As often as needed: appropriate use of emergency contraceptive pills

Unprotected intercourse in the 2 weeks prior to requesting emergency intrauterine contraception

BACKGROUND

Previous emergency contraception studies have excluded women who report >1 episode of unprotected or underprotected intercourse. Thus, clinical recommendations are based on exposure to a single episode of underprotected intercourse.

OBJECTIVE

We sought to assess the prevalence and timing of underprotected intercourse episodes among women requesting emergency contraception and to examine the probability of pregnancy following an emergency contraception regimen including placement of either a copper intrauterine device or a levonorgestrel intrauterine device with simultaneous administration of an oral levonorgestrel pill in women reporting multiple underprotected intercourse episodes, including episodes beyond the Food and Drug Administration-approved emergency contraception time frame (6-14 days).

STUDY DESIGN

Women seeking emergency contraception who had a negative pregnancy test and desired either a copper intrauterine device or levonorgestrel emergency contraception regimen enrolled in this prospective observational study. At enrollment, participants reported the number and timing of underprotected intercourse episodes in the previous 14 days. Two weeks later, participants reported the results of a self-administered home pregnancy test.

RESULTS

Of the 176 women who presented for emergency contraception and received a same-day intrauterine device, 43% (n = 76) reported multiple underprotected intercourse episodes in the 14 days prior to presenting for emergency contraception. Women with multiple underprotected intercourse episodes reported a median of 3 events (range 2-20). Two-week pregnancy data were available for 172 (98%) participants. Only 1 participant had a positive pregnancy test. Pregnancy occurred in 0 of 97 (0%; 95% confidence interval, 0-3.7%) women with a single underprotected intercourse episode and 1 of 75 (1.3%; 95% confidence interval, 0-7.2%) women reporting multiple underprotected intercourse episodes; this includes 1 of 40 (2.5%; 95% confidence interval, 0-13.2%) women reporting underprotected intercourse 6-14 days prior to intrauterine device insertion.

CONCLUSION

Women seeking emergency contraception from clinics commonly reported multiple recent underprotected intercourse episodes, including episodes occurring beyond the Food and Drug Administration-approved emergency contraception time frame. However, the probability of pregnancy was low following same-day intrauterine device placement.

The Complexity of Multiple Contraceptive Method Use and the Anxiety That Informs It: Implications for Theory and Practice

Despite clinical guidelines and national data describing the use of one contraceptive method as the best and most common way to prevent unintended pregnancy, limited evidence indicates a more complex picture of actual contraceptive practice. Face-to-face in-depth interviews were conducted in November of 2013 with a sample of women from two cities in the United States (n = 52). The interviews explored the ways participants used contraception to protect themselves from unintended pregnancy over the past 12 months. Most respondents reported using multiple methods, many of which are considered to be less-effective, within this timeframe. The practice of combining methods in order to increase one's level of protection from pregnancy was prevalent, and was mainly enacted in two ways: by backing up inconsistent method use with other methods and by "buttressing" methods. These practices were found to be more common, and more complex, than previously described in the literature. These behaviors were mainly informed by a deep anxiety about both the efficacy of contraceptive methods, and about respondents' own perceived ability to prevent pregnancy. These findings challenge prevailing assumptions about women's contraceptive method use and have implications for clinical contraceptive counseling practice.

Serbian gynecologists' and pharmacists' beliefs about emergency contraception

Emergency contraception (EC) in Serbia is available in two products: Levonorgestel, which has nonprescription status, and Ulipristal acetate, which is a prescription-only medicine. Considering their dispensing statuses, gynecologists and pharmacists are health care professionals (HCPs) with the widest impact on EC use. Yet little is known about their beliefs and practices regarding these medicines. We surveyed 166 gynecologists (during October 2012-October 2013) and 452 community pharmacists (during January-April 2014). Results showed significant differences between these two groups, suggesting that provision of EC to users may be inconsistent. Gynecologists were more convinced than pharmacists that EC would reduce the abortion rate (86% versus 53%, p < .001). However, they were more concerned than pharmacists that easy access to EC would cause less regular contraceptive use (66% versus 29%, p < .001) and risky sexual behaviors, including initiating sexual activity at a younger age (37% versus 19%, p < .001) and having more sexual partners (33% versus 12%, p < .001). Additionally, more pharmacists than gynecologists (12% versus 2%, p < .001) said they would not provide EC to anyone under any circumstance, even to victims of sexual assault. These results indicated a need for reevaluating and establishing official guidelines for dispensing practices.

