Emergency contraception: global challenges, new opportunities

Over-The-Counter Availability of Levonorgestrel Emergency Contraception in Pharmacies on Oahu

Since the United States Food and Drug Administration’s approval of over-the-counter levonorgestrel emergency contraception, access to this time-sensitive medication has improved. However, multiple barriers, including the cost of the medication and pharmacy availability, still exist. The objective of this study was to determine the over-the-counter availability of levonorgestrel emergency contraception in pharmacies on Oahu, Hawaii. We conducted a cross-sectional population-based study using in-person simulated patient encounters at all pharmacies on Oahu. Out of 109 chain pharmacies and 13 independent pharmacies, 102 (84%) pharmacies had levonorgestrel emergency contraception available over the counter. Of pharmacies in which it was available, 12.7% required an employee to unlock the medication, 37.3% required the medication to be unlocked at the register, 29.4% were packaged in a large plastic box, and 3.9% were packaged in a blister pack. Levonorgestrel emergency contraception is widely available as an over-the-counter medication in pharmacies on Oahu, yet there are packaging and display practices that make it less accessible. Many of these practices could be improved with pharmacy education or changes in store policies. Systems-based interventions are needed to improve the access to levonorgestrel emergency contraception as an over-the-counter medication.

Exposure to domestic violence and abuse and consultations for emergency contraception: nested case-control study in a UK primary care dataset

Background

Evidence of an association between exposure to domestic violence and abuse (DVA) and use of emergency contraception (EC) is lacking in the UK.

Aim

To quantify the association between exposure to DVA and consultations for EC in general practice.

Design and setting

Nested case-control study in UK general practice.

Method

Using the Clinical Practice Research Datalink, the authors identified all women all women aged 15–49 years registered with a GP between 1 January 2011 and 31 December 2016. Cases with consultations for EC (n = 43 570) were each matched on age and GP against four controls with no consultations for EC (n = 174 280). The authors calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between exposure to DVA in the previous year and consultations for EC. Covariates included age, ethnicity, socioeconomic status, pregnancy, children, alcohol misuse, and depression.

Results

Women exposed to DVA were 2.06 times more likely to have a consultation for EC than unexposed women (95% CI = 1.64 to 2.61). Women aged 25–39 years with exposure to DVA were 2.8 times more likely to have a consultation for EC, compared with unexposed women (95% CI = 2.08 to 3.75). The authors found some evidence of an independent effect of exposure to DVA on the number of consultations for EC (OR 1.48, 95% CI = 0.99 to 2.21).

Conclusion

A request for EC in general practice can indicate possible exposure to DVA. Primary care consultation for EC is a relevant context for identifying and responding to DVA as recommended by the World Health Organization and National Institute for Health and Care Excellence guidelines. DVA training for providers of EC should include this new evidence.

Use of emergency contraception among women with experience of domestic violence and abuse: a systematic review

BACKGROUND

Exposure to domestic violence and abuse (DVA) results in a reduction of women's use of regular contraceptives. This evidence suggests that women exposed to DVA are more likely to have unprotected sexual intercourse and therefore may use more emergency contraception (EC) than those women who are not exposed to DVA. We aimed to test this hypothesis through evaluating the evidence for an association between exposure to DVA and use of EC.

METHODS

We systematically searched eight electronic databases from inception until December 2017, checked references and citations, and contacted corresponding authors. Primary studies that evaluated the association between exposure to DVA and use of EC were included. Two reviewers were involved in screening, data extraction, quality assessment and analysis. We evaluated the quality of included studies with the adapted Newcastle-Ottawa Scale. We used tables and descriptive text to summarise and synthesise the data. Odds ratios (ORs) and 95% confidence intervals (CIs) for each estimate of the association between DVA and use of EC were plotted on a forest plot.

RESULTS

Our search retrieved 1216 records of which six studies with 15,297 women were included. Five studies were observational; one study included intervention on the outcome (advance supply of EC). All studies were at high risk of bias. Four studies provided evidence of an association between DVA and EC use - ORs from 1.51 (95% CI 1.13, 2.02) to 6.50 (95% CI 4.15, 10.17). Two studies found no evidence of a such association - ORs 0.46 (95% CI 0.11, 1.96) and 0.76 (95% CI 0.29, 1.98). The latter differed by how the authors recruited participants, measured EC use and adjusted for confounders.

CONCLUSIONS

This systematic review provides some evidence of increased use of EC among women exposed to DVA. Request for EC can indicate possible exposure to DVA. Therefore, each consultation for EC could be an appropriate context for clinical enquiry about DVA and signposting/referral to specialist DVA services.

PROTOCOL REGISTRATION

PROSPERO CRD42017058221 .

History, policy and nursing practice implications of the plan b(®) emergency contraceptive

Numerous policy changes have expanded access to emergency contraception, such as Plan B®, in recent years. Plan B® is a progesterone-based medication that prevents pregnancy from occurring up to 120 hours after unprotected intercourse by preventing ovulation and tubal transport. Increased access to Plan B® allows women to make independent decisions regarding reproductive health. Nurses play an important role in providing education as well as comprehensive, compassionate and holistic care.

Contraceptive adherence among women Veterans with mental illness and substance use disorder

OBJECTIVE

Emerging data suggest that mental illness and substance use disorder (SUD) are important risk factors for inconsistent contraceptive use. We investigated whether mental illness without or with SUD is associated with contraceptive adherence and continuation of hormonal methods among women Veterans.

