What will it take to get emergency contraception to women who need it?
14% of hotline calls failed to gain appointment or pills in 72 hours
You might be an active prescriber of emergency contraception (EC). In fact, you might be listed in the provider directory offered by the national Emergency Contraception Hotline ( NOT-2-LATE) and companion Web site (not-2-late.com). But are women who contact you able to obtain EC?
While many requests for EC are indeed being fulfilled, results from a just-published quality assurance study shows that 14% of calls to providers listed in the national directory resulted in failure to get an appointment or prescription for EC within 72 hours of calling.1 The main reasons for a hotline call being classified as a failure were inability to make telephone contact, refusal to see women who were not established clients, and unavailability of appointments, researchers say.
The results of the study are both "encouraging and disappointing," says James Trussell, PhD, professor of economics and public affairs, faculty associate of the Office of Population Research (OPR), and associate dean of the Woodrow Wilson School of Public and International Affairs at Prince ton (NJ) University. The OPR and the Washington, DC-based Repro ductive Health Technologies Project operate the national hotline, which is a toll-free, automated, confidential service available 24 hours a day in English and Spanish.
"The vast majority of the more than 3,000 providers [listed in the directory] do an excellent job of providing women with access to emergency contraception, but we found it very worrisome that we were unable to get an appointment or prescription for ECPs within 72 hours of calling from 14% of the providers in our sample," remarks Trussell. "In general, women seeking emergency contraception are likely to fare less well, because the providers in our sample had proactively asked to be listed on the hotline and Web site, and our mystery callers were highly educated about emergency contraception."
The research study employed college-educated investigators who identified themselves as women who had a condom break the previous night. A total of 200 providers were contacted, with calls made during standard business hours only. No calls were made on weekends or holidays.
Approximately 76% of attempts resulted in an appointment or telephone prescription from a hotline provider within 72 hours, researcher note. A total of 11% resulted in referrals to other providers not listed on the hotline or Web site.
Of the attempts that resulted in appointments or telephone prescriptions within 72 hours, nearly three-fourths of callers were offered appointments for the same day, 16% for the next day, and 2% for the day after that. Telephone prescriptions were offered in 8% of successful calls. Calls to Planned Parenthood affiliates were more likely to result in successes than other calls; however, only one Planned Parenthood provider offered to call in a prescription.
Of the attempts that resulted in referrals, the top reasons cited were unavailability of appointments, refusal to see women who were not established clients, and unavailability of emergency contraception at that site.
Tests, exams, and costs
The road to EC doesn’t always end with a provider appointment, researchers found. For those facilities that offered appointments, 31% required pregnancy tests and 27% required pelvic examinations prior to prescription.
For many low-income women and teens, the cost of pills and related services can be a potential barrier to EC access. Three-fourths of sites that responded to questions about service costs charged a fixed price, including the cost of the clinic visit, the prescription, or both. Researchers added $20 — the market price for the dedicated ECP Preven (Gynétics, Belle Meade, NJ) — to the cost quoted by those who explicitly stated that pills were not included in the overall fee.
"Costs at the sites with flat fees ranged from free to $220, with mean and median costs of $48 and $38, respectively," researchers note. "Fifteen percent of providers offered services at no cost, 36% charged $25 or less, and 10% charged $100 or more." Costs for those providers who used sliding-scale pay systems ranged from free to $54, with mean and median costs of $22 and $18, respectively; 29% provided services at no cost, and 67% charged $25 or less.
Not only do access barriers weaken a woman’s ability to obtain EC, they delay when she can start it, says Anita Nelson, MD, professor in the obstet rics and gynecology department at the University of California in Los Angeles (UCLA) and medical director of the women’s health care clinic and nurse practitioner training program at Harbor-UCLA Medical Center in Torrance. Because the efficacy of emergency contraceptive pills declines significantly with time following unprotected intercourse, treatment should be initiated as soon as possible.2 "We know that the sooner EC is initiated, the better it protects women from unplanned pregnancy," she says. "The ultimate goal for EC is to make it available to all at-risk women before they need it."
Advance prescription should be routine practice for all barrier users and for women who forget to take oral contraceptives or who are late returning for their contraceptive injections, advocates Nelson. Just as women keep antiseptic and bandages on hand in the medicine cabinet "just in case," so should providers make EC available to women, she notes.
Melanie Gold, DO, assistant professor of pediatrics at the University of Pittsburgh’s school of medicine, agrees that advance prescriptions would reduce many of the barriers to EC. "I think if every health care provider prescribed it prophylactically, it would solve part of the problem," she states." But [some providers] are still so worried that it will cause people to have bad contraceptive behavior that they are unwilling to or uncomfortable to prescribe it that way."
One step providers can take is to counsel about EC at every opportunity, says Gold. "Sports physicals, driver’s physicals, acne check — any time where EC is a possible issue," she says. "Even talk to virginal kids about what their plans are for the future in terms of when they think they might be sexually active, and at least educate them about EC so they know that it exists."
"I believe EC should be in every medicine cabinet in America, and I want to see EC over the counter," says Sharon Schnare, RN, FNP, CNM, MSN, women’s health consultant and clinician with the Seattle King County Health Department and the International District Community Health Center in Seattle. She now provides Plan B (the levonorgestrel ECP from Women’s Capital Corp., Bellevue, WA) or a prescription for Preven to nearly all her patients.
ECPs are now available over the counter without prescription in France, notes Trussell. While such an option is not available in the United States, clinicians can maximize ECP access by providing pills or a prescription in advance, prescribing by telephone, and eliminating unnecessary pregnancy tests and physical exams, he advocates. (See tips on easing access, below.)
1. Trussell J, Duran V, Shochet T, et al. Access to emergency contraception. Obstet Gynecol 2000; 95:267-270.
2. Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998; 332:428-433.