Knowledge, attitude, and practice about Emergency Contraception among health staff in Bushehr state, south of Iran

Emergency Contraception (EC) is used within a few days of unprotected sex to prevent an unintended pregnancy. About one quarter of pregnancies in south of Iran are unintended. EC is important option that women can use after unprotected sex or contraceptive failure for preventing of unplanned pregnancies and adverse maternal and perinatal health outcomes. Health staff have influence on women’s contraceptive behavior and their knowledge and attitudes about EC can affect women’s contraceptive behaviors. Data are lacking about the knowledge, attitude and practice of hormonal EC method among health staff in Bushehr state, south of Iran. A cross-sectional study using self administered questionnaire was conducted. A sample of 170 health staff were surveyed. The mean age of respondents was 30.6±5.1. Overall 6.5% of participants had poor knowledge, 25.2% moderate knowledge, 68.3% good knowledge about EC. Half of participants had positive and half had negative attitude towards the EC method. Midwives and family health workers were more knowledgeable (p<0.05) and more frequently counseled women about EC than general practitioners (GPs) (p<0.001). The most cited reason for EC prescriptions were rupture condom and none use of contraception. Our findings showed despite of majority of health staff had good knowledge about EC, their knowledge about the indications for prescription of EC and its side effects was inadequate. The educational efforts for health staff should be focused more on the specific aspects of EC method. GPs also should be more involved in family planning program.

Changes in contraceptive choice after emergency contraception

OBJECTIVE

To determine whether women use emergency contraception (EC) repeatedly instead of regular contraception methods if they have access to EC.

METHODS

Data from the records of 9201 women who underwent EC 11014 times in the years 2006 through 2008 at Hong Kong clinics were retrospectively analyzed. The χ(2) test was used to look for associations between demographic characteristics and repeated EC use and the Wilcoxon signed rank test was used to compare the significance of changes in contraceptive use over time.

RESULTS

A total of 10845 courses of EC pills and 168 intrauterine devices were provided to the 9201 women, 89.4% of whom used EC once and 8.5% twice within a year. Using EC more than twice was only associated with unstable relationships. The percentages of women using no contraceptives during intercourse decreased from 20.6% at baseline to 4.7% four to 6 weeks after EC, 4.0% at 6 months, and 3.4% at 12 months. The percentages of women using highly effective methods of contraception increased from 3.5% to 20.8%, 27.3%, and 27.7% at the same time points.

CONCLUSION

The low rate of repeated EC use and the positive changes in contraceptive choice after EC are reassuring.

Provision of emergency contraception at student health centers in California community colleges

BACKGROUND

Approximately half of all pregnancies in the United States are unintended, with the highest rates reported among college-age women. The availability of emergency contraception (EC) pills can be an important component of efforts to reduce unintended pregnancy. Student health centers at community colleges can uniquely support student retention and academic achievement among college students by making EC available to reduce the rate of unintended pregnancy and prevent college drop-out. This article highlights findings from an assessment of EC provision in student health centers within the California community college system (n = 73).

METHODS

A web-based survey was used to explore the provision of EC, challenges and barriers of EC administration, promotion of EC availability, and attitudes toward EC.

FINDINGS

Descriptive statistics conducted revealed that more than 6 out of 10 (62%) student health centers provided EC, 77% of which dispense EC on site during clinic visits. The most common EC promotion methods were providing brochures at the health center (80%) and through information provided at family planning or primary care visits (73%). Challenges to EC administration included a perceived lack of awareness of EC among students (71%), followed by the notion that some students may overutilize EC (40%). Attitudes toward EC provision were more favorable among health center staff whose campuses offered EC than those who did not (p < .05).

CONCLUSION

This article provides recommendations for community college health centers to improve access and delivery of EC by addressing issues such as cost and offering more novel EC promotion methods.

