Advance Provision of Emergency Contraception for Pregnancy Prevention

Advance provision of medication for induced abortion: A qualitative study of patient perspectives

OBJECTIVES

To examine potential users' perspectives regarding the provision of abortion medications for future use or "advance provision."

STUDY DESIGN

In this qualitative study, we partnered with an independent reproductive health care clinic in Washington State to conduct semistructured, in-depth interviews with 22 individuals who obtained a medication abortion between August 2021 and January 2022. We asked participants their views on advance provision of abortion medications. Interviews were transcribed and deidentified. Inductive content analysis was used to identify major themes.

RESULTS

Participants in our sample generally reacted positively to the idea of abortion medications for future use. Having pills in advance could improve timeliness and convenience of care and decrease the stigma associated with their use. Participants stressed the importance of adequate information regarding medication use, what to expect, and potential side effects. Most concerns about advance provision related to the safety and efficacy of medication abortion.

CONCLUSIONS

This study found that individuals who recently obtained a medication abortion supported the provision of abortion medications for future use.

IMPLICATIONS

Patient-centered educational materials, with adequate information for self-managing pregnancy termination, can be shared at time of prescription. Clinicians have an opportunity to offer these safe and effective medications in advance of need and increase timely access to this essential health care service. User concerns regarding abortion medications for future use should inform clinical innovation and evaluative research of service options.

Hormonal contraception without a prescription: opinions of pharmacists, general practitioners and gynaecologists in Flanders, Belgium

OBJECTIVE

The accessibility of contraceptives varies greatly from country to country. Because unintended pregnancies have a considerable impact, programmes have been initiated in some countries to make certain contraceptives available without a prescription. We therefore investigated whether or not Flanders, the Dutch-speaking part of Belgium, is ready for such an initiative.

METHOD

We used a mixed-methods approach with a mainly qualitative methodology. The opinions of pharmacists, general practitioners (GPs) and gynaecologists, the three types of health care provider most closely involved in the prescription and delivery of contraception, were examined.

RESULTS

A majority of pharmacists supported the idea. Moreover, a large majority occasionally dispensed hormonal contraception without a prescription. Pharmacists expected negative responses from physicians. Among GPs and gynaecologists, a small majority supported the idea conditionally. A minority either fully supported the idea or found it completely unacceptable.

CONCLUSION

Economic aspects were clearly important in forming an opinion on the topic, although medical arguments were often used when they happened to point in the same direction. Flemish pharmacists were willing to train for and implement a new service that would provide contraceptives without a prescription. The majority of GPs and gynaecologists expressed reservations about such a service and doubted that it would reduce unintended pregnancies. If this service were to be implemented, caution would be needed to avoid giving contraceptive users conflicting information.

State of emergency contraception in the U.S., 2018

Emergency contraception is indicated in instances of unprotected sexual intercourse, including reproductive coercion, sexual assault, and contraceptive failure. It plays a role in averting unintended pregnancies due to inconsistent use or non-use of contraception. Options for emergency contraception vary by efficacy as well as accessibility within the U.S. This paper provides an overview of levonorgestrel (Plan B One-Step and generic counterparts), ulipristal acetate (sold as ella), and the copper intrauterine device (IUD, sold as ParaGard), including the mechanisms of action, administration, efficacy, drug interactions, safety, side effects, advantages, and drawbacks. It will also review current misconceptions about emergency contraception and access for subpopulations, including adolescents, immigrants, survivors of sexual assault, rural populations, and military/veteran women. This paper will address barriers such as gaps in knowledge, and financial, health systems, and practice barriers. Continuing areas of research, including the impact of body weight on the efficacy of emergency contraceptive pills and potential interactions between ulipristal acetate and ongoing hormonal contraceptives, are also addressed.

One-year continuation of copper or levonorgestrel intrauterine devices initiated at the time of emergency contraception

OBJECTIVE(S)

This study compares 1-year intrauterine device (IUD) continuation among women presenting for emergency contraception (EC) and initiating the copper (Cu T380A) IUD or the levonorgestrel (LNG) 52 mg IUD plus 1.5 mg oral LNG.

