Workforce interventions to improve access to emergency contraception pills: a systematic review of current evidence in low- and middle-income countries and recommendations for improving performance

Emergency Contraception: Access and Challenges at Times of Uncertainty

BACKGROUND

The UN Commission on Life-Saving Commodities for Women's and Children's Health identified emergency contraceptive pills as 1 of the 13 essential underused, low-cost, and high-impact commodities that could save the lives of millions of women and children worldwide. In the US, 2 emergency contraceptive regimens are currently approved, and their most plausible mechanism of action involves delaying and/or inhibiting ovulation.

AREAS OF UNCERTAINTY

Abortion and contraception are recognized as essential components of reproductive health care. In the US, in the wake of the Dobbs v. Jackson Women's Health Organization Supreme Court decision on June 24, 2022, 26 states began to or are expected to severely restrict abortion. It is anticipated that these restrictions will increase the demand for emergency contraception (EC). Several obstacles to EC access have been described, and these include cost, hurdles to over-the-counter purchase, low awareness, myths about their mechanisms of action, widespread misinformation, and barriers that special populations face in accessing them. The politicization of EC is a major factor limiting access. Improving sex education and health literacy, along with eHealth literacy, are important initiatives to improve EC uptake and access.

DATA SOURCES

PubMed, The Guttmacher Institute, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization, The United Nations.

THERAPEUTIC ADVANCES

A randomized noninferiority trial showed that the 52 mg levonorgestrel intrauterine device was noninferior to the copper intrauterine device when used as an EC method in the first 5 days after unprotected intercourse. This is a promising and highly effective emergency contraceptive option, particularly for overweight and obese patients, and a contraceptive option with a different bleeding profile than the copper intrauterine device.

CONCLUSIONS

EC represents an important facet of medicine and public health. The 2 medical regimens currently approved in the US are very effective, have virtually no medical contraindications, and novel formulations are actively being investigated to make them more convenient and effective for all patient populations. Barriers to accessing EC, including the widespread presence of contraception deserts, threaten to broaden and accentuate the already existing inequities and disparities in society, at a time when they have reached the dimensions of a public health crisis.

Dynamics of Emergency Contraceptive Use in Accra, Ghana

Recent data suggest increasing rates of emergency contraception (EC) use in Ghana, particularly in urban areas. In 2018, we collected survey data from 3,703 sexually experienced women aged 16-44 years living in low-income settlements of Accra. We estimated the prevalence of lifetime and current EC use. Multivariate logistic regression was used to assess factors associated with current use of EC. Retrospective monthly calendar data on contraceptive use were analyzed to identify patterns of EC use, including repeat and continuous use, and uptake of other contraceptive methods in the months following EC use. Nearly 15 percent of women had ever used EC. About half of recent EC users (52 percent) used EC for at least four months cumulatively within a 12-month window. There was no evidence of adoption of other modern methods in the months after using EC. Our results suggest that EC is a common method for pregnancy prevention in Accra, particularly among young, unmarried, highly educated women. Counseling on effective EC use and strategies that promote equitable access should be prioritized.

Pharmacists as youth-friendly service providers: documenting condom and emergency contraception dispensing in Kenya

Objectives

This Kenya-based study ascertained whether pharmacies were an untapped source of ‘youth-friendly’ health services by determining (1) whether young people (aged 18–24) could successfully obtain condoms and emergency contraception (ECP); (2) whether contraceptives were dispensed according to national guidelines; and (3) how young people felt about obtaining ECP and condoms from pharmacy personnel.

Methods

This study used several methods to capture and cross-check purchasing experiences as reported by young people with those of dispensing pharmacy personnel. These included: focus group discussions; in-depth interviews; key informant interviews; and mystery shoppers.

Results

When in stock, young people were successfully able to obtain ECP and condoms from pharmacies. Counselling was sporadic: when it happened, it was not always accurate. Despite a lack of counselling, young people reported being satisfied with the quick, transactional interaction with pharmacy personnel.

Conclusions

The brief, transactional interactions between pharmacy personnel and young clients appear to be ‘youth-friendly enough’. While there is room to strengthen the services provided (improving both accuracy and scope), this should be done in a manner that does not fundamentally alter the current interaction.

