Advance EC pills don’t decrease contraceptive use

When it comes to emergency contraception (EC), are you impeding access to women who might need it? According to research recently presented at the annual meeting of the Washington, DC-based American Public Health Association, provider attitudes may be the stumbling block when it comes to women obtaining the method.1

Even though the American College of Obstetricians and Gynecologists (ACOG) in Washington, DC, has promoted advance prescription of EC, some providers may be hesitant in following through with the directive.

In performing a qualitative study of Bronx, NY-area family medicine providers designed to identify barriers to the prescription and use of EC, researchers found that most physicians had heard of EC, but very few discussed it with their patients on a regular basis, and almost none prescribed it proactively.1

There are many situations, such as when a woman misses her appointment for a contraceptive injection or has yet to get a refill of oral contraceptives, when an advance prescription for EC can be of great use, says Marji Gold, MD, professor of clinical family and social medicine at the Albert Einstein College of Medicine, Bronx, NY. Patients who participated in the study agree with that concept, she notes, but the providers offered a differing viewpoint, she notes.

Some providers said they would not want to offer advance prescription because it might promote promiscuous behavior or lead women to have unprotected sex that would put them at risk for sexually transmitted diseases (STDs.)

"It really evolved into a question of morality, and the issue that if you don’t use contraception all the time, then you are being irresponsible," says Gold. Since the conclusion of the research, she has worked to enact EC education for providers in her area, as well as to begin staff inservice sessions. She also has communicated with other facilities that are interested in replicating the study to check their own providers’ attitudes on EC.

Advance Rx is OK

In a randomized clinical trial that compared EC use and contraceptive compliance of patients given EC in advance of need with patients given information only, preliminary results indicate that giving EC in advance does not decrease contraceptive use. In addition, advance prescription nearly doubles the use of the EC method, and it is taken correctly by most women.2

The study, coordinated by the Los Angeles- and Berkeley-based California Family Health Council (CFHC), recruited women from more than 25 family planning clinics throughout California. More than 9,000 English- and Spanish-speaking women seeking gynecologic services other than obstetric care were enrolled. Half received a packet containing EC product and instructions, while others received an identical-appearing packet containing EC information only. Clinicians did not know the contents of the packet they gave to their patients.

About four months after the enrollment visit, about 10% of the participants were selected for a 10-minute phone interview, which included questions about whether the participant had unprotected intercourse or a contraceptive failure, whether EC was used and, if so, how it was self-administered. The interview also contained several questions about the participant’s knowledge and attitude about EC.

Clinicians need to increase women’s confidence in EC and allay their fears about health effects, including future fertility. Such education is important: 88% of those interviewed said they would feel safer talking to a clinician first before taking EC, says Terri Walsh, MPH, director of clinical trials at CFHC. CFHC researchers are continuing to analyze their findings and will be publishing further results from the investigation.

Many of the adult and adolescent women interviewed in Gold’s research thought that the reason that their clinician had not mentioned EC to them was because it was unsafe.1,3 It is important to talk about EC and its safety so women feel comfortable in using the method when it is needed, says Gold. Many women confuse EC with mifepristone, the abortion drug, she says.

"I have to spend a little time, explaining that EC is contraception, it prevents pregnancy, and this is what you use if you have had unprotected sex and don’t want to be pregnant," explains Gold. "People ask a lot of questions, and then I’d say 99% of people want to walk out of my office with a prescription they can fill and keep in their medicine cabinet."

If the federal Food and Drug Administration does move EC to over-the-counter status, providers still will play an important role in advocating advance preparation for EC use, notes Walsh.

"Just like promoting condom use, clinicians will need to keep reinforcing the message: EC is safe, effective, available — protect yourself," she says. "There’s also a big difference between having the EC in the medicine cabinet instead of the drug store."

References

1. Gold M, Panton T. A qualitative study of barriers to use of emergency contraception. Presented at the annual meeting of the American Public Health Association. San Francisco; November 2003.

2. Walsh TL, Holloway C, Suden E, et al. Does advanced provision of emergency contraception lead to risky behavior? Presented at the annual meeting of the American Public Health Association. San Francisco; November 2003.

3. Gold M, Panton T. What do adolescents think about emergency contraception? Knowledge, attitudes, and behavior. Presented at the annual meeting of the American Public Health Association. San Francisco; November 2003.

Resource

For more information on the emergency contraception provider research, contact:

Marji Gold, MD, Albert Einstein College of Medicine, Department of Family and Social Medicine, 3544 Jerome Ave., Bronx, NY 10467. E-mail: mgold@montefiore.org.