Does readily available emergency contraception increase women's awareness and use?

Over-the-counter provision of emergency contraceptive pills: a systematic review

OBJECTIVE

To synthesise evidence around over-the-counter (OTC) emergency contraceptive pills (ECPs) to expand the evidence base on self-care interventions.

DESIGN

Systematic review (PROSPERO# CRD42021231625).

ELIGIBILITY CRITERIA

We included publications comparing OTC or pharmacy-access ECP with prescription-only ECPs and measuring ECP uptake, correct use, unintended pregnancy, abortion, sexual practices/behaviour, self-efficacy and side-effects/harms. We also reviewed studies assessing values/preferences and costs of OTC ECPs.

DATA SOURCES

We searched PubMed, CINAL, LILACS, EMBASE, clinicaltrials.gov, WHO International Clinical Trials Registry Platform, Pan African Clinical Trials Registry, Australian New Zealand Clinical Trials Registry, Cochrane Fertility Regulation and International Consortium for Emergency Contraception through 2 December 2020.

RISK OF BIAS

For trials, we used Cochrane Collaboration's tool for assessing risk of bias; for other studies, we used the Evidence Project risk of bias tool.

DATA EXTRACTION AND SYNTHESIS

We summarised data in duplicate using Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence Profile tables, reporting findings by study design and outcome. We qualitatively synthesised values/preferences and cost data.

RESULTS

We included 19 studies evaluating effectiveness of OTC ECP, 56 on values/preferences and 3 on costs. All studies except one were from high-income and middle-income settings. Broadly, there were no differences in overall ECP use, pregnancy or sexual behaviour, but an increase in timely ECP use, when comparing OTC or pharmacy ECP to prescription-only ECP groups. Studies showed similar/lower abortion rates in areas with pharmacy availability of ECPs. Users and providers generally supported OTC ECPs; decisions for use were influenced by privacy/confidentiality, convenience, and cost. Three modelling studies found pharmacy-access ECPs would lower health sector costs.

CONCLUSION

OTC ECPs are feasible and acceptable. They may increase access to and timely use of effective contraception. Existing evidence suggests OTC ECPs do not substantively change reproductive health outcomes. Future studies should examine OTC ECP's impacts on user costs, among key subgroups and in low-resource settings.

Pharmacy-based initiatives to reduce unintended pregnancies: A scoping review

BACKGROUND

Community pharmacy contraception services are thought to improve access, with the potential to reduce the persistent sexual and reproductive health inequities observed globally.

OBJECTIVES

We aimed to identify the range of pharmacy-based initiatives addressing unintended pregnancy in the primary literature and examine their feasibility, acceptability and effectiveness.

METHOD

Using the Joanna Briggs Institute Methodology for Scoping Reviews, we searched seven bibliographic databases using combinations of keywords and subject headings for related to contraception and community pharmacy. Studies of any design undertaken in high income countries for reproductive-aged women were eligible provided they evaluated intervention or legislation after the implementation of these initiatives. Included articles were critically appraised and findings summarised narratively.

RESULTS

We identified 49 articles, 80% of which involved pharmacist supply of emergency contraception (EC), 14% of regular contraception methods, and 6% involved adjuncts of EC dispensing: counselling (2%) and bridging initiatives to link clients with regular contraception (4%). EC initiatives were perceived as feasible and were facilitated by interdisciplinary partnerships but there are persistent barriers to the provision of initiatives congruous with the retail pharmacy setting. Furthermore, consumers may be reluctant to receive contraceptive counselling from pharmacists but often value the convenience and anonymity pharmacy services offer. Overall, interventions improved access to contraceptive products but did not consistently reduce inequities, and the health benefits of pharmacy initiatives are either small (EC) or lacking description in the literature (other contraceptive methods and contraceptive counselling).