STUDY DESIGN

We conducted a retrospective analysis of national Veteran's Administration data among women aged 18-45 with a hormonal contraceptive prescription (pill/patch/ring/injectable) during the first week of fiscal year 2013. We tested associations between mental illness diagnoses (depression, posttraumatic stress disorder, anxiety, bipolar disorder, schizophrenia, adjustment disorder) without or with SUD diagnoses (drug/alcohol abuse) and 12-month contraceptive adherence (number and length of gaps ≥7 days between refills and months of contraceptive coverage) using multivariable regression models.

RESULTS

Among 9780 Veterans, 43.6% had mental illness alone, 9.4% comorbid mental illness and SUD, and 47.0% neither diagnosis. In adjusted analyses, compared to women with neither diagnosis, women with mental illness alone had a similar rate of gaps but increased odds of having gaps longer than 30 days [odds ratio (OR): 1.35, 95% confidence interval (CI): 1.10-1.52] and fewer months of contraceptive coverage (β_coefficient: -0.39, 95% CI: -0.56 to -0.23). Women with mental illness and SUD experienced more gaps (incidence rate ratio: 1.12, 95% CI: 1.03-1.21), increased odds of gaps longer than 30 days (OR: 1.46, 95% CI: 1.10-1.79), fewer months of contraceptive coverage (β_coefficient: -0.90, 95% CI: -1.20 to -0.62) and reduced odds of continuous 12-month coverage (adjusted OR: 0.76, 95% CI: 0.63-0.93).

CONCLUSIONS

Mental illness, particularly with comorbid SUD, is associated with reduced contraceptive adherence and continuation among women Veterans. Women with these risk factors could potentially benefit from use of long-acting reversible methods.

IMPLICATIONS

Women Veterans have a high burden of mental illness and SUD, which we found are associated with inconsistent contraceptive use. Efforts to improve adherence to hormonal contraceptives and to increase availability of long-acting reversible methods in this vulnerable population are warranted.

Slowly rising hilly young population of himachal: a step towards stabilization

BACKGROUND

Socioeconomic development is the best contraceptive. Himachal Pradesh has made developments in all the fields, especially reducing the size of the family via family planning program.

AIM

The objectives of this analysis are to describe the various methods of family planning used from 2003 to 2010 and their impact in averting the births in the state and in stabilizing the population.

MATERIALS AND METHODS

We collected secondary data of the family planning program and the various methods employed from the total population (Census 2011) covered under family planning program (FPP) of the state. We analyzed and compared the results with India. We measured the impact of the program due to FP methods adopted. We employed the standardized program indicators- total fertility rate, birth rate, death rate, growth rate and census trend towards population growth; fertility rate (in %), birth rate and death rate (per thousand of the population per year) from 3.8, 31.5 and 11.1 in 1981 to 1.9, 17.2 and 7.2 in 2009. We entered dataset by double data entry technique and analyzed descriptively using Epi info version 3.3.2 and stat calc software.

RESULTS

The state has the population of 6,856,509, sex ratio in age 0-6 years is 906/1000 males. The unmet need for family planning services is 15%. The impact of family planning program has resulted in averting of 3,387,744 of pregnancies from 2003 to 2010. The total fertility rate (TFR) has come down to 1.9 in 2008 from 3.8 children per woman in 1981. The death rate has declined from 11.1 per 1000 live births in 1981 to 7.2 per 1000 live births in 2009. The trend in decadal growth rate of the state is observable as 23.0% in 1971 while in 2011, it is 12.8%; more towards young population and for geriatric one as well but not exploding like India.

CONCLUSION

Total population is on the increase with reference to the population of reproductive age bracket (15-49 years) and also geriatric population above 60 steadily despite good social and health indicators. Bulging reproductive age group with mild upward shift of the geriatric population is the root cause for increasing population in hills of Himachal Pradesh.

Emerging options for emergency contraception

Emergency post-coital contraception (EC) is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD) and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method), and less commonly, mifepristone. Some options are available over-the-counter, while others require provider prescription or placement. There are no absolute contraindications to the use of emergency contraceptive pills, with the exception of ulipristal acetate and mifepristone. This article reviews the mechanisms of action, efficacy, safety, side effects, clinical considerations, and patient preferences with respect to EC usage. The decision of which regimen to use is influenced by local availability, cost, and patient preference.

Acceptability and use of emergency contraception among married women in Bangalore, India

OBJECTIVE

To assess knowledge, acceptability, and use of emergency contraceptive pills (ECs) among lower-income married women in Bangalore, India.

METHODS

EC counseling and supplies were offered to 322 women aged 18-25 years participating in a longitudinal reproductive health study. Participants completed interviews at enrollment and were followed for 1 year. EC acceptability and use were assessed, and factors associated with use were identified.

RESULTS

206/320 (64.4%) participants did not desire pregnancy but only 46/321 (14.3%) used an intrauterine device or contraceptive pills. Only 25 (7.8%) had heard of ECs. Overall, 123 (38.2%) participants requested advance provisions of ECs after counseling. Over a year, 37/263 (14.1%) women used ECs, usually within 3 days of unprotected sex (33 [89.2%]), and 32 (86.5%) took both pills together or 1 day apart. Thirty-six (97.3%) felt glad and 31 (83.8%) were relieved after taking ECs. Twenty-five (67.6%) women who used ECs sought permission from their husbands. The only factor associated with EC use was couples' pregnancy intentions (odds ratio 4.71; 95% confidence interval, 1.43-15.58; P≤0.01).

CONCLUSION

Indian women with access to ECs generally used them correctly and found them acceptable. Efforts to expand EC knowledge and access should be coupled with efforts to promote gender equality in the reproductive sphere.