Emergency contraception has been on the rise in Italy in the past 10 years, especially after recent liberalization laws. Gianpiero Dalla-Zuanna, Anna Giraldo and Marzia Loghi discuss the pros and cons of this relatively new contraceptive method.
Emergency Contraception Pills (ECPs) first appeared in the early 1990s, with the first ECP being approved by the US Food and Drug Administration in 1999 for use on prescription. Over the last decades, new ECPs have emerged and become increasingly widespread in both developed and developing countries. The most widely used ECPs are based on two different active ingredients:
1) levonorgestrel (LNG), a synthetic progestogen commonly known as the morning-after pill, that can prevent pregnancy if taken within 48 hours of sexual intercourse, and
2) ulipristal acetate (UPA), which can inhibit conception if taken within 120 hours (5 days) of unprotected sex.
ECPs are not recommended as ordinary contraception, but only in case of contraceptive error (condom breakage, forgetting the daily pill…) or after unprotected sex. The side effects of ECPs are modest, and they have few contraindications. There is general consensus in the scientific literature that neither LNG nor UPA are abortive drugs, as they prevent fertilization by inhibiting or delaying ovulation.
The diffusion of ECPs in Italy
ECPs became available in Italian pharmacies in 2006 (LNG) and 2012 (UPA). Between 2012 and 2021, the diffusion of ECPs in Italy increased considerably: from 2.2 per 100 women aged 15–49 in 2012 to 5.5 in 2021. This level is similar to those estimated in other European countries such as France (6.2% in 2016), and the Netherlands (5.0% in 2017), although lower than the United Kingdom (33% in 2014), where ECPs have always been free of charge (ECEC 2024). However, the increase was not linear over time: while sales remained stable at around 340,000 single doses per year in the three years 2012-14, there was a continuous increase over the following five years, reaching more than 588,000 in 2019. Sales then fell in 2020, only to rise again the following year.
The spread of ECPs in Italy increased significantly when UPA (in March 2015) and LNG (in May 2016) became available over the counter, without a prescription (Dalla-Zuanna, Giraldo & Loghi 2025). Sales rose from 30,000 to 40,000 single-dose packs per month from 2014 to 2016, compared to the three-year period of 2012-14 when the number of doses sold remained constant (Figure 1). The estimated number of unwanted pregnancies prevented thanks to ECP rose from about 10,000 in 2014 to some 16,000 in 2016, and 21,500 in 2021, helping to make the abortion rate in Italy one of the lowest in Europe. This increase in sales, and in particular the preference for UPA – whose sales have steadily exceeded those of LNG since early 2021 – was also bolstered by UPA becoming available as an over-the-counter drug for minors without a prescription in October 2020.
The effect of COVID-19 lockdown
During the strict COVID-19 lockdown of March-May 2020, sales of emergency contraceptive pills in Italy decreased by 38% compared to the same quarter in 2019, with a 61% reduction in April 2020, the month of strict and complete lockdown, compared to April 2019 (Figure 2). Nonetheless, conceptions during the lockdown also declined significantly, especially those resulting in an abortion and those among women below age 25. This result suggests that
a) ECPs are widely used by non-cohabiting partners, and
b) ECPs have played a non-marginal role in the second Italian contraceptive revolution, in particular by reducing unwanted pregnancies among singles, who are frequent condom users and/or exposed to the risk of unprotected sexual intercourse.
The importance of ECPs sales and dissemination strategies
Although there are no recent nationally representative surveys on the diffusion of contraception in Italy, data on oral contraceptive sales and some surveys on particular groups suggest that the drop in conception and abortion in Italy in the first decades of the twenty-first century has mainly been due to the decline in coitus interruptus as a contraceptive method, and the spread of condoms (especially for casual and juvenile sexual intercourse) and the daily pill (particularly in stable couple relationships). However, the contribution of ECPs has grown steadily since liberalization, and it may continue to do so, as there is considerable room for improvement, for example, by bridging current geographical disparities: 6.4 doses of ECP per 100 women aged 15-49 were sold annually in 2019‒2021 in Liguria, compared with just 3.6 in Sicily. Unfortunately, little is known about the socio-demographic characteristics of ECP users (social class, age, relationship status…) or the reasons for using this method (condom breakage, forgetting the daily pill, direct contraception…).
Based on the probabilities of conception for a single act of sexual intercourse followed by the use of LNG or UPA – as estimated by Glasier et al. (2010) – ECPs alone are much less effective in preventing conception than other contraceptive methods. The annual probability of becoming pregnant with perfect use is 1% for the daily pill, 0. 6% for the IUD, 2% for condoms. In contrast, for a woman who has sex once a week (about 52 times a year), without avoiding her fertile days, and without any other hormonal contraceptive method, the annual probability of conception jumps to 68% for LNG and 51% for UPA, if she uses only ECPs. Moreover, misconceptions about the contraceptive efficacy of ECPs are widespread in Italy: 49% of a sample of Italian women aged 16-45 interviewed by Nappi et al. (2014) “agreed” or “strongly agreed” with the statement “ECP is 100% effective if taken the next day”. This proportion was higher than, for, instance, in France (43%), Spain (42%), Germany (37%), and the UK (35%).
What policy indications can be drawn from these figures? It would be judicious to maintain the current policy of selling ECPs in pharmacies, which guarantees interaction with the pharmacist who is required by law to warn users of the limited contraceptive power of ECPs and their unsuitability as an ordinary contraceptive method. It would also be useful to extend LNG without a medical prescription to minors, as was done for UPA in October 2020. The free distribution of emergency contraception may not be desirable, because it could lead to improper use as a substitute for more effective methods, although the current prices are high: €21.50 and €28.90, respectively, for a single dose of the most popular commercial brands of LNG and UPA at the end of 2024.
Extensive information campaigns are needed, both on the high risk of pregnancy in case of unprotected intercourse and on the use of ECPs. No such information campaign has ever been launched in Italy, despite evidence that the main reason for inappropriate or poor use of ECPs (and of contraception in general) is insufficient knowledge about the risk of pregnancy, available contraception, and reproductive health more generally.
References
Dalla-Zuanna G., A. Giraldo and M. Loghi (2025) “Ten years of emergency contraception in Italy (2012‒21) in the context of the second contraceptive revolution”, Popolazione e Storia, https://popolazioneestoria.it/article/view/1696
ECEC – European Consortium for Emergency Contraception (2024) https://www.ec-ec.org/about-ecec/aims/ visited 22nd February 2024.
Glasier A.F. et al. (2010) “Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis”, The Lancet, 375, 9714, 13-19 February 2010, 555‒562.
Nappi R.E., P.L. Abascal, D. Mansour, T. Rabe, R. Shojai and The Emergency Contraception Study Group (2014) “Use of and attitudes towards emergency contraception: A survey of women in five European countries”, The European Journal of Contraception & Reproductive Health Care, 19, 2, 93‒101.