Sarah Rich is Senior Technical Advisor at the International Consortium for Emergency Contraception, hosted by Management Sciences for Health.
Mapingure was raped and sought EC at a hospital. The provider told her that she needed a police report. But by the time she came back… she was told it was too late to assist her. She became pregnant as a result of the rape.
–Zimbabwe case from 2014, presented by Godfrey Dalitso Kangaude in “Country overviews of legal grounds/policies related to health, rape, and safe abortion,” April 2016
Emergency contraception (EC) can prevent pregnancy after unprotected sex, including in cases of rape. Global guidance on EC access for sexual assault survivors is clear: EC should be offered to women and girls within 120 hours of the assault to prevent the traumatic consequences of pregnancy resulting from rape. The World Health Organization’s (WHO) clinical and policy guidelines for sexual assault and clinical handbook include strong recommendations to provide EC as part of comprehensive, woman-centered care.
Yet women and girls around the world who have been sexually assaulted do not routinely have access to EC pills. Why is a treatment that is so safe, effective, and easy to administer not always provided? In April, I participated in a three-day meeting hosted by WHO and Population Council to discuss national pregnancy prevention and abortion policies for sexual assault survivors in Eastern and Southern Africa. The meeting brought together global experts with key stakeholders from six countries: Botswana, Ethiopia, Kenya, Malawi, Rwanda, and Zambia.
All six of the participating countries have sexual assault treatment policies in place, and all include EC as a core component of care. But the details in the policies and the ways the policies are implemented matter greatly in determining whether rape survivors can access EC. The Population Council conducted a review of post-rape care policies and programs in Sub-Saharan Africa that uncovered many barriers, and the meeting in April further illuminated the challenges.
National policies tend to be less detailed than global guidance on EC. For example, some are clearer than others that EC should be provided as soon as possible after the assault but that it can be offered up to 120 hours later. Gray areas in the policies can lead to lower access because front-line responders may be likely to err on the side of caution – not providing treatment – when the policy is unclear. Therefore, national policies must include detailed information aligned with global guidance on EC.
Clinics providing treatment do not always have supplies of EC pills. While the national sexual assault policies focus on dedicated EC pills (those packaged and labeled for use as EC), in many clinics these pills are not actually available. Stocks vary by country; in Botswana, for example, the public sector does not procure dedicated EC pills at all. Ideally, countries should procure and distribute dedicated EC pills in their public sector systems; however, if they do not, or if stock outs are a problem, sexual assault treatment guidelines must include information about using regular oral contraceptive pills to make EC.
There is no clear global consensus on when to provide EC to child survivors of sexual assault. Unfortunately, many rape survivors are children and young adolescents. Should a 9-year-old girl who has been raped be offered EC? Some guidance suggests that girls who have not started menstruating should be offered EC if they have secondary sex characteristics, but there is not a global consensus on this suggestion. Forthcoming WHO guidance (expected in 2017) on treating child rape survivors will hopefully provide some clarification.
How can we ensure that survivors know about EC and can access it? Many sexual assault survivors never report the rape or seek clinical treatment. For these women and girls, knowing about EC and being able to obtain it elsewhere is critical. Yet in five of the six countries at the meeting, less than 40% of women have ever heard of EC. Moreover, barriers such as prescription requirements unnecessarily restrict EC access. Making EC widely known and available can help survivors, especially those who do not report or seek clinical care, obtain EC. Some countries have explored provision of EC through community health workers and even through police stations (see evidence from Zambia and Malawi)
These challenges suggest a need for further work to ensure that survivors can prevent pregnancy following rape. For more information about EC access as part of sexual assault care, see ICEC’s fact sheet or sign up for ICEC’s listserv.