The benefits and risks of over-the-counter availability of levonorgestrel emergency contraception

Trends in Utilization of Emergency Contraceptives in Tanzania: A Retrospective Longitudinal Study From 2018 to 2023

Introduction Emergency contraceptives (ECs) are a critical method for preventing unwanted pregnancies following unprotected sexual intercourse. However, Tanzania is experiencing an alarming surge in the misuse of ECs among reproductive-aged females, particularly younger girls and women. Reports of their use as regular contraceptives are a rising concern. Deviations from their intended use in emergencies may not only increase the risk of contraceptive failure but also increase the risk of adverse health events. This study aims to delineate and evaluate the utilization patterns of ECs over six consecutive years using importation data obtained from the Tanzania Medicines and Medical Devices Authority (TMDA). Materials and methods We analyzed the EC data collected by TMDA over six consecutive years using a retrospective longitudinal design. Microsoft Power BI (Microsoft® Corp., Redmond, WA) was used to clean, organize, and aggregate the data. IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States) was used to analyze annual trend utilization using linear regression. Results We analyzed 114 importation consignments for ECs, identifying 95.6% (109 records) as oral ECs and 4.4% (five records) as intrauterine devices (IUDs) between 2018 and 2023. This data revealed a significant increase in the volume of EC imports, with its contribution increasing from 1.9% in 2018 to 60.1% in 2023. This highlights the marked increase in EC consumption in Tanzania. In 2023, the defined daily dose per 1000 inhabitants per year (DID) peaked at 3.917826, indicating an unprecedented increase of 4,983.06% compared to the lowest DID observed in 2019 at 0.0873552. The year 2023 alone accounted for 41.63% of the total DID (9.43) over the entire study period. In 2019 and 2020, there was a decrease in EC consumption, followed by a rapid increase from 2021 to 2023. The reduction in EC consumption from 2019 to 2020 was 36.9% compared to that between 2021 and 2022. Conclusions The significant rise in EC importation and utilization in Tanzania between 2018 and 2023, marked by fluctuating consumption trends and a notable surge, highlights the urgent need for targeted educational and policy intervention. This will guide the rational and informed use of ECs, ensuring access aligns with best practices for reproductive health.

A Detailed Analysis of the Past 20 Years of US FDA-Approved Prescription to Over-the-Counter Switches

OBJECTIVES

This evaluation assesses the quantity, uniqueness, and innovative nature of the past 20 years of Rx-to-OTC (RTO) switches, where a current prescription (Rx) product is reclassified for over-the-counter (OTC) status. Broadening access to more OTC drugs with well-established safety and efficacy could help to reduce healthcare expenditure and address public health challenges.

METHODS

The FDA-maintained RTO switch list website was accessed to generate the primary dataset. Each product listed was assessed for the current OTC availability in the United States of its active ingredient, pharmacological class, and indication to determine its innovative quality. Descriptive statistics were employed in this study.

RESULTS

From January 2002 through August 2022 there were 45 RTO switches. Among these, 51.1% involved a new to OTC active ingredient, 22.2% involved a new pharmacological class, 6.6% involved a new indication, and 82.2% were considered follow-on products that introduced a new to OTC active ingredient or new dosage form of an already marketed active ingredient to treat an existing OTC indication. A small minority (6.6%) were considered an exceptional innovation that would offer US consumers a genuinely novel OTC product, providing a new to OTC active pharmaceutical ingredient, pharmacological class, and indication. Overall, there was 1 exceptional innovation every 6.7 years.

CONCLUSIONS

Over 40 RTO switches have come to the OTC market in the past 20 years; however, exceptional innovations that expand access to new to OTC active ingredients for new indications are rare. Policies and strategies that result in more innovative switches that can benefit consumers and public health should be evaluated.

Medical barriers to emergency contraception: a cross-sectional survey of doctors in North India

BACKGROUND

Some medical doctors in India have publicly expressed opposition to making emergency contraceptive pills (ECPs) easily accessible, even though ECPs are included in the method mix of the Ministry of Health and Family Welfare program and as an over-the-counter (OTC) product. Such opposition affects access to ECPs by influencing policy, procurement, and distribution, besides stigmatizing the ECP user. This study was conducted to assess ECP knowledge, attitudes, and practices of doctors in North India.

METHODS

A cross-sectional survey of 83 doctors who provide ECPs, randomly selected from 3 cities in the state of Uttar Pradesh, was conducted in 2011. The quantitative data were complemented by 19 in-depth interviews with purposively selected senior gynecologists and other opinion leaders.