STUDY DESIGN

This cohort study enrolled 188 women who presented at a single family planning clinic in Utah between June 2013 and September 2014 and selected either the Cu T380A IUD or LNG 52 mg IUD plus oral LNG for EC. Trained personnel followed participants by phone, text or e-mail for 12 months or until discontinuation occurred. We assessed reasons for discontinuation and used Cox proportional hazard models, Kaplan-Meier estimates and log-rank tests to assess differences in continuation rates between IUDs.

RESULTS

One hundred seventy-six women received IUDs; 66 (37%) chose the Cu T380A IUD and 110 (63%) chose the LNG 52 mg IUD plus oral LNG. At 1 year, we accounted for 147 (84%) participants, 33 (22%) had requested removals, 13 (9%) had an expulsion and declined reinsertion, 3 (2%) had a pregnancy with their IUD in place and 98 (67%) were still using their device. Continuation rates did not differ by IUD type; 60% of Cu T380A IUD users and 70% of LNG 52 mg IUD plus oral LNG users were still using their device at 12 months (adjusted hazard ratio 0.72, 95% confidence interval 0.40-1.3).

CONCLUSION(S)

Two-thirds of women who chose IUD placement at the EC clinical encounter continued use at 1 year. Women initiating Cu T380A IUD and LNG 52 mg IUD had similar 1-year continuation rates. These findings support same-day insertion of IUDs for women who are seeking EC and would like to use a highly effective reversible method going forward.

IMPLICATIONS

Providing IUD options for EC users presents an opportunity to increase availability of highly effective contraception.

Over-the-Counter Access to Oral Contraceptives for Adolescents

Oral contraceptives (OCs) are used by millions of women in the U.S. The requirement to obtain OCs by prescription from a clinician may serve as a barrier to contraceptive initiation and continuation for women, in particular adolescents. Over-the-counter (OTC) availability would reduce this barrier and could further reduce unintended pregnancy rates. This review explores the scientific issues and regulatory processes involved in switching OCs to OTC status for minor adolescents. We review: (1) the regulatory criteria for switching a drug to OTC status; (2) risk of pregnancy and safety during use of OCs including combined oral contraceptives and progestin-only pills for adolescents; (3) the ability of adolescents to use OCs consistently and correctly; (4) OTC access to OCs and potential effect on sexual risk behaviors; and (5) the potential for reduced opportunities for clinicians to counsel and provide recommended reproductive health care to adolescents. We find strong scientific rationale for including adolescents in any regulatory change to switch OCs to OTC status. OCs are safe and highly effective among adolescents; contraindications are rarer among adolescents compared to adult women. Ready access to OCs, condoms, and emergency contraception increases their use without increasing sexual risk behaviors.

Appreciation for Analysis of how Levonorgestrel Works and Reservations with the use of Meloxicam as Emergency Contraception

This paper is a response to Dr. Kathleen Raviele's recent article on her critical analysis of the use of levonorgestrel given to women postsexual assault and her suggestion that the use of Meloxicam may be an ethical alternative.

Awareness and Attitudes Toward Emergency Contraceptives Among College Students in South India

BACKGROUND

In India every year, a large number of pregnancies are unplanned resulting in unsafe abortion. This has tremendous implications both on health and survival of women. Usage of emergency contraceptive pills (ECPs) could be a solution provided the usage is as per guidelines and social issues do not cause objections.

AIM

This study was done to assess the awareness and attitudes regarding ECPs.

METHODS

Data were collected using self-administered questionnaire from the university students.

RESULTS

Out of 449 students, 384(85.5 %) had heard about ECPs. The commonest source of information was television 299(77.9 %). Only 128(33.3 %) students knew that ECPs do not help in prevention of STDs. 209(54.4 %) participants knew the correct time frame for taking ECPs. 109(28.4 %) were unaware of its side effects. Only 149(33.2 %) had received reproductive health education (RHE) in the past. The awareness level of students about ECPs was moderate among 231(60.2 %) participants. Awareness was significantly more among males (p = 0.013), students with science background (p = 0.001) and those who had RHE previously (p = 0.043). 219(57 %) had average level of perception toward ECPs. 254(66.2 %) participants favored prescription before procuring ECPs from drug stores. 261(68 %) participants favored information about ECPs to be given in educational institutions, and a majority, 186(48.4 %), said they would recommend ECPs to their friends. Average-to-good perception about ECPs was seen in significantly greater proportion of females (p = 0.034).