Policy maker and provider knowledge and attitudes regarding the provision of emergency contraceptive pills within Lao PDR

Background

The Ministry of Health (MOH) launched the National Reproductive Health Policy in 2005, which included recommendations regarding the use of emergency contraceptive pills (ECP). However, ECP have not yet been introduced officially in the public sector of the Lao PDR. Thus, their availability is limited. Understanding the knowledge of ECP and attitudes about their provision, barriers to use, and availability among health providers and policy makers is essential to successfully incorporate ECP into reproductive health services.

Methods

Qualitative research methods using in-depth interviews were employed to collect data from policy makers and health providers (auxiliary medical staff, nurses, and medical doctors). Altogether, 10 policy makers, 22 public providers, and 10 providers at private clinics were interviewed. Content analysis was applied to analyze the transcribed data.

Results

The majority of policy makers and health care providers had heard about ECP and supported their introduction in the public sector. However, their knowledge was poor, many expressed inconsistent attitudes, and their ability to meet the demand of potential users is limited.

Conclusions

There is a need to train health providers and policy makers on emergency contraception and improve their knowledge about ECP, especially regarding the correct timing of use and the availability of methods. In addition, the general public must be informed of the attributes, side effects, and availability of ECP, and policy makers must facilitate the approval of ECP by the Lao Food and Drug Administration. These interventions could lead to increased access to and demand for ECP.

Contraception and abortion

This article is the fourth in a series of articles on sexuality and sexual health.

Identifying barriers to emergency contraception use among young women from various sociocultural groups in British Columbia, Canada

CONTEXT

Despite advances related to the provision of emergency contraception in Canada, particularly the granting of independent prescriptive authority to pharmacists in 2000, little is known about the ways in which women perceive potential barriers to using it.

METHODS

In 2004, an ethnically diverse sample of 52 women living in Greater Vancouver participated in interviews that were analyzed for an assessment of women's knowledge, attitudes and experiences related to emergency contraception, with particular attention to the ways in which ethnicity affected their stories.

RESULTS

Participants generally misperceived emergency contraception as an abortifacient, and often mistakenly thought that it has long-term effects on health and fertility. Knowledge gaps regarding reproductive physiology impeded clear understanding of when it is most effective. Participants also reported receiving subtle and sometimes overtly stigmatizing messages from providers when they sought emergency contraception. Asian and South Asian women were particularly concerned about negative interactions with providers; for example, they feared that female providers from their sociocultural community might recognize, chastise or gossip about them. Institutional policies (e.g., a Catholic hospital's refusal to provide the method), coupled with low awareness of pharmacists' prescriptive authority, also created barriers to use.

CONCLUSIONS

Women's ability to benefit from emergency contraception is hampered by lack of knowledge and conservative cultural or social mores. Serious contextual and structural shifts are required before woman-centered approaches to provision of the method become the norm.

Risk of pregnancy and external validity in clinical trials of emergency contraception

OBJECTIVES

To compare women who enroll in emergency contraception (EC) trials to those who decline and to understand why eligible women decline to participate.

METHODS

Data were collected from all women seeking EC (n = 5,787) at three clinics in the USA and UK during a period of nearly 1 year (from September 1997 to August 1998). The main outcome measures were pregnancy risk calculated by adjusted cycle day of ovulation.

RESULTS

Enrolled and non-enrolled women had similar mean ages and similar mean cycle lengths. However, the enrolled and non-enrolled groups were different with respect to adjusted cycle day of unprotected sexual intercourse (UPSI), the regularity of their cycles, recent hormone use, breastfeeding, the number of other acts of UPSI they had engaged in during the same cycle, and their willingness to participate in the study. Expected pregnancy risk among enrolled patients was higher than among non-enrolled EC seekers (6.5% vs 5.0%, p<0.001, calculated using Dixon conception probabilities, and 5.4% vs 4.6%, p = 0.086, calculated using Trussell conception probabilities). Unwillingness to take part in the study was the most common reason women did not enrol in the trial. Otherwise-eligible women most often declined to enrol because they were concerned about the effectiveness of the trial regimen.

CONCLUSIONS

Women in EC trials are likely to face higher pregnancy risk than the general population. Clinical trials might overestimate the number of pregnancies averted by treatment because the number of expected pregnancies in trial populations is not representative of the population of all EC seekers. This information could be useful in projecting the public health impact of expanded EC access.