RESULTS

All surveyed physicians cited the correct dose and regimen for ECPs. However, the large majority of those surveyed believed that ECPs work by preventing implantation. (The best evidence currently indicates that ECPs do not work by preventing implantation.) Most doctors also believed incorrectly that ECPs have several contraindications and side effects. They also had strong reservations against OTC provision of ECPs by pharmacists and community health workers (CHWs) and negative attitudes toward ECP users, which serve as serious medical barriers to mainstreaming use of ECPs.

CONCLUSION

Physicians and their professional associations exert a strong influence on the operationalization of national contraceptive policies. Evidence-based advocacy and educational campaigns targeting doctors are needed to address and resolve their reservations about ECPs, particularly about its provision as an OTC product and its distribution by CHWs. Partnerships with medical associations can help reduce doctors' negative attitudes and create a conducive environment for influencing clinical practices. Such changes are needed to increase the availability and use of ECPs as part of a package of a full range of contraceptive method options to prevent unwanted pregnancy among the most vulnerable populations.

Double-standards in reporting of risk and responsibility for sexual health: a qualitative content analysis of negatively toned UK newsprint articles

Background

The need to challenge messages that reinforce harmful negative discourses around sexual risk and responsibility is a priority in improving sexual health. The mass media are an important source of information regularly alerting, updating and influencing public opinions and the way in which sexual health issues are framed may play a crucial role in shaping expectations of who is responsible for sexual health risks and healthy sexual practices.

Methods

We conducted an in-depth, qualitative analysis of 85 negatively toned newspaper articles reporting on sexual health topics to examine how risk and responsibility have been framed within these in relation to gender. Articles published in 2010 in seven UK and three Scottish national newspapers were included. A latent content analysis approach was taken, focusing on interpreting the underlying meaning of text.

Results

A key theme in the articles was men being framed as a risk to women’s sexual health, whilst it was part of a women’s role to “resist” men’s advances. Such discourses tended to portray a power imbalance in sexual relationships between women and men. A number of articles argued that it was women who needed to take more responsibility for sexual health. Articles repeatedly suggested that women and teenage girls in particular, lacked the skills and confidence to negotiate safer sex and sex education programmes were often presented as having failed. Men were frequently portrayed as being more promiscuous and engaging in more risky sexual health behaviours than women, yet just one article drew attention to the lack of focus on male responsibility for sexual health. Gay men were used as a bench mark against which rates were measured and framed as being a risk and at risk.

Conclusions

The framing of men as a risk to women, whilst women are presented at the same time as responsible for patrolling sexual encounters, organising contraception and preventing sexual ill health reinforces gender stereotypes and undermines efforts to promote a collective responsibility for sexual health. This has implications for sexual ill health prevention and could continue to reinforce a negative culture around sex, relationships and sexual health in the UK.

A systematic review of effectiveness and safety of different regimens of levonorgestrel oral tablets for emergency contraception

BACKGROUND

Unintended pregnancy is a complex phenomenon which raise to take an emergency decision. Low contraceptive prevalence and high user failure rates are the leading causes of this unexpected situation. High user failure rates suggest the vital role of emergency contraception to prevent unplanned pregnancy. Levonorgestrel - a commonly used progestin for emergency contraception. However, little is known about its pharmacokinetics and optimal dose for use. Hence, there is a need to conduct a systematic review of the available evidences.

METHODS

Randomized, double-blind trials were sought, evaluating healthy women with regular menstrual cycles, who requested emergency contraception within 72 h of unprotected coitus, to one of three regimens: 1.5 mg single dose levonorgestrel, two doses of 0.75 mg levonorgestrel given 12 h apart or two doses of 0.75 mg levonorgestrel given 24 h apart. The primary outcome was unintended pregnancy; other outcomes were side-effects and timing of next menstruation.

RESULTS

Every trial under consideration successfully established the contraceptive effectiveness of levonorgestrel for preventing unintended pregnancy. Moreover, a single dose of levonorgestrel 1.5 mg for emergency contraception supports its safety and efficacy profile. If two doses of levonorgestrel 0.75 mg are intended for administration, the second dose can positively be taken 12-24 h after the first dose without compromising its contraceptive efficacy. The main side effect was frequent menstrual irregularities. No serious adverse events were reported.

CONCLUSIONS

The review shows that, emergency contraceptive regimen of single-dose levonorgestrel is not inferior in efficacy to the two-dose regimen. All the regimens studied were very efficacious for emergency contraception and prevented a high proportion of pregnancies if taken within 72 h of unprotected coitus. Single levonorgestrel dose (1.5 mg) can substitute two 0.75 mg doses 12 or 24 h apart. With either regimen, the earlier the treatment is given, the more effective it seems to be.

