Experience with oral emergency contraception since the OTC switch in Germany

The current status of emergency contraception use in reproductive-aged Korean women: a population-based internet survey

Objective

This study was conducted to assess the current status of emergency contraception (EC) use in reproductive-aged Korean women.

Materials and methods

This study utilized a population-based, cross-sectional online survey using a self-completed questionnaire in women aged 20-44 years who had visited a clinic in the previous six months for contraception counseling. Reason for use, anxiety, and counseling for further contraception at EC use were analyzed according to age, history of childbirth, and contraceptive failure in EC users.

Results

Among 1,011 respondents, 461 (45.6%) had experience with EC use. Younger age, need for EC due to inadequate contraception, and high anxiety were highly prevalent among EC users. However, women in the 20s were less likely to get counseling for further contraception at EC use. Additionally, the proportions of women who used EC due to inadequate contraception during sexual intercourse and who experienced high anxiety were lower among women who had a history of childbirth. Women who had a history of contraceptive failure worried less about EC use.

Conclusion

Our findings offer insight for developing and improving individualized strategies for appropriate contraception, especially in young Korean EC users.

Messaging and access strategies for improving emergency contraceptive knowledge and uptake among Italians

OBJECTIVES

Over-the-counter emergency contraception (EC) purchase was legalised in Italy in 2015. Knowledge and access gaps, however, remain. The goal of this study was to explore women's and men's EC informational and access needs.

METHODS

As part of a larger reproductive study, researchers conducted 42 in-depth interviews (May-June 2019) with English-speaking women and men aged 18-50 years (mean ± standard deviation, 29.1 ± 7.9 years) living in or near Florence, Italy, and using the Italian health care system. Researchers completed qualitative data analysis to identify emergent themes related to EC knowledge, attitudes and access. HyperRESEARCH aided data organisation and analysis. Researchers used a comparative method to contextualise data and identify emergent themes.

RESULTS

Findings demonstrated that peer communication and experiences served as influential factors in others' EC use. This propagated misinformation, reducing participants' confidence in EC efficacy and safety. Women described the relevance of relationship type in whether to engage men in EC discussion, while men desired an active supportive role. Finally, participants described various messaging and access channels to increase EC knowledge and access.

CONCLUSION

Findings offer practical recommendations to guide social marketing and behaviour change interventions to increase EC access among women and men in Italy. The utility of pharmacists to individuals wishing to access EC is explored.

Dispensing and practice use patterns, facilitators and barriers for uptake of ulipristal acetate emergency contraception in British Columbia: a mixed-methods study

BACKGROUND

Ulipristal acetate 30 mg became available as prescription-only emergency contraception in British Columbia, Canada, in September 2015, as an addition to over-the-counter levonorgestrel emergency contraception. In this study, we determined dispensing and practice use patterns for ulipristal acetate, as well as facilitators of and barriers to emergency contraception for physicians, pharmacists and patients in BC.

METHODS

In the quantitative component of this mixed-methods study, we examined ulipristal acetate use from September 2015 to December 2018 using a database that captures all outpatient prescription dispensations in BC (PharmaNet) and another capturing market sales numbers for all oral emergency contraception in BC (IQVIA). We analyzed the quantitative data descriptively. We conducted semistructured interviews from August to November 2019, exploring barriers and facilitators affecting the use of ulipristal acetate. We performed iterative qualitative data collection and thematic analysis guided by Michie's Theoretical Domains Framework.

RESULTS

Over the 3-year study period, 318 patients filled 368 prescriptions for ulipristal acetate. Use of this agent increased between 2015 and 2018. However, levonorgestrel use by sales (range 118 897-129 478 units/yr) was substantially higher than use of ulipristal acetate (range 128-389 units/yr). In the 39 interviews we conducted, from the perspectives of 12 patients, 12 community pharmacists, and 15 prescribers, we identified the following themes and respective theoretical domains as barriers to access: low awareness of ulipristal acetate (knowledge), beliefs and experiences related to shame and stigma (beliefs about consequences), and multiple health system barriers (reinforcement).

