Forensic Nurses Need Facts on Emergency Contraception
Forensic nurses, who work with victims of violence, hold a fair amount of misinformation about how emergency contraception (EC) works, according to new research.
Researchers found that about 22% believe ulipristal acetate (UPA), a prescription EC called ella, could disrupt an established pregnancy. About 17% say the same about oral levonorgestrel (LNG) EC, which is sold over the counter as Plan B.1
Despite misinformation, 96.5% prescribed or dispensed one of the two EC medications at the time of medical forensic exams, the study shows. But they were far more likely to prescribe LNG, although UPA is more effective and can work better in women who weigh more than 165 pounds.
“If there was no access to emergency contraception or reproductive choice, up to 25,000 pregnancies would occur as a result,” says Nancy R. Downing, PhD, RN, FAAN, SANE-A, SANE-P, lead study author and an associate professor in the Texas A&M University School of Nursing. “We want to make sure healthcare providers have the correct knowledge about emergency contraceptive mechanisms, and the general public can make a decision that’s right for them. Transparency and knowledge can go a long way in deciding what’s right.”
Forensic nurses who lack accurate information about EC could make treatment decisions that are influenced by what they believe is true, so they need additional education on how EC works — both the over the counter and the prescribed versions.
For one thing, nurses need to know that the FDA changed package labeling for Plan B (LNG) in December 2022. The new label eliminates wording that suggests the pill may prevent a fertilized egg from implanting in the womb.2,3
The FDA updated the Plan B labeling after the U.S. Supreme Court overturned Roe v. Wade. But the FDA has not yet updated the packaging on ella.
“We should be offering [ella] in exams after sexual assault,” Downing says. “Although there is no evidence that the medication interferes with implantation, the packaging insert still says it’s a potential mechanism. Some programs say they’ll offer Plan B, but not the other one.”
Health systems may be faith-based, or they may be concerned that prescribing ella could get them in legal trouble because of some states’ anti-abortion laws, Downing says.
The problem is that LNG is efficacious for less time than UPA. UPA also is more effective at all time points after unprotected intercourse.
“There are nuances mentioned in my publication that you may want to consider some cases in which it might be less effective to give UPA because a person is taking oral contraceptives and it could interfere with the efficacy of UPA or vice versa,” Downing explains. “Without this knowledge or a deeper understanding of the mechanisms, people may not get the only opportunity they have to prevent an unplanned pregnancy because of rape.”
Downing and colleagues are trying to educate nurses about EC and how it works. “I’m doing a presentation at a national forensic nurses conference, hoping to give accurate information so they can make a decision that fits their ethics and morality and what they want to do,” she says.
Forensic nursing is growing as a profession, and scrutiny is increasing over how forensic nurses are educated and what continuing education they need. “Can we increase the quality so we’re not wrongfully convicting people? But more importantly — are we providing the highest quality and standard of care?” Downing asks. “We’re trying to identify the standards and make sure they receive education that is evidence-based and make sure they have education that is knowledge-based.”
It is about accountability. “No one is holding forensic nurses accountable for their practice,” Downing laments. “They may be getting clinical education, but how does it drift away from best practices if they’re not maintaining a currency of evidence-based knowledge?”
Believing inaccurate information is more of a problem than nurses’ personal religious beliefs. “I know many forensic nurses who do have religious beliefs that may not comport with how they offer treatment,” Downing says. “They understand the decisions they would make for themselves should not be imposed on their patients.”
The bigger concern is a hospital system that will not provide EC because they believe it goes against their religion. “It’s important that we educate them that this is the mechanism. Some still think they should leave it in the hands of the person, their god, and they have a right to do that,” Downing notes.
It is surprising that fewer forensic nurses provide sexual assault victims with UPA than LNG because the national protocol is to provide UPA because of its efficacy, Downing says.
“Some of their reasons for not offering [UPA] are related to the cost. A lot of clinicians work under delegated orders, and they feel more comfortable providing delegated medication that is not prescription,” she explains. “Some will not allow nurses to provide ulipristal acetate to patients under age 18 with the rationale that they cannot access it over the counter themselves, and they don’t give them prescription medications.”
But that also is illogical because they will provide all sexual assault victims — regardless of age — with prescription medication for treating sexually transmitted infections, Downing adds.
Forensic nurses and health systems need to give patients accurate information and all available options so they can make a choice that is right for them, Downing says.
- Downing NR, Avshman E, Valentine JL, et al. Forensic nurses’ understanding of emergency contraception mechanisms: Implications for access to emergency contraception. J Forensic Nurs 2023;19:150-159.
- Plan B One-Step. How Plan B works. 2023.
- Seitz A. FDA changes Plan B label, clarifies it won’t cause abortion. AP News. Dec. 23, 2022.
Forensic nurses, who work with victims of violence, hold a fair amount of misinformation about how emergency contraception works, according to new research.
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