Are modern contraceptives acceptable to people and where do they source them from across Nigeria?

BACKGROUND

Understanding the extent that different modern contraceptives are acceptable to different populations groups and where they get the commodities from will help in developing specific interventions that will help to scale-up the availability of the contraceptives.

METHODS

The study took place in urban and rural sites in six states across Nigeria. Data on acceptability and sources of the contraceptives was collected from at least 770 randomly selected mostly female householders from each state respectively using a questionnaire. Acceptability of the different contraceptives was scored by the respondents on a scale of 1 (lowest) to 10 (highest). The relationships between acceptability and sources of the contraceptives with socio-economic status and geographic location of the respondents were examined.

RESULTS

The use of modern contraceptives in general was acceptable to 87% of the respondents. Male condom was the most acceptable means of contraceptive with an average score of 5.0. It was followed by implants with and oral contraceptive pill with average scores of 4.0, whilst IUD was the least acceptable with an average score of 2.9. The private sector was the major source of contraceptives to different population groups. Both male and female condoms were mostly procured from patent medicine dealers (PMD) and pharmacy shops. Intra Uterine Devices (IUDs) and implants were mostly sourced from public and private hospitals in the urban areas, whilst injectibles were mostly sourced from private hospitals. Oral contraceptives were mostly sourced from pharmacy shops and patent medicine dealers. There were SES and geographic differences for both acceptability and sources of the contraceptives. Also, the sources of different contraceptives depended on the type of the contraceptive.

CONCLUSION

The different contraceptives were acceptable to the respondents and the major source of the contraceptives was the private sector. Hence, public-private partnership arrangements should be explored so that universal coverage with contraceptives could be easily achieved. Interventions should be developed to eliminate the inequities in both acceptability and sources of different contraceptives. The acceptability of all the contraceptives should be enhanced with relevant behaviour change communication interventions especially in areas with the lowest levels of acceptability.

Emergency contraceptive pills: Exploring the knowledge and attitudes of community health workers in a developing Muslim country

Background:

Unsafe abortion is a major Public health problem in developing countries, where women make several unsafe attempts at termination of the unintended pregnancy before turning to health services. Community health workers can act as a bridge between the community and their health facilities and can use Emergency Contraceptive Pills to significantly reduce the mortality and morbidity related to unsafe abortions.

Aims:

This study explores the knowledge, attitudes and practices of the Lady Health Supervisor of the National Program for Family Planning, district Rawalpindi, regarding emergency contraception pills.

Materials and Methods:

The cross sectional survey was conducted during the monthly meeting of Lady Health Supervisors. Self administered, anonymous and voluntary questionnaire consisting of 17 items, regarding demographic profile, awareness, knowledge, attitudes and practices, was used.

Results:

Insufficient knowledge, high misinformation and strongly negative attitudes were revealed. More than half did not know that emergency contraceptive pills do not cause abortion. About four fifths believed that emergency contraceptive pills will lead to ‘evil’ practices in society. More than four fifths recognized that the clients of National Program for Family Planning need emergency contraceptive pills. The attitudes were significantly associated with knowledge (P=0.034, Fisher's Exact Test).

Conclusion:

The awareness of emergency contraceptive pills is high. Serious gaps in knowledge have been identified. There is a clear recognition of the need of emergency contraceptive pills for the clients of National Program for Family Planning. However, any strategy to introduce emergency contraceptive pills must cater for the misplaced beliefs of the work force.

Misconceptions about missed conceptions: the meanings of emergency contraceptive pills use among young adult couples

Emergency contraceptive pills (ECP) are a safe and efficacious backup method of birth control. Despite widespread availability, ECP is underutilized by young women. While partner level of involvement has been shown to influence contraceptive behavior, there is a dearth of knowledge regarding any possible association between partner influence and ECP use. To better understand the reasons for the seemingly underuse of ECP, a grounded theory study was conducted to elucidate the relationship of couple dynamics and knowledge of, attitudes toward, and decision making regarding the use of ECP in coupled young adults. Consistent with contemporary constructivist grounded theory methods, several categories were identified including the meanings associated with ECP use. This article presents an elaboration of this particular finding. The meanings that participants ascribed to ECP use represented a continuum of value attributes regarding ethics, safety, efficacy, and responsibility.

The Debate About Over-the-Counter Emergency Contraceptive Pills

Many prescription drugs have been converted to over-the-counter (OTC) status in recent years. Another drug that has been proposed for OTC status is a levonorgestrel-only emergency contraceptive pill. The debate surrounding OTC access to emergency contraceptive pills echoes issues encountered in previous reclassification processes and raises new challenges. This article discusses the emergency contraceptive pill, the evolution of its access options, and the context and implications of changing its status from a prescription to an OTC medication.

