The issue of  emergency contraception has been around for decades but up until now our laws did not allow doctors to prescribe such pills as they are not available in a single pill form wrongly called ‘morning-after pill’.

I am writing this piece in my capacity as a family doctor. As GPs we are the first doctors to encounter requests for such measures as emergency contraception.

First of I must say that contraceptive pills have been on the local market for decades and some doctors use them as a form of emergency contraception to prevent unwanted pregnancies after a couple would have performed sex a number of hours before.

This is done by giving more than one and up to six contraceptive tables in one dose depending on the brand, followed by a second loading dose 12 hours later. These can be given up to 120 hours after intercourse. So we must not illude ourselves thatemergency contraception is not practised in Malta.

The problem arose when a single pill wrongly called ‘morning-after pill’ of whatever brand was proposed to be made legal. These emergency contraceptive pills (ECPs) can be taken up to 120 hours after intercourse and can still be effective, so it is not just the morning after.

On the international market there are three types of such pills.  There are the combined containing both, oestrogen and progestin, progestin-only and others containing an anti-progestin.   The latter are out of the question for many women, as they are used as abortion pills and currently only available in Armenia, China, Russia and Vietnam.

Scientifically we know that life begins with fertilisation but the pro-ECPs lobbyists say instead pregnancy begins with implantation

So the first thing which should be cleared is which of these will be available. They have different mechanisms of action, effectiveness and side effects.

What is most important in my opinion is their mode of action. It is known that combined pills can inhibit or delay ovulation provided you take them before ovulation. Now the time of ovulation is difficult to calculate and there is no easy and practical way of knowing.

So these are very effective if taken during the first half of the menstrual cycle, before ovulation has occurred. In this case they are purely preventing ovulation and there is no question of being abortive.

But if taken later on they act by impairing endometrial receptivity to subsequent implantation of a fertilised egg. So we are speaking of a life which has already begun even though a bunch of cells.

Scientifically we know that life begins with fertilisation but the pro-ECPs lobbyists say instead pregnancy begins with implantation, which is totally different.  At this stage human life has already started, so these pills have an abortive effect.

Also, these combined pills are as effective as it is claimed because they must have a mechanism of action other than delaying or preventing ovulation.

Regarding the other type of pills, the levonorgestrel-only pills, their method of action is dual. If taken before ovulation the primary mechanism of action is blockade and/or of ovulation.  So in such cases only, they are purely contraceptive and they have no abortive effect. But the reduced efficacy of these pills with a delay in treatment   suggests that interference with implantation is likely.

These are the objective facts. My point is that, no matter what is their mode of action in general and how this is stated on the package insert, every pill when taken acts on a unique way on a particular patient. Nobody knows what really happens, whether a prevention of ovulation or prevention of implantation has occurred. Both things can happen.  In the latter case it is abortion.

Mario Saliba is a specialist in family medicine.

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