CONCLUSION

RHE is must at educational institutions so as to promote awareness and to remove misconceptions about ECPs among youth. This would help users in preventing unintended pregnancies and unsafe abortions.

Emergency contraception. Widely available and effective but disappointing as a public health intervention: a review

Emergency contraception (EC) prevents pregnancy after unprotected sex or contraceptive failure. Use of EC has increased markedly in countries where a product is available over the counter, yet barriers to availability and use remain. Although effective in clinical trials, it has not yet been possible to show a public health benefit of EC in terms of reduction of unintended pregnancy rates. Selective progesterone receptor modulators developed as emergency contraceptives offer better effectiveness than levonorgestrel, but still EC is less effective than use of ongoing regular contraception. Methods which inhibit ovulation whenever they are taken or which act after ovulation to prevent implantation and strategies to increase the uptake of effective ongoing contraception after EC use would prevent more pregnancies.

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.

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

METHODS

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Improving access to emergency contraception under the Scottish Sexual Health Strategy: can rates of unintended pregnancy be reduced?

Unintended pregnancy is a global sexual health problem. Outcomes of unintended pregnancy include unwanted childbirth and abortion, which may be associated with negative physical and psychosocial health implications for women. In Scotland, the Scottish Sexual Health Strategy has the stated goal of improving the sexual health of the people of Scotland. One aim of the Strategy is to reduce rates of unintended pregnancy and one policy designed to achieve this is 'widening access to emergency contraception'. This paper examines the success of this policy with reference to the implicit link it makes between expanding access to emergency contraception and increasing its effective use, aiming thereby to reduce rates of unintended pregnancy. Since there is evidence that previous policies and strategies expanding access to emergency contraception have failed to reduce such rates, alternative approaches to achieve a reduction in unintended pregnancies are discussed.

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.

Emergency contraception and risk for sexually transmitted infections among U.S. women

BACKGROUND

Since Food and Drug Administration (FDA) licensure of emergency contraception (EC) over-the-counter (OTC) in 2006, this is the first U.S. study to use a nationally representative sample of reproductive-aged women (15-44) to explore the relationship between receipt and use of EC and sexually transmitted infection (STI)-related health services.

METHODS

Using a sample of 6329 women from the National Survey of Family Growth 2006-2008, we examined the relationship between lifetime EC use and recent receipt of EC and demographics, sexual behaviors, and STI-related services. Variables significant at p<0.10 in bivariate analyses were examined using multivariable logistic regression models.

RESULTS

Overall, 10% (704) of the sample had ever used EC. Most EC users had received EC from a family planning clinic (51%), drugstore (23%), or doctor's office (17%). In adjusted analyses, demographic factors associated with receipt of EC in the past 12 months included never married (adjusted odds ratio [AOR] 4.0) and living in a metropolitan statistical area (AOR 4.2). Women reporting multiple partners (2+) (AOR 2.4), inconsistent condom use (AOR 3.4), and having recently been tested for chlamydia (AOR 2.0) had higher odds of receiving EC in the past 12 months. Findings among women ever reporting EC use were similar, except women who had 4+ lifetime partners (AOR 2.5) and had recently received a chlamydia diagnosis (AOR 2.2) had higher odds of ever having used EC.

CONCLUSIONS

EC recipients were no more likely than nonrecipients to have received STI counseling or screening despite greater numbers of sex partners in the past year. This research indicates that women are accessing EC in pharmacies, which may be a missed opportunity for counseling and testing.

Condom migration resulting from circumcision, microbicides and vaccines: brief review and methodological considerations

OBJECTIVE

To provide an updated review of condom migration as a means of highlighting methodological issues for future studies of this behavioural issue.

METHODS

Electronic searches of PubMed, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were carried out in October 2010 and updated in January 2011 for English-language articles published from 1994 onward.

RESULTS

Evidence addressing condom migration from microbicides and vaccines is vastly underdeveloped, simply because these products are still experimental. In contrast, the more advanced evidence regarding male circumcision is hopeful because it suggests that migration may not be an overwhelming issue. Nonetheless, the entire body of empirical evidence on this question could be substantially expanded and improved.

