broader advocacy strategy, using online social networks, for example, and expanding the coalition to address the needs of all low-income and uninsured women, not just those who are Medicaid eligible.

There are reports of efforts underway to bring another generic EC pill to the US market when the current non-patent exclusivity for Plan B(R) ends in August 2009. It is anticipated that this product will break the price barrier.

Since research has shown that taking both pills in an EC packet at the same time has the same benefit as taking them 12 hours apart, it is likely that a single pill version of EC will come to the US market in the not-too-distant future. There are already 14 single-pill brands being sold in other countries. This may improve the efficacy, at least in those instances when the consumer fails to take the second pill at the right time.

New EC compounds and delivery modalities are also being developed and tested. Stage III clinical trials of a new pill to be marketed under the trade name "Ella" have just been completed and it is anticipated that application for FDA approval will occur in the first quarter of 2009. The clinical trials will determine if Ella has a longer duration of efficacy than currently available compounds. If it does, this product's greater efficacy may be more likely to contribute to the desired population effect of reducing unintended pregnancies. Additional compounds are in exploratory phases of development and will not be brought to market for years, if ever.

The Population Council is developing a vaginal ring for regular birth control that contains a different hormone in association with an estrogen. The ring, when first inserted, has a "burst effect" which results in it working as a possible form of emergency contraception. If removed, the burst effect upon later reinsertion reoccurs but at a much lower level. The ring can be inserted late in the cycle and blocks ovulation but its efficacy as an EC method has not been established. If left in, the ring provides normal birth control for up to 12 months. The ring, developed for a regular birth control method, is in Stage III clinical trials but its availability for reproductive health programs is likely to be a few years away. Another possibility is an injectable form of levonorgestrel that would work as emergency contraception initially and would continue to provide contraceptive protection for the period of time that it remains in the bloodstream; the World Health Organization is in early stage exploration of this modality according to one of the people interviewed for this report. It is unlikely that such an injectable EC will be available for many years, if ever.

There is a great deal of interest in so-called "bridging" of EC users to regular contraceptive measures. Studies are underway in Africa that will look at how programs can increase the likelihood that women who seek EC can be persuaded to adopt a longer-term method of birth control. Both the vaginal ring and the injectable method mentioned above have the prospect of being "self-bridging" methods, automatically providing the EC benefit while continuing to provide longer-term contraceptive coverage. Another suggested approach to bridging puts EC pills in the same package with a monthly cycle of birth control pills, with the EC pills being the first taken. Several people have observed that EC users may not want to be "bridged." One study in Kenya found that one-quarter of the women in the study used EC as their primary method of birth control. One observer suggested that Plan B(R) might in fact be Plan A for some women.

Not much is known about EC users and their motivations. It is widely reported that women use EC after some acts of unprotected intercourse but not others. There are anecdotes referring to the user's feelings about her partner that influence the decision whether to take EC: if she definitely would not want to become pregnant by the partner, she will take EC; if she would not mind becoming pregnant by the partner, she may not. A better understanding of EC consumers' thinking and behavior with regard to EC use could help providers better frame their communications and perhaps increase consistency of use; research is needed in this area. A recently completed online survey of EC users undertaken by the Academy for Educational Development may provide some early clues and interesting findings, but the acknowledged bias in the sample limit the lessons that can be learned.

It is anticipated that in the future there will be reduced donor interest in funding programs that focus exclusively on emergency contraception. It would be unfortunate if some of the organizations that have developed the capacity to continue forward momentum of the EC movement, such as the consortia, were unable to obtain funding to continue their work. Their work increases the efficiency and effectiveness of efforts to fully achieve mainstreaming of EC as a component of quality reproductive health programs. Moreover, a number of very experienced experts interviewed for this report noted that the emergency contraceptive movement has re-energized reproductive health advocates, and as a result there has been a spill-over effect that has renewed the field generally. Clearly, when emergency contraception is fully mainstreamed - readily available and affordable - the need for an "EC Movement" will disappear, but that time has not yet arrived.

What Edith Eddy believed at the launch of the Compton EC initiative remains true today. The private sector in the U.S. has not come forward to promote awareness of and access to emergency contraception at anywhere near the level that some had expected and hoped. The manufacturers of Plan B(R) have been the beneficiaries of years of major investment by many foundations in the promotion of emergency contraception, as well as the tireless energy of advocates and activists who are committed to assuring all women can obtain this woman-empowering, second-chance method of birth control. We can only hope that increased competition in the marketplace will be a catalyst to action in the private sector.

Afterword: Some Lessons Learned

The initiative, by virtue of the size of its commitment in dollars and length of implementation, positioned the Foundation as a leader in the area of emergency contraception. Moreover, in so doing, it resulted in the attraction of other donors and the leveraging of additional resources to help achieve its goal.

The innovative use of an initiative coordinator, combined with an expert committee, proved to be a successful model that contributed to the positioning of the Foundation as a leader in this field. Without this structure, the initiative might not have achieved the recognition that it did nor have accomplished as much. It brought the Foundation expertise, input, reach and influence that it might not have obtained under traditional grant-making mechanisms.

By becoming established as the nexus of activities in the EC advocacy and service delivery community, the initiative was able to promote synergies among organizations and individuals, contributing to the better use of resources by both donors and recipients.

By focusing on projects aimed at mainstreaming EC into health systems, the initiative invested its money in ways that will have lasting impact.