CONCLUSIONS

Pharmacy initiatives may not negate all barriers to access or reduce unintended pregnancy rates, however they are valued by pharmacists and consumers. Evidence gaps including the lack of description of health outcomes of regular contraception provision, contraceptive counselling and the perceived barriers and facilitators of access and provision from end-user perspectives, should be pursued in future research, to establish initiatives' utility and effectiveness.

Protocol for ACCESS: a qualitative study exploring barriers and facilitators to accessing the emergency contraceptive pill from community pharmacies in Australia

INTRODUCTION

The rate of unplanned pregnancy in Australia remains high, which has contributed to Australia having one of the highest abortion rates of developed countries with an estimated 1 in 5 women having an abortion. The emergency contraceptive pill (ECP) offers a safe way of preventing unintended pregnancy after unprotected sex has occurred. While the ECP has been available over-the-counter in Australian pharmacies for over a decade, its use has not significantly increased. This paper presents a protocol for a qualitative study that aims to identify the barriers and facilitators to accessing the ECP from community pharmacies in Australia.

METHODS AND ANALYSIS

Data will be collected through one-on-one interviews that are semistructured and in-depth. Partnerships have been established with 2 pharmacy groups and 2 women's health organisations to aid with the recruitment of women and pharmacists for data collection purposes. Interview questions explore domains from the Theoretical Domains Framework in order to assess the factors aiding and/or hindering access to ECP from community pharmacies. Data collected will be analysed using deductive content analysis. The expected benefits of this study are that it will help develop evidence-based workforce interventions to strengthen the capacity and performance of community pharmacists as key ECP providers.

ETHICS AND DISSEMINATION

The findings will be disseminated to the research team and study partners, who will brainstorm ideas for interventions that would address barriers and facilitators to access identified from the interviews. Dissemination will also occur through presentations and peer-reviewed publications and the study participants will receive an executive summary of the findings. The study has been evaluated and approved by the Monash Human Research Ethics Committee.

Emergency Contraception Pill Awareness and Knowledge in Uninsured Adolescents: High Rates of Misconceptions Concerning Indications for Use, Side Effects, and Access

STUDY OBJECTIVE

To determine the awareness of, access to, and knowledge of the proper use of emergency contraception pills (ECPs) among uninsured adolescents.

DESIGN

Anonymous surveys were used to assess awareness of, knowledge of, and access to ECPs.

SETTING

From 2010 to 2012 at mobile primary care clinic in the San Francisco Bay Area.

PARTICIPANTS

Patients were uninsured adolescents aged 13 to 25; 40% of the participants were currently or had been homeless in the past year. Ethnicity was 50% Asian, 22% Hispanic, 17% Pacific Islanders, 5.5% white, and 5.5% other/mixed ethnicity.

INTERVENTIONS

Post survey completion, patients received one-on-one 15-minute dedicated ECP education.

MAIN OUTCOME MEASURES

Awareness of, knowledge of, and access to ECPs.

RESULTS

Of the study population of 439, 30% of the participants were 13-16 years old and 70% were 17-25 years old (mean age 17.8 years); 66% were women. Young women (86%) reported higher rates of "hearing about emergency contraception" than did young men (70%) (P < .0001). Many incorrectly identified or were uncertain if ECPs were an abortion pill (40%) or could be used as regular birth control (40%) or to prevent sexually transmitted infections (19%). Only 40% of women and 43% of men aged 17 and older correctly answered that they could obtain EC over the counter; 72% did not know that males could receive EC for use by their partner; 12% incorrectly selected that infertility was a side effect; 44% were under the false impression that EC had to be taken within 1 day of unprotected sex.

CONCLUSIONS

Uninsured adolescents have high rates of ECP awareness but low ECP knowledge. These adolescents need more ECP education to alleviate misconceptions and increase practical knowledge, specifically, education about male access, side effects, over-the-counter availability for young men and women, and the 120-hour window of use.