CONCLUSION

Until stronger evidence suggests that condom migration is unlikely, it is important to be mindful of the potential for condom migration to occur in response to biomedical interventions (circumcision, microbicides and vaccines).

Use of levonorgestrel emergency contraception in Utah: is it more than "plan B"?

CONTEXT

It is important to understand why some women use levonorgestrel emergency contraceptive pills repeatedly, because the method is not intended for repeated use, and current evidence suggests that it is approximately 77% effective at preventing pregnancy.

METHODS

An anonymous patient survey of 1,040 women aged 18-29 purchasing levonorgestrel at Planned Parenthood clinics in Utah was conducted during a 4-6-week period in 2007. Chi-square tests and analyses of variance were used to examine associations between selected characteristics and level of levonorgestrel use. Logistic regression was used to assess characteristics independently associated with repeated use.

RESULTS

Twenty-nine percent of participants had used levonorgestrel more than twice in the prior year. Fifty-eight percent believed that levonorgestrel is at least 90% effective in protecting against pregnancy; 16% believed that it is 100% effective. In univariate analyses, lifetime number of partners, currently having multiple partners, substance use at last intercourse and perceived effectiveness of levonorgestrel were positively associated with repeated levonorgestrel use in the previous year. The measure most strongly associated with repeated levonorgestrel use in multivariate analyses was perceived effectiveness: Women who believed that the method is 90-99% or 100% effective in preventing pregnancy had greater odds of repeated use than those who believed it is 75-89% effective (odds ratios, 1.8 each).

CONCLUSION

Women who repeatedly use levonorgestrel may have an inflated perception of its effectiveness. Future research, including qualitative research, may help clarify factors that lead to inflated perceptions of effectiveness.

Is repeat use of emergency contraception common among pharmacy clients? Evidence from Kenya

BACKGROUND

As emergency contraception (EC) becomes more widely available in African pharmacies, public concern in many countries has emerged over perceived "repeat use" of the method. This study examines issues of repeat use in Kenya, a country where women almost exclusively obtain EC from pharmacies.

STUDY DESIGN

Interviews were conducted with all clients who purchased EC from private pharmacies located in five urban areas across Kenya. Over a period of 5 days, a total of 182 male and female EC purchasers were interviewed. χ(2) tests were used to determine the statistical significance of differences between repeat and nonrepeat users.

RESULTS

The majority (58%) of respondents had purchased EC at least twice in the past 1 month. All women interviewed reported purchasing EC a mean of 3.8 times in the 6 months prior to the survey. Those who purchased EC at least twice in the past 1 month were significantly more likely to hold misperceptions about EC's efficacy or side effects. Two thirds of all users reported having a chance to ask questions at the pharmacy, although one quarter felt that they did not receive adequate information.

CONCLUSIONS

This study indicates that many of the women surveyed, particularly those who had sex on an infrequent basis, chose to use EC as a regular family planning method. Among these women, it also indicates the need for better information on EC's efficacy and side effects. Such information-sharing could take place within pharmacies, although interventions must not undermine the core benefits of pharmacy access: convenience and confidentiality.

Advance provision of emergency contraception among adolescent and young adult women: a systematic review of literature

OBJECTIVE

The purpose of this review is to summarize the findings of randomized controlled trials assessing the advance provision of emergency contraception (EC) to women 24 years of age or younger.

DESIGN

We conducted a comprehensive search of the PubMed database from 1950 to November 11, 2009. This review includes seven studies that randomly assigned women aged 24 and younger to advance provision of EC or a control group.

RESULTS

All studies reviewed found that women assigned to advance provision were more likely to use EC, though not all reached statistical significance. Furthermore, studies assessing time to EC use (N = 4) found that those with advance provision used EC sooner following intercourse. Most studies found that women assigned to advance provision of EC did not engage in more sexual risk taking behaviors (assessed by reported number of sexual partners, number of episodes of unprotected intercourse, and acquisition of sexually transmitted infections) or switch to less reliable contraceptive methods. Despite increased use and decreased time to use, women who were provided EC in advance did not report significantly lower pregnancy rates.

