Clinical practice. Emergency contraception

Emergency contraception: unresolved clinical, ethical and legal quandaries still linger

Emergency contraception (EC) has been prescribed for decades, in order to lessen the risk of unplanned and unwanted pregnancy following unprotected intercourse, ordinary contraceptive failure, or rape. EC and the linked aspect of unintended pregnancy undoubtedly constitute highly relevant public health issues, in that they involve women's self-determination, reproductive freedom and family planning. Most European countries regulate EC access quite effectively, with solid information campaigns and supply mechanisms, based on various recommendations from international institutions herein examined. However, there is still disagreement on whether EC drugs should be available without a physician's prescription and on the reimbursement policies that should be implemented. In addition, the rights of health care professionals who object to EC on conscience grounds have been subject to considerable legal and ethical scrutiny, in light of their potential to damage patients who need EC drugs in a timely fashion. Ultimately, reproductive health, freedom and conscience-based refusal on the part of operators are elements that have proven extremely hard to reconcile; hence, it is essential to strike a reasonable balance for the sake of everyone's rights and well-being.

Contraceptive information on pregnancy resource center websites: a statewide content analysis

OBJECTIVE

Most pregnancy resource centers (PRCs) in the US are affiliated with national organizations that have policies against promoting or providing contraceptives, yet many provide information about contraception on their websites. In 2016, the state of Georgia passed a new law to publicly fund PRCs. This study sought to describe the contraceptive information on Georgia PRC websites.

STUDY DESIGN

We systematically identified all accessible Georgia PRC websites April-June 2016. We downloaded entire websites and used defined protocols to code and thematically analyze content about contraceptives.

RESULTS

Of the 64 websites reviewed, 20 (31%) presented information about contraceptives. Most of the content was dedicated to emergency contraception. Emphasis on risks and side effects was the most prominent theme. However, no site presented information about the frequency or prevalence of risks and side effects. Sites also emphasized contraceptive failure and minimized effectiveness. We found a high degree of inaccurate and misleading information about contraceptives.

CONCLUSIONS

Georgia PRC websites presented skewed information that may undermine confidence in the safety and efficacy of contraceptive methods and discourage use. Public funding for PRCs, an increasing national trend, should be rigorously examined. Increased regulation is urgently needed to ensure that online information about contraceptives presented by publicly funded centers is unbiased, complete and accurate.

IMPLICATIONS

We examined contraceptive information on Georgia PRC websites and found sites minimize benefits and emphasize barriers to use. They contain high levels of medically inaccurate and misleading information that may undermine public health goals. Public funding for PRCs should be rigorously examined; increased regulation is urgently needed.

Impact of emergency contraception status on unintended pregnancy: observational data from a women's health practice

Objective:

This study aimed to determine if nonprescription emergency contraception (EC) availability impacted self-reported unintended pregnancy rates and to assess women’s knowledge and awareness of EC prior to and after nonprescription availability.

Methods:

A survey regarding contraception use and knowledge was verbally administered to a cross-sectional, convenience sample of 272 pregnant women receiving prenatal care at a large urban community women’s clinic between August 2003 and October 2008. Statistical analyses determined the differences between two groups (before [BA] and after, [AA] non-prescription EC availability in the U.S. drug market) in terms of self-reported unintended pregnancy rates, knowledge and awareness of EC.

Results:

The AA group reported higher incidence of unintended pregnancy when compared to the BA group (90.7% vs. 72.7%, P = 0.0172). The majority of both groups reported that they were not using any contraception at the time of conception (BA-84.4%; AA-83.3%). There was no significant difference in the participants’ awareness of EC between the two groups (BA-46.8% vs. AA-43.0%) nor was there a significant difference between the two groups in the self-reported willingness to use EC in the future (BA-53.1% vs. AA-63.4%). However, among participants who were unaware of EC, 61% reported they would consider using it in the future after receiving brief EC counseling from a pharmacist or student pharmacist. Neither age nor pregnancy intention was associated with self-reported EC awareness but there was an association with income (P = 0.0410) and education (P = 0.0021).

Conclusion:

The change from prescription-only to non-prescription status of EC in the U.S. drug market did not impact the unintended pregnancy rate in this patient population. Lack of knowledge and awareness is still a major barrier to widespread EC use.

Adjudicating rights or analyzing interests: ethicists' role in the debate over conscience in clinical practice

The analysis of a dispute can focus on either interests, rights, or power. Commentators often frame the conflict over conscience in clinical practice as a dispute between a patient's right to legally available medical treatment and a clinician's right to refuse to provide interventions the clinician finds morally objectionable. Multiple sources of unresolvable moral disagreement make resolution in these terms unlikely. One should instead focus on the parties' interests and the different ways in which the health care delivery system can accommodate them. In the specific case of pharmacists refusing to dispense emergency contraception, alternative systems such as advanced prescription, pharmacist provision, and over-the-counter sales may better reconcile the client's interest in preventing unintended pregnancy and the pharmacist's interest in not contravening his or her conscience. Within such an analysis, the ethicist's role becomes identifying and clarifying the parties' morally relevant interests.

