By Rebecca H. Allen, MD, MPH, Editor

SYNOPSIS: In this national sample of obstetrician-gynecologists, the majority (84%) reported offering at least one form of emergency contraception, with 80% offering the levonorgestrel pill, 18% offering ulipristal acetate, and 29% offering the copper intrauterine device.

SOURCE: Castleberry NM, Stark L, Schulkin J, Grossman D. Oral and IUD emergency contraception provision among a national sample of obstetrician-gynecologists. Contraception 2020;102:406-408.

The authors of this study sought to describe national prescribing patterns for emergency contraception among obstetrician-gynecologists (OB/GYNs). The survey was offered to 2,500 American College of Obstetricians and Gynecologists (ACOG) members via email between August 2016 and March 2017. Potential participants received five weekly email reminders, one postcard reminder, and one paper mailing. The goal of the study was to achieve at least a 50% response rate, which is typical for physician surveys.

A total of 47 participants were retired and no longer in practice, leaving 2,453 active members of whom 1,280 responded, for a response rate of 52.2%. Of these, 371 were excluded for incomplete responses and, thus, data analysis then was conducted on 909 participants. In the previous 12 months, 84.3% of respondents reported offering at least one form of emergency contraception (EC). The majority, 80.4%, offered levonorgestrel 1.5 mg, 30.5% offered combined hormonal contraceptive pills, 29% offered the copper intrauterine device (IUD), and 17.9% offered ulipristal acetate (UA), 30 mg.

Approximately 5.4% of participants reported not offering any form of EC and 11.3% referred patients elsewhere or reported not having patients who requested EC. Of the 264 participants who offered the copper IUD for EC in the prior 12 months, 30.3% had placed one device, 22.7% had placed the device once or twice, and 7.6% reported placing the device three times or more. Those who offered the copper IUD were more likely to be younger, live in the West, and work for a university-affiliated faculty practice. The main reasons why clinicians reported not recommending a copper IUD for EC included: patients rarely came to the office seeking EC (52.4%), lack of patient interest (33.7%), and the copper IUD was not stocked on site (27.8%).

COMMENTARY

EC refers to contraceptive methods that can be used to prevent pregnancy in the first five days following unprotected intercourse, contraceptive failure, or sexual assault. Three types are commonly used: the copper T380A IUD, which is the most effective; 30 mg of oral UA, which is the next most effective; and, finally, 1.5 mg of oral levonorgestrel. The levonorgestrel pill is available without a prescription to women of any age. However, UA requires a prescription. UA is more effective than levonorgestrel in preventing pregnancy at any point in time within 120 hours after unprotected intercourse and among women with a body mass index of 25 and above.¹ Certain combinations of combined oral contraceptive pills also can be used for emergency contraception but, typically, have more side effects and there is not dedicated packaging for these regimens.

The authors of this study found that, although UA and the copper IUD are the most effective forms of EC, they are the least offered by OB/GYNs. Furthermore, about one-third of OB/GYNs reported offering combined oral contraceptives as a method of EC even though this regimen is no longer recommended as first-line. These findings are not surprising. First, 1.5 mg of levonorgestrel (“Plan B”) is the most widely known type of EC, with both physicians and patients being familiar with it. Second, a recent study found that only 10% of pharmacies in 10 large U.S. cities stocked UA.² I, too, have had difficulties prescribing UA because pharmacies in my area do not have the medication. Therefore, physicians likely are not prescribing UA because it is not available. In terms of the copper IUD, it is probable that patients are unaware of this method and are, therefore, not requesting it. Additionally, physicians may not have the device stocked in their offices or offer same-day access to the IUD. Evidence-based guidelines now recommend same-day provision of long-acting reversible contraceptives if possible.³ However, economics sometimes prohibit physicians from stocking expensive devices in the office. Even if both the patient and the physician are aware of the copper IUD and it is offered, it may not be acceptable for the patient to use long term because of its expected effect on menses. Nevertheless, we need to do a better job educating patients about emergency contraception and how to access it when needed.

Barriers to the use of emergency contraception among both providers and patients include misconceptions about its mechanism of action (it is not an abortifacient) and the cost for the over-the-counter medications or lack of insurance coverage. Providing advance prescriptions for 1.5 mg of levonorgestrel and 30 mg of UA will help patients obtain the medication at a lower cost using health insurance (compared to over-the-counter prices) and will ensure they can obtain the medication any day or night, as needed.³ This survey addresses provider-level barriers, but there also are barriers in the pharmacy that patients may encounter as well — in terms of accessing an available provider in the healthcare system. Although this study has certain limitations — as does any national survey — in terms of representative sampling of the target audience (OB/GYNs), it likely is an accurate picture of emergency contraception prescribing patterns in the United States. Although levonorgestrel methods were made over-the-counter in 2013, we still have a long way to go. ACOG recommends that providers consider the following to increase access to emergency contraception:¹

• Counsel patients that a copper IUD is the most effective form of emergency contraception and integrate same-day copper IUD emergency contraception provision into their practices.
• Prescribe UA when possible because it is more effective than levonorgestrel at all times up to five days after unprotected intercourse and in women of all weights.
• Write advance prescriptions for emergency contraception, particularly for UA, to increase awareness and reduce barriers to immediate access.
• Provide a referral for a woman who desires emergency contraception if her healthcare provider, pharmacy, or institution has an objection to providing it.

REFERENCES

1. [No authors listed]. Committee Opinion No. 707 summary: Access to emergency contraception. Obstet Gynecol 2017;130:251-252.
2. Shigesato M, Elia J, Tschann M, et al. Pharmacy access to ulipristal acetate in major cities throughout the United States. Contraception 2018;97:264-269.
3. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1-66.