Awareness, use and associated factors of emergency contraceptive pills among women of reproductive age (15-49 years) in Tamale, Ghana

BACKGROUND

Emergency contraceptive pills (ECPs) are one of the means by which women can use after intercourse to prevent pregnancy. ECPs can be used to reduce the prevalence of unwanted pregnancies and unsafe abortions. This study investigated awareness and use of ECPs among reproductive age (15-49 years) women in Tamale, Ghana. Factors associated with the use of ECPs were also investigated.

METHODS

This cross sectional study was conducted among 200 women of reproductive age (15-49 years) in Tamale, Ghana. Data on socio-demographic variables, awareness and usage of ECPs were assessed by means of a previously validated questionnaire. Univariate and multivariate logistic regression analyses were performed to identify factors associated with the use of ECPs.

RESULTS

Awareness level of ECPs were found to be 69.0% (n = 138); 42.8% (n = 59) got the awareness from a health worker, 31.8% (n = 44) from the radio/TV and 25.4% (n = 35) from family members/friends. Eighty-five percent (n = 117) knew the correct time-frame for an effective use of ECP to prevent pregnancy. Forty percent (39.9%, n = 55) of the participants who had awareness have ever used ECPs. Factors that were found to be associated with the use of ECPs were; participants who said ECPs were affordable (AOR = 6.1, 95% CI = 2.51-10.40, p = 0.001), available (AOR 2.1, 95% CI = 0.61-6.01, p = 0.001), cultural (AOR = 3.5, 95% CI = 1.01-10.15, p = 0.011) and religious unacceptable (AOR = 4.0, 95% CI = 1.02-10.0, p = 0.005).

CONCLUSION

A relatively high level of awareness and usage of ECPs was found. Factors that were associated with the use of ECPs were availability and affordability. Cultural and religious unacceptability did not hinder the use of ECPs. Health authorities should continue to make ECPs available to women of reproductive age.

Effect of changes to cost and availability of emergency contraception on users' profiles in an emergency department in Catalunya

OBJECTIVE

Emergency contraception (EC) accessibility has evolved differently in Catalunya as compared with other autonomous communities in Spain. Free-of-charge access within the Public Health System was authorised in 2004, and over-the-counter (OTC) access was implemented in 2009. The aim of the study is to assess the impact of these measures on demand and users' profiles at our institution.

METHODS

A retrospective study, in our Emergency Department, was conducted to evaluate EC requests in relationship to accessibility modifications. The age of women and which days of the week they attended were analysed.

RESULTS

The number of EC requests, the distribution by age and the demand over the week remained stable after access to EC became free of charge. However, requests sharply decreased following OTC access implementation. Distribution by age also changed, with a significant increase in requests from women under 25 years (72% vs 56%, p < 0.001). Demand was greatest on Sunday and Monday, and this distribution persisted over the study period.

CONCLUSION

EC requests remained unchanged following free-of-charge access to EC, but decreased after OTC implementation. Women currently seeking EC at no cost at our institution are more likely to be younger and to request it on a Monday.

Changing oral contraceptives from prescription to over-the-counter status: an opinion statement of the Women's Health Practice and Research Network of the American College of Clinical Pharmacy

Addressing the issue of unintended pregnancy is a national priority. One proposed strategy to reduce unintended pregnancy is to improve access to oral contraceptives by changing them to over-the-counter (OTC) status. Existing data indicate that oral contraceptives meet safety criteria required of OTC products. Available literature demonstrates that women can self-screen for contraindications to oral contraceptives and can do this as well as clinicians, and experience with OTC emergency contraception suggests that OTC oral contraceptives would not increase sexual risk-taking behavior. Women support OTC access to oral contraceptives, but express an interest in accessing pharmacist counseling. On the basis of these data, the Women's Health Practice and Research Network of the American College of Clinical Pharmacy supports changing oral contraceptives to OTC status under two conditions: that they are sold where a pharmacist is on duty and that there are mechanisms in place to cover OTC contraceptives through Medicaid. Future research should address the issues of out-of-pocket costs to individuals, label-comprehension studies, and models for pharmacist reimbursement for time spent counseling on contraception.

