Chapter 3 Emergency Contraception

Emergency contraception - A review

Emergency contraception (EC), or postcoital contraception, is a therapy aimed at preventing unintended pregnancy after an act of unprotected or under-protected sexual intercourse. Options include both emergency contraceptive pills (most commonly containing levonorgestrel or ulipristal acetate) and insertion of an intrauterine device. The aim of this paper is to summarize current evidence surrounding the use of emergency contraceptives and to present an evidence-based approach to EC provision. Emergency contraception is a safe and effective option in preventing unwanted pregnancy, irrespective of age, weight, or breastfeeding status. Efforts should be made to increase their availability, as well as knowledge of these methods, both among patients and healthcare providers.

Emergency contraception subsidy in Canada: a comparative policy analysis

BACKGROUND

In Canada, cost prohibits access to emergency contraception (EC) which may assist to prevent unintended pregnancy. The drug, ulipristal acetate (UPA-EC), is more clinically effective and cost-effective than the prior standard levonorgestrel (LNG-EC). We analyzed provincial EC subsidization policies and examined underlying decision-making processes.

METHODS

We undertook documentary analysis of provincial EC subsidization policies in publicly available drug formularies. We conducted semi-structured interviews with key informants to explore the processes underlying current policies.

RESULTS

Quebec is the only province to subsidize UPA-EC, whilst all ten provinces subsidize LNG-EC. As such, provincial EC subsidization policies do not align with the latest UPA-EC evidence. Interviews revealed that evidence was valued in the policymaking process and formulary decisions were made through interdisciplinary consensus.

CONCLUSIONS

We identify a gap between EC subsidization policies and the latest evidence. Institutional structures affect policies reflecting evolving evidence. Increasing interdisciplinary mechanisms may encourage evidence-based policies.

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.

Exploring the Availability of Emergency Contraception in New Brunswick Pharmacies: A Mystery-Client Telephone Study

Although levonorgestrel-only emergency contraceptive pills (LNg-ECPs) have been available over the counter in Canada for more than a decade, barriers to access persist. We aimed to obtain information about the availability and cost of LNg-ECPs in New Brunswick. Using a mystery-client study design, we called all 207 non-specialty pharmacies in the province posing as a 17-year-old woman seeking something to prevent pregnancy after sex. We evaluated the information provided for accuracy and quality. The overwhelming majority of pharmacies (n = 180, 87%) had at least one brand of LNg-ECPs in stock; the price averaged CAD28.69 (USD21.65). Although the majority of pharmacy representatives provided accurate information about LNg-ECPs, a small number made incorrect statements about the timeframe for use, side effects, and mechanism of action. In nine interactions (4%) pharmacy representatives incorrectly indicated that a male partner could not obtain LNg-ECPs; none indicated that parental involvement was required to procure LNg-ECPs. None of the pharmacy representatives referenced any other modality of emergency contraception, including ulipristal acetate. Our findings suggest that LNg-ECPs are widely available and that most pharmacy representatives are providing accurate medical and regulatory information. However, supporting the continuing education of pharmacists and pharmacy staff, particularly around alternative modalities of emergency contraception, appears warranted.