Adolescência e contracepção de emergência: Fórum 2005

OBJETIVO: Relatar os resultados do Fórum "Adolescência e Contracepção de Emergência", que teve como proposta trazer maiores esclarecimentos sobre a contracepção de emergência (CE), além de apoio ético e técnico para sua prescrição, a partir da análise de três vertentes principais de discussão: o perfil da clientela adolescente; as questões éticas que envolvem a CE; a eficácia e o risco do método. FONTES DE DADOS: Discussão dos temas propostos a partir da literatura atual sobre o tema do Fórum organizado em 2005, que envolveu a participação de pediatras, ginecologistas, profissionais ligados a Comissões de Bioética, ao Conselho Federal de Medicina e ao Ministério da Saúde, advogados e juízes. SÍNTESEDOS DADOS: A adolescência caracteriza-se por mudanças, transformações e experimentações que vinculam essa fase da vida à vulnerabilidade e risco. Alguns desses riscos estão relacionados ao exercício inadvertido ou impensado da sexualidade, cujas conseqüências são bem conhecidas: gravidez precoce, aborto e doenças sexualmente transmissíveis, entre as quais HPV e AIDS. É fundamental, portanto, que a assistência a essa faixa etária inclua o enfoque de prevenção, na qual a educação sexual seja vista como um processo do qual é parte relevante a orientação anticoncepcional, incluindo-se nesta a contracepção em situações de emergência. CONCLUSÕES: O artigo apresenta as conclusões resultantes das discussões realizadas durante esse evento. Seu principal desdobramento foi a Resolução do Conselho Federal de Medicina: a CE não é abortiva e pode ser usada em qualquer etapa da vida reprodutiva.

Pharmacy access to emergency hormonal contraception in Jacksonville, FL: a secret shopper survey

OBJECTIVE

Emergency hormonal contraception (EC) has the potential to reduce the number of unintended pregnancies and induced abortions, but many barriers to more prevalent usage exist. We evaluated one aspect of access--pharmacy availability of levonorgestrel EC (Plan B) or alternatives--in Jacksonville, FL.

METHOD

Female "secret shoppers" presented in person and by telephone to pharmacies in Jacksonville, FL, and inquired if Plan B would be available if they were to return with a prescription. Availability of the medication, as well as offers of EC alternatives or alternate methods of obtaining EC, was noted. Furthermore, pharmacist and pharmacy staff knowledge regarding appropriate use of the product was assessed.

RESULTS

Of 54 pharmacies visited by secret shoppers, 21 (39%) had Plan B in stock and were willing to dispense it. Sixteen pharmacies (29%) could order it and have it available within 24 h, or knew of nearby pharmacies that stocked the medication. Neither Plan B nor other EC options were offered by 17 pharmacies (31%). One hundred thirty-three pharmacies, including those that were visited in person, were contacted by telephone. Forty-two (32%) of these had Plan B in stock. Another 22 pharmacies (17%) offered to order Plan B for availability within 24 h or less. Furthermore, 11 pharmacies suggested other stores that were more likely to carry it. Of 40 pharmacy staff members asked how long following unprotected intercourse a patient had to take the product, 20 (50%) correctly stated 72 h.

CONCLUSION

Plan B was not in stock in a majority of pharmacies within this large city. Availability was increased by offers to order the medication or by suggestions to seek the prescription at nearby pharmacies. Many pharmacists and their staff were unfamiliar with the medication and its correct usage.

Risk of Pregnancy Among Women Seeking Emergency Contraceptives From Pharmacists in British Columbia

OBJECTIVE

Recent revision of the method used to estimate risk of pregnancy among women requesting medication for emergency contraception (EC) suggests that the effectiveness of EC may be lower than is generally believed. We undertook a population-based study to estimate the risk of pregnancy among women requesting EC from pharmacists in British Columbia under conditions of routine care.

METHODS

We obtained data on time since unprotected intercourse and medication provided for women in British Columbia requesting EC from January 1, 2001 to December 31, 2002.

RESULTS

More women obtained levonorgestrel (60.7%) than the Yuzpe regimen (39.3%) for EC, and of those reporting contraceptive failure, 90% requested EC because of condom failure. Overall, the estimated risk of pregnancy among the 11 795 women who obtained EC was 4.12 % (95% confidence interval 3.77-4.49).