The use of an electronic medical record based automatic calculation tool to quantify risk of unplanned readmission to the intensive care unit: a validation study

OBJECTIVE

The aim of this study was to refine and validate an automatic risk of unplanned readmission (Stability and Workload Index for Transfer, or SWIFT) calculator in a prospective cohort of consecutive medical intensive care unit (ICU) patients in a teaching hospital with comprehensive electronic medical records (EMRs).

DESIGN

A 2-phase (derivation and validation) prospective cohort study was conducted.

SETTINGS

The study was conducted in an academic medical ICU.

SUBJECTS

A consecutive cohort of adult (age >18 years) patients with research authorization were analyzed.

INTERVENTION

The EMR-based automatic SWIFT calculator was used for this study.

MEASUREMENT

Agreement between the manual ("gold standard") and automatic SWIFT calculation tool was obtained.

MAIN RESULTS

During the derivation phase, we enrolled 191 consecutive medical ICU patients. Scores of SWIFT for these patients calculated manually by the 2 reviewers had strong positive correlation (r = 0.97), and the mean (SD) difference was 0.43 (3.5). The first iteration of the automatic SWIFT calculator in the derivation cohort demonstrated excellent agreement with manual calculation, partial pressure of carbon dioxide in arterial blood (κ = 0.95), partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio (κ = 0.69), length of ICU stay (κ = 0.91), and Glasgow comma scale (κ = 0.90) and no agreement for source of ICU admission (κ = -0.15). After adjustment in rules, the κ value for hospital admission source improved to 1.0. Automatic calculation demonstrated strong correlation with manual (r = 0.92), and mean (SD) difference was -2.3 (5.9). During validation phase, 100 subjects were enrolled at 5 days. The automatic tool retained excellent correlation with gold-standard calculation for SWIFT (r = 0.92), and the mean (SD) difference was -2.2 (5.5).

CONCLUSION

The EMR-based automatic tool accurately calculates SWIFT score and can facilitate ICU discharge decisions without the need for manual data collection.

Pharmacy access to the emergency contraceptive pill: a national survey of a random sample of Australian women

BACKGROUND

The emergency contraceptive pill (ECP) has the potential to assist in reducing unintended pregnancy and abortion rates. Since its rescheduling to pharmacy availability without prescription in Australia in January 2004, there is little information about Australian women's knowledge, attitudes and use of the ECP. The aim of this study was to measure the knowledge about the ECP and sociodemographic patterns of and barriers to use of the ECP.

STUDY DESIGN

A cross-sectional study, using a computer-assisted telephone interview (CATI) survey conducted with a national random sample of 632 Australian women aged 16-35 years.

RESULTS

Most women had heard of the ECP (95%) and 26% had used it. The majority of women agreed with pharmacy availability of the ECP (72%); however, only 48% were aware that it was available from pharmacies without a prescription. About a third (32%) believed the ECP to be an abortion pill. The most common reason for not using the ECP was that women did not think they were at risk of getting pregnant (57%). Logistic regression showed that women aged 20-29 years (OR 2.58; CI: 1.29-5.19) and 30-35 years (OR 3.16; CI: 1.47-6.80) were more likely to have used the ECP than those aged 16-19 years. Women with poor knowledge of the ECP were significantly less likely to have used it than those with very good knowledge (OR 0.28; CI: 0.09-0.77). Those in a de facto relationship (OR 2.21; CI: 1.27-3.85), in a relationship but not living with the partner (OR 2.46; 95% CI 1.31-4.63) or single women (OR 2.40; CI: 1.33-4.34) were more likely to have used the ECP than married women.

CONCLUSIONS

Women in Australia have a high level of awareness of the ECP, but more information and education about how to use it and where to obtain it are still needed.