CONCLUSIONS

The existing literature suggests that among women 24 years of age or younger, advance provision has a positive impact on use and time to use of EC. Most findings indicate that increased use of EC does not have significant negative effects for ongoing contraceptive use or sexual risk taking behaviors. Despite increased use, advanced provision of EC has not been associated with a significant corresponding decrease in pregnancy.

Advance provision of emergency contraception for adolescents

Emergency contraception is most effective at preventing unintended pregnancy when taken as early as possible following unprotected sexual intercourse. Advance provision of this medication supports more timely and effective use. In the midst of rising teen pregnancy rates, current policies often limit access to emergency contraception for adolescents. A literature search identified three recent experimental studies of advance provision for adolescents. This article reviews those studies and finds strong support for advance provision for adolescents. Usage of emergency contraception increased with advance provision and there was no increase in negative sexual behaviors or decrease in usage of other contraceptive forms. Implications of these findings for school nurses and school-based health center staff are also discussed.

Contraception for cancer survivors

Women who have survived cancer may need guidance in choosing a method of contraception. This paper reviews the evidence supporting the safety and efficacy of available methods of contraception for cancer survivors and concludes that the Copper T380A intrauterine device (IUD), a highly effective, reversible, long-acting, hormone-free method should be considered a first-line contraceptive option for women with a history of a hormonally mediated cancer. However, the levonorgestrel-containing IUD may be preferable for women being treated with tamoxifen and women who have survived non-hormonally mediated cancers. Women with IUDs can undergo all forms of imaging, including computed tomography and magnetic resonance imaging.

Attitude and behavior effects in a randomized trial of increased access to emergency contraception

OBJECTIVE

To explore the effects of providing unrestricted access to emergency contraception in advance of need on various psychosocial outcomes and pregnancy.

METHODS

In the trial, women were randomly assigned to either increased access to emergency contraception (two free packs at enrollment with unlimited free resupply) or standard access. Participants were evaluated for 1 year for pregnancy and other outcomes. Psychosocial data were collected at enrollment and at 6 and 12 months. We applied exploratory factor analysis for data reduction. We compared the resulting psychosocial factors (including factors related to "aversion to pregnancy" and to the perceived "relative benefit" and "accessibility" of emergency contraception), two items directly assessing substitution, and pregnancy between randomization groups over time.

RESULTS

On average, women in the increased access group had significantly stronger perceptions of both the "relative benefit" and "accessibility" of emergency contraception (P<.001 for each). Women in the increased access group were significantly more likely to report that they had ever used emergency contraception because they did not want to use either condoms or another contraceptive method (P<.001). Regarding pregnancy, we noted a significant interaction between randomization group and "aversion to pregnancy" (P=.010): among the least "averse" women, increased access had a protective effect (hazard ratio 0.64, 95% confidence interval 0.39-1.04); among the most "averse" women, increased access had a deleterious effect (hazard ratio 1.73, 95% confidence interval 1.01-2.98).

CONCLUSION

As a result of having unrestricted access, some women substituted emergency contraception for their usual contraceptive methods.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00060463

LEVEL OF EVIDENCE

I.

Behind-the-counter status and availability of emergency contraception

OBJECTIVE

The objective of the study was to determine whether the 2006 Food and Drug Administration approval of Plan B for behind-the-counter status increased availability.

STUDY DESIGN

We conducted a survey in 2005 and 2007 of pharmacies listed in Atlanta, GA, Boston, MA, and Philadelphia, PA. We measured ability to dispense Plan B within 24 hours. Also measured were reasons for lack of availability and cost of Plan B.

RESULTS

Pharmacists were interviewed at 1087 pharmacies (75% response rate) in 2005 and 795 pharmacies (82% response rate) in 2007. In 2007, 8% of pharmacies were unable to provide Plan B within 24 hours, compared with 23% of pharmacies in 2005 (P < .001). The total refusal rate in 2007 was half the rate of 2005 (2% vs 4%, P = .004). The average cost of Plan B was $43.

CONCLUSION

Availability of Plan B in Atlanta and Philadelphia increased after it was awarded behind-the-counter status.