College students' perceptions of emergency contraception provision

BACKGROUND AND OBJECTIVE

The authors examined college students' perceptions regarding emergency contraception (EC) provision in light of the then pending U.S. Food and Drug Administration (FDA) decision about the over-the-counter (OTC) status of EC.

METHODS

We randomly sampled 7000 male and female students who were enrolled full-time at the University of Michigan during the winter 2006 semester. A total of 1585 (22.6%) students responded to our web-based survey and were included in these descriptive analyses.

RESULTS

Nearly all (94%) respondents knew of EC. When asked whether EC should be made available OTC, 60% of respondents agreed, 23% disagreed, and 17% were unsure. If EC were to be made available OTC, 34% of respondents indicated that they (or their partner) would purchase EC in advance of need, and 44% stated that they would purchase it only after unprotected sexual intercourse or contraceptive failure. Advance discussion and provision of EC is underused. Only 10% of all female respondents indicated that their current healthcare provider had spoken to them about EC in a routine health visit, and just 5% of female respondents were offered a supply of EC in advance of need.

CONCLUSIONS

Continued efforts are needed to ensure timely access to EC in this population.

Essay: the limits of conscience: moral clashes over deeply divisive healthcare procedures

Refusals by individual pharmacies and pharmacists to fill prescriptions for emergency contraceptives (“EC”) have dominated news headlines, from the Washington Post to the Miami Herald. In the act that sparked a firestorm of controversy, an Eckerd pharmacist refused to fill a rape victim’s prescription for Plan B. A few months later, 11 Alabama nurses resigned positions at state clinics rather than provide EC against their moral convictions. These refusals do not seem to be driven by moral concerns about promiscuity, since pharmacists have refused to dispense Plan B to married couples as well. Instead, the refusals reflect moral and religious concerns about facilitating an act that would cut-off a potential human life.

The profile of emergency contraception users in a chlamydia prevalence study in primary care in Belgium

INTRODUCTION

We describe the use of emergency contraception (EC) and its association with sociodemographic, contraceptive and behavioural characteristics in a sample of family practice attendants in Belgium.

METHODS

The study was part of a large Chlamydia trachomatis (CT) prevalence study in general practice. Sexually active women under 40 who consulted their general practitioner for routine gynaecological care were enrolled in the study. Participants completed a questionnaire on sociodemographic variables, urogenital symptoms, sexual history and sexual behaviour, and delivered a sample for CT testing. Logistic regression analysis was performed to identify determinants of a history of EC use in women in this sample.

RESULTS

Of 815 questioned women, 23.5% had ever used EC. EC users were a heterogeneous group with respect to educational level, age and ethnicity. The use of emergency contraception was associated with the level of urbanisation, condom use, not having children yet, young age of first sexual intercourse, having had multiple partners in the past year, a history of unintended pregnancy, and current or previous STI.

DISCUSSION

Information on availability and correct use of EC, and on the need for additional testing for STI, are necessary to help primary care attendees to preserve their future reproductive health.

Acceptance and use of emergency contraception with standardized counseling intervention: results of a randomized controlled trial

OBJECTIVE

The objective of this work was to evaluate the acceptance, use and recall of an optional advance prescription for emergency contraception (EC).

MATERIALS AND METHODS

This study used as randomized controlled trial evaluating contraceptive counseling intervention with women aged 16-44 years who were at risk for unintended pregnancy (N=737). Intervention participants (n=365) received contraceptive counseling with optional advance EC prescription. Control women (n=372) received no contraceptive or EC counseling. Among intervention participants, initial acceptance and use of EC in first 2 months were evaluated. Among all participants, differences were evaluated between recall of EC discussion and use of EC.

RESULTS

Among 365 intervention women, 336 received EC counseling and 51% of these 336 accepted advance EC prescription. At 2 months, among the women who had accepted EC, 6% had filled and used their prescription and 8% had filled but not used their prescription. At 12 months, intervention women were significantly more likely than controls to recall talking about EC (33% vs. 5%) and obtaining a prescription (38% vs. 6%), but there were no differences in the use of EC (6% vs. 6%).

CONCLUSION

When the option is available for EC counseling, approximately half of women accepted advance prescription for EC. However, few women who received information and/or an advance prescription remembered discussing EC, filled the prescription or used EC over 12 months.