INTERPRETATION

Use of ulipristal acetate in BC was low compared with use of levonorgestrel emergency contraception; lack of knowledge, beliefs about consequences and health system barriers may be important impediments to expanding use of ulipristal acetate. These findings illuminate potential factors to explain low use of this agent and point to the need for additional strategies to support implementation.

Translating policy to practice: theory-based formative research to improve messaging and over-the-counter access to emergency contraception in Florence, Italy

OBJECTIVES

Italy's 2015 emergency contraception (EC) policy made EC available without prescription for individuals aged 18 years and older; however, women living in Italy continue to face barriers to accessing EC. The purposes of this study were to understand EC knowledge, attitudes and behaviours among women living in Italy and explore the impact of the 2015 policy.

METHODS

Researchers conducted 30 interviews with women living in Florence, Italy, aged 18-50 years and using the Italian health care system. Researchers used an expanded grounded theory approach to understand women's EC experiences, with diffusion of innovations (DOI) serving as a conceptual lens. Researchers completed open and axial coding to identify emerging themes.

RESULTS

Participants had low awareness of the 2015 EC policy and suggested increased messaging in strategic locations to overcome this barrier. They held positive and negative attitudes towards EC: while some perceived the advantage of EC compared with unintended pregnancy, others expressed concerns about irresponsible behaviour and safety. Finally, conscientious objection impacted access, despite women's desire for autonomous EC decision making.

CONCLUSION

The findings offer practical recommendations to guide EC messaging in Italy to increase women's access to EC. Recommendations include using theory- and audience-based methods to overcome gaps in policy knowledge and real and perceived barriers to EC access. Incorporating DOI as a theoretical framework with women's voices presents a novel opportunity to enhance policy and EC dissemination.

Ulipristal acetate and pregnancy outcome-an observational study

STUDY QUESTION

Is the failure of the selective progesterone receptor modulator ulipristal acetate (UPA) as emergency contraception (EC; 30 mg, single) or inadvertent exposure for myoma treatment (5 mg/d) in pregnancy associated with a higher risk of birth defects, spontaneous abortion (SAB) or elective termination of pregnancy (ETOP)?

SUMMARY ANSWER

We did not find an increased risk for birth defects, SABs or ETOPs after UPA exposure during implantation and early embryogenesis.

WHAT IS KNOWN ALREADY

Pregnancy outcome data after exposure to UPA are very limited. In cases of EC failure or unplanned pregnancy during myoma treatment, women need well-grounded risk assessment to minimize anxiety and prevent unjustified termination of pregnancy.

STUDY DESIGN, SIZE, DURATION

Observational study of prospectively ascertained pregnancies from the German Embryotox institute with UPA exposure (EC, n = 95; myoma, n = 7). Four retrospectively reported pregnancy outcomes were evaluated separately.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 226 requests on ulipristal were directed to the German Embryotox institute during the study period 2010-2018. Outcomes of pregnancies exposed-(i) precycle, (ii) preconceptional or (iii) first trimester-were ascertained using standardized questionnaires. Descriptive statistics were applied.

MAIN RESULTS AND THE ROLE OF CHANCE

Failed EC with UPA resulted in 95 prospectively ascertained pregnancies, of which 56 had completed follow-up: 37 live births, 7 SABs and 12 ETOPs. There was no major birth defect. Just 34% of women had taken UPA during the fertile window. Seven prospectively enrolled pregnancies were treated for myoma and had known pregnancy outcomes: five healthy live births and two SABs. Among the four retrospectively reported pregnancies after EC, there was one child diagnosed with Beckwith-Wiedemann syndrome (BWS).

LIMITATIONS, REASONS FOR CAUTION

Our limited sample size does not allow concluding safety of UPA use in pregnancy.