Public and private providers' involvement in improving their patients' contraceptive use

BACKGROUND

This study measured differences in the provision of care between public and private providers of contraceptive services, what problems using contraception these providers perceived their patients to have and providers' views on how to improve their patients' method use.

STUDY DESIGN

A nationally representative mixed-mode survey (mail, Internet and fax) of private family practice and obstetrician/gynecologist physicians who provided contraceptive care in 2005 was conducted. A parallel survey was administered to public contraceptive care providers in community health centers, hospitals, Planned Parenthood clinics and other sites during the same period. Descriptive and multivariate analyses were conducted across both surveys.

RESULTS

A total of 1256 questionnaires were completed for a response rate of 62%. A majority of providers surveyed believed that over 10% of their contraceptive clients experienced ambivalence about avoiding pregnancy, underestimated the risk of pregnancy and failed to use contraception for one or more months when at risk for unintended pregnancy. Implementation of protocols to promote contraceptive use ranged widely among provider types: a full 78% of Panned Parenthood clinics offered quick-start pill initiation, as did 47% of public health departments. However, 38% of obstetrician-gynecologists, 27% of "other public" clinics and only 13% of family physicians did so. Both public and private providers reported that one of the most important things they could do to improve patients' contraceptive method use was to provide more and better counseling. At least 46% of private providers and at least 21% of public providers reported that changing insurance reimbursement to allow more time for counseling was very important.

CONCLUSIONS

Strategies to improve contraceptive use for all persons in need in the United States have the potential to be more effective if the challenges contraceptive providers face and the differences between public and private providers are taken into account.

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.

Advance provision of emergency contraception for pregnancy prevention (full review)

BACKGROUND

Emergency contraception can prevent pregnancy when taken after unprotected intercourse. Obtaining emergency contraception within the recommended time frame is difficult for many women. Advance provision, in which women receive a supply of emergency contraception before unprotected sex, could circumvent some obstacles to timely use.

OBJECTIVES

To summarize randomized controlled trials evaluating advance provision of emergency contraception to explore effects on pregnancy rates, sexually transmitted infections, and sexual and contraceptive behaviors.

SEARCH STRATEGY

In August 2006, we searched CENTRAL, EMBASE, POPLINE, MEDLINE via PubMed, and a specialized emergency contraception article database. We also searched reference lists and contacted experts to identify additional published or unpublished trials.

SELECTION CRITERIA

We included randomized controlled trials comparing advance provision and standard access, which was defined as any of the following: counseling which may or may not have included information about emergency contraception, or provision of emergency contraception on request at a clinic or pharmacy.

DATA COLLECTION AND ANALYSIS

We evaluated all identified titles and abstracts found for potential inclusion. Two reviewers independently abstracted data and assessed study quality. We entered and analyzed data using RevMan 4.2.8. We calculated odds ratios with 95% confidence intervals for dichotomous data and weighted mean differences with 95% confidence intervals for continuous data.

MAIN RESULTS

Eight randomized controlled trials met our criteria for inclusion, representing 6389 patients in the United States, China and India. Advance provision did not decrease pregnancy rates (OR 1.0; 95% CI: 0.78 to 1.29 in studies for which we included twelve month follow-up data; OR 0.91; 95% CI: 0.69 to 1.19 in studies for which we included six month follow-up data; OR 0.49; 95% CI: 0.09 to 2.74 in a study with three month follow up data), despite increased use (single use: OR 2.52; 95% CI 1.72 to 3.70; multiple use: OR 4.13; 95% CI 1.77 to 9.63) and faster use (weighted mean difference (WMD) -14.6 hours; 95% CI -16.77 to -12.4 hours). Advance provision did not lead to increased rates of sexually transmitted infections (OR 0.99; 95% CI 0.73 to 1.34), increased frequency of unprotected intercourse, nor changes in contraceptive methods. Women who received emergency contraception in advance were equally as likely to use condoms as other women.

AUTHORS' CONCLUSIONS

Advance provision of emergency contraception did not reduce pregnancy rates when compared to conventional provision. Advance provision does not negatively impact sexual and reproductive health behaviors and outcomes. Women should have easy access to emergency contraception, because it can decrease the chance of pregnancy. However, the interventions tested thus far have not reduced overall pregnancy rates in the populations studied.