Reconceptualizing Measurement of Emergency Contraceptive Use: Comparison of Approaches to Estimate the Use of Emergency Contraception

Estimated use of emergency contraception (EC) remains low, and one reason is measurement challenges. The study aims to compare EC use estimates using five approaches. Data come from Performance Monitoring and Accountability 2020 surveys from 10 countries, representative sample surveys of women aged 15 to 49 years. We explore EC use employing the five definitions and calculate absolute differences between a reference definition (percentage of women currently using EC as the most effective method) and each of the subsequent four, including the most inclusive (percentage of women having used EC in the past year). Across the 17 geographies, estimated use varies greatly by definition and EC use employing the most inclusive definition is statistically significantly higher than the reference estimate. Impact of using various definitions is most pronounced among unmarried sexually active women. The conventional definition of EC use likely underestimates the magnitude of EC use, which has unique programmatic implications.

Provider Bias in Family Planning Services: A Review of Its Meaning and Manifestations

Provider bias, including bias regarding client age, parity, and marital status, persists as an important barrier to contraceptive choice and access. Newer approaches to mitigate bias that have moved beyond training and guideline development to more fundamental behavior change show promise.

Family planning programs are guided by the principle of informed choice as well as the goal of providing a broad choice of contraceptive methods to clients. Provider bias is an important barrier to realizing this goal, but it must be clearly defined and understood to be effectively addressed. This review presents an overview of the concept of provider bias in family planning, focusing on the following issues: (1) what it is, (2) how widespread it is, (3) its underlying causes, (4) its impacts, and (5) how it can be effectively addressed. The definitions of provider bias include common themes about providers creating barriers to choice, typically based on the characteristics of either a client or a contraceptive method. However, an agreed-upon definition is lacking. Measurement of provider bias has often relied on self-reports by providers but has also included observation and use of mystery clients for supplemental data. The general trend in the data is clear: large numbers of providers impose barriers and restrictions beyond those that are in guidelines or are necessary for any medical reasons. This trend indicates the presence of bias. Providers have shown bias based on age, parity, marital status, and other criteria, with a bias against provision of various contraceptive methods to youth being the most common. Provider bias often stems from broader social norms, particularly judgments about sexual activity among youth and concerns about the impact of hormonal methods on future fertility. Little documentation of the impact of provider bias exists, although method mix skew has been identified as a possible red flag for bias. Newer approaches to address bias that have moved beyond traditional training and guidelines development to more fundamental behavior change efforts show promise, and learning from their lessons will be important. A major question is how to scale up such approaches.

The context of emergency contraception use among young unmarried women in Accra, Ghana: a qualitative study

BACKGROUND

Over the past decade, awareness and use of emergency contraceptive pills (ECPs) among young women has rapidly increased in Ghana; however, the rate of unintended pregnancy among this group remains high. We conducted a qualitative study to better understand the context and patterns of ECP use among young unmarried women in Ghana.

METHODS

We conducted in-depth interviews with unmarried sexually active women aged 18-24 in Accra, Ghana to explore their perceptions, experiences, and opinions regarding sexual relationships and contraceptive methods, and to examine the factors that influence choice of ECPs. A total of 32 young women participated in the study.

RESULTS

Most participants had used ECPs at least once. Participants described being unable to plan for sexual encounters, and as a result preferred ECPs as a convenient post-coital method. Despite being widely and repeatedly used, women feared the disruptive effects of ECPs on the menstrual cycle and were concerned about long-term side-effects. ECPs were sometimes used as a back-up in cases of perceived failure of traditional methods like withdrawal. Misinformation about which drugs were ECPs, correct dosage, and safe usage were prevalent, and sometimes spread by pharmacists. Myths about pregnancy prevention techniques such as urinating or washing after sex were commonly believed, even among women who regularly used ECPs, and coincided with a misunderstanding about how hormonal contraception works.

CONCLUSIONS

ECPs appear to be a popular contraceptive choice among young urban women in Ghana, yet misinformation about their correct usage and safety is widespread. While more research on ECP use among young people is needed, these initial results point to the need to incorporate information about ECPs into adolescent comprehensive sexuality education and youth-friendly services and programmes.

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.