Hormonal contraception in adolescents: special considerations

With the rates of unintended pregnancies in teenagers remaining high, it is crucial to present adolescents with all of the contraceptive options available to them. While barrier methods, for example, male condoms, are easily accessible and do not have adverse effects, their use must be consistent and correct with each act of intercourse. Hormonal contraception affords much better efficacy in preventing pregnancy when used with full compliance. Oral contraceptives are a popular method of contraception among adolescents and offer many non-contraceptive benefits along with the prevention of pregnancy. They have very few significant adverse effects, which are outweighed by the significant morbidity associated with teenage pregnancies, and can be used by most adolescent females. However, their minor bothersome effects do contribute to the high discontinuation rates seen. In addition, many girls find it difficult to remember to take a pill every day, leading to higher failure rates in teenagers than in adult women. The advent of long-acting, progestogen (progestin)-only methods, such as injectables and implantables, has been generally accepted by adolescents and these methods have proven to be more efficacious by avoiding the need for daily compliance. However, progestogen-only methods cause irregular bleeding and amenorrhea, which is not acceptable to many teenagers. In addition, the most widely used implant was taken off the market a few years ago and newer forms are not yet widely accessible. Other novel methods are currently available, including the transdermal patch and the vaginal ring. Both are combinations of estrogen and progestogen and have similar efficacy and adverse effect profiles to oral contraceptives. Their use may be associated with greater compliance by adolescents because they also do not require adherence to a daily regimen. However, there may be some drawbacks with these newer methods, for example, visibility of the patch and difficulty with insertion of the vaginal ring. When regular contraceptive modalities fail, emergency contraception is available. Choices include combination oral contraceptives, progestogen-only pills, mifepristone, or placement of a copper-releasing intrauterine device. These methods can be very useful for preventing pregnancy in adolescents as long as adolescents are aware of their existence and have easy access to them.

Do Indonesian medical practitioners approve the availability of emergency contraception over-the-counter? A survey of general practitioners and obstetricians in Jakarta

Background

Few studies have examined the attitude of medical practitioners towards the availability of emergency contraception (EC) without prescription. In Indonesia, EC (either Yuzpe regimen or Postinor-2) is available by prescription only. We aimed to examine the level of knowledge, attitudes and practices of medical practitioners in Indonesia about EC, in particular their attitudes to the availability of EC over-the-counter (OTC), using a questionnaire.

Methods

Data were collected by an anonymous structured questionnaire. Questionnaires were distributed to general practitioners in 36 Community Health Centres and 25 private clinics using stratified random sampling according to area in Jakarta, and to obstetricians practicising in 24 government and private hospitals and eight private clinics in Jakarta. Two hundred and five general practitioners and 142 obstetricians and gynaecologists participated; overall response rate was 75%.

Results

Although most participants were familiar with EC, only 22% received a very good knowledge score (4 or 5/5 answers correct), while 52% received a poor score (0–2/5 correct). Most participants did not support the OTC availability of EC (70%). Logistic regression identified that participants who prescribed EC had an Odds of 3.8 (95% CI 1.90, 7.73) of approving OTC EC, after adjustment for age and speciality.

Conclusion

Although many organisations are working towards OTC availability of EC, it needs to be recognized and addressed that doctors who do not prescribe EC are unlikely to support the increased availability of EC.

Trends in the use of emergency contraception: An epidemiological study in Barcelona, Spain (1994–2002)

We conducted a retrospective review of the medical records of women requesting emergency contraception (EC) at our emergency department over a 9-year period (1994-2002). EC accounted for 5.9% of all visits (n = 95,288) and increased from 1.26% in 1994 to 9.82% in 2002 (p < 0.001). Reasons for EC were condom problems in 79.5% of cases. EC was used only once by 93% of women. The mean daily number of visits was significantly higher in August (2.46), July (2.01) and September (2.02) than in other months (p < 0.05), and was more frequent on Sunday (3.26), Saturday (2.92) and Monday (2.05) compared to other week days (p < 0.001). New Year's Day and the St. John's Night registered the highest number of visits (mean of 17.2 and 11.7, respectively), with significant differences compared to the remaining days of the year (p < 0.001).

Improving adolescent sexual and reproductive health. A view from Australia: learning from world's best practice

There is increasing awareness worldwide of the importance of sexual and reproductive health in adolescents. Australia's high rates of teenage pregnancy and increasing rates of sexually transmitted infections in young people reflect a failure to prioritise adolescent sexual and reproductive health on the public health agenda. This paper reviews adolescent sexual and reproductive health in Australia in comparison with international data, and examines the systemic, social and cultural factors that influence it. Based on comparisons with international best practice, recommendations are included for improvement in adolescent sexual and reproductive health within the Australian context.