CONCLUSION

Under routine conditions, the population-based predicted risk of pregnancy is lower than has previously been estimated. This suggests that the relative reduction in pregnancies achieved with EC is lower than is currently assumed by clinicians and patients.

Unintended rapid repeat pregnancy and low education status: any role for depression and contraceptive use?

OBJECTIVE

The purpose of this study was to assess the contribution of depressive symptoms and poor contraceptive use early in the first postpartum year to the risk of unintended repeat pregnancy at the end of that year among adults with low educational status (< 12th grade or equivalence).

STUDY DESIGN

This was a prospective observational cohort study of 643 sexually active, low-income, inner-city adult women (age > or = 19) who enrolled prenatally (14.7 +/- 6.9 weeks gestational age) and were followed twice after delivery (3.3 +/- 1.3 months and 11.0 +/- 1.3 months). Associations were assessed by multivariate logistic regression.

RESULTS

Low educational status (odds ratio, 2.32; 95% CI, 1.25-4.33) and less effective contraceptive use (odds ratio, 2.31; 95% CI, 1.05-4.51) were associated with unintended pregnancy. Neither depressive symptoms nor contraceptive use reduced the risk of pregnancy that was associated with low educational status.

CONCLUSION

Low educational status was associated with more than twice the risk of unintended pregnancy 1 year after delivery. We found no evidence that depression or poor contraceptive use mediate this relationship.

Emergency contraception - a human rights issue

Emergency contraception is the only resource that women can use to avoid becoming pregnant after having sexual intercourse without contraceptive protection. It could be a powerful means to prevent unwanted pregnancies and their devastating consequences for women's health, social wellbeing and life project, and for the unwanted child, if all people had ample access to good quality information, education and services for sexual and reproductive health. In spite of the preventive medicine value of emergency contraception, conservative sectors oppose its availability, appealing to moral values that are not universally shared in pluralistic societies. Excluding the only contraceptive that can be used after intercourse because some consider the mechanism of action to be unacceptable would mean restricting the right of choice of others, and imposing one particular belief or set of values on all members of the community, thus violating the freedom of conscience. Authorities have a moral obligation to protect human rights.

Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional surveys

OBJECTIVE

To examine the impact on contraceptive practice of making emergency hormonal contraception available over the counter.

DESIGN

Analysis of data on contraceptive practice for women aged 16-49 years in the period 2000-2 from the Omnibus Survey, a multipurpose survey in which around 7600 adults living in private households are interviewed each year.

SETTING

Private households in Great Britain.

MAIN OUTCOME MEASURES

Use of different types of contraception and rates of unprotected sex.

RESULTS

After emergency hormonal contraception was made available over the counter, levels of use of different types of contraception by women aged 16-49 remained similar. No significant change occurred in the proportion of women using emergency hormonal contraception (8.4% in 2000, 7.9% in 2001, 7.2% in 2002) or having unprotected sex. A change did, however, occur in where women obtained emergency hormonal contraception; a smaller proportion of women obtained emergency hormonal contraception from physicians and a greater proportion bought it over the counter. No significant change occurred in the proportion of women using more reliable methods of contraception, such as the oral contraceptive pill, or in the proportion of women using emergency hormonal contraception more than once during a year.

CONCLUSIONS

Making emergency hormonal contraception available over the counter does not seem to have led to an increase in its use, to an increase in unprotected sex, or to a decrease in the use of more reliable methods of contraception.

Beyond the pill: new data and options in hormonal and intrauterine contraception

With the goal of helping clinicians facilitate contraceptive success for their patients, this Clinical Opinion provides an update regarding older hormonal and intrauterine contraceptives and details newer methods that include the progestin-releasing intrauterine system, the contraceptive patch and ring, and extended and emergency oral contraception. Last, I will look over the horizon and briefly describe potential future methods that include the single rod progestin-releasing implant, folic acid-supplemented oral contraceptives, and hormonal contraception for men.

[Present and potential uses of mifepristone in gynecology, obstetrics and other medical specialties]

Mifepristone, a derivative of norethindrone, a first generation synthetic progestative, has a very potent antiprogestative activity and to a lesser degree antiandrogenic and antiglucocorticoid activities. This action makes it potentially useful in the treatment of multiple hormone dependent diseases in obstetrics-gynecology as well as in a variety of medical specialties such as neurology, ophthalmology, and oncology. Nevertheless, the label of abortive pill has incited numerous ethical and political debates concerning the permission to market this drug, and this has contributed to the delay in the assessment of the potential indications of mifepristone. Largely under-utilized in practice despite its increasing theoretical benefit, clinical studies should now de conducted. Thus, based on an international review of literature during the last ten years, we have shed light on the present and potential indications of mifepristone in medical practice.