WIDER IMPLICATIONS OF THE FINDINGS

We provide a preliminary basis for reassuring women who wish to carry their pregnancy to term after EC or myoma treatment with UPA. However, because of the report of a BWS after UPA exposure, a possible epigenetic effect could not be excluded and requires further evaluation.

STUDY FUNDING/COMPETING INTEREST(S)

This work was performed with financial support from the German Federal Institute for Drugs and Medical Devices (BfArM). All authors declare that they have no conflicts of interest.

TRIAL REGISTRATION NUMBER

Registered with the German Clinical Trial Register (DRKS00015155).

Trends in dispensing oral emergency contraceptives and safety issues: a survey of German community pharmacists

Background Oral emergency contraceptives containing levonorgestrel or ulipristal acetate are available without prescription and only in pharmacies in Germany since March 2015. Due to this change community pharmacists are responsible for evaluating whether the product is appropriate and to educate women on proper use. Objective To measure the utilization of emergency contraceptives without a prescription and describe potential concerns and safety issues identified by community pharmacists in Germany. Setting The Drug Commission of German Pharmacists' nationwide network of reference pharmacies which includes 860 community pharmacies. Methods Reference community pharmacies were asked to participate in the eleven-questions online survey. Respondents were asked to recall their experiences with oral emergency contraceptives in the past 3 months. Data were collected between January 8 and February 19, 2018. Main outcome measure The survey focused on the utilization of emergency contraceptives without a prescription in Germany, and on the pharmacists’ experiences with (potential) problems and concerns regarding safe use. Results In total, 555 community pharmacies (64.5%) participated. Overall 38.2% of community pharmacists stated they dispensed six to ten courses of emergency contraceptives within the past 3 months. In addition, 54.3% of the pharmacists estimated they dispensed emergency contraceptives exclusively without prescription and 35.9% dispensed more than 30% of emergency contraceptives during night-time and emergency services. Moreover, 82.8% of pharmacists stated that emergency contraceptives were requested not by the women concerned but a third person and 44.3% identified uncertainties in woman's self-diagnosis. Three out of four pharmacists had concerns about the effective and safe use of emergency contraceptives. In situations suggesting sexually transmitted diseases, or suspicion for use of force, 59.5% and 55.8% of the pharmacists, respectively, dispensed emergency contraceptives. In cases of acute health impairment or chronic disease, or (potentially) relevant drug/drug interaction, the vast majority (91.0% and 90.5%) did not. Here, most pharmacists referred to gynecologists. Conclusion Pharmacists had safety concerns when dispensing emergency contraceptives. Professional expertise in evaluating the need for oral emergency contraceptives and the proper use is needed.

The attitudes of Korean physicians toward emergency contraceptive pills: regarding women's access and rescheduling

OBJECTIVE

This study investigated the attitude of Korean physicians toward women's access to emergency contraceptive pills (ECPs) and the reclassification of ECP to a behind-the-counter (BTC) drug.

METHODS

This study involved 946 physicians who had prescribed ECP in South Korea. The written questionnaires were completed by obstetricians and gynecologists, family physicians, internal medicine doctors, and pediatricians.

RESULTS

Regarding the barriers limiting women's access to ECP, 24.8% of physicians responded that women lacked information about ECP and 22.5% felt that women were likely to be emotionally burdened by visits to clinics or hospitals to obtain ECP prescriptions. Ninety-two percent of physicians responded that ECP should remain a prescription drug while 6.1% stated preferences for a switch to a BTC drug. Physicians who opposed the switch were concerned about the potential abuse of ECP. In order to prevent ECP abuse, the most important factor to be considered was education on contraception.

CONCLUSION

A majority of Korean physicians opposed the reclassification of ECP to a BTC drug owing to their belief in increasing the role of educational initiatives about contraception and contraceptive practices before improving the access to ECP. This study is also of the opinion that contraceptive education for youth and adults in Korea should be more realistic and active, with an emphasis on regular contraception use before reclassification. Furthermore, we believe that efforts are needed to ensure accuracy of information on contraception to facilitate women's access to ECP.