Current Issues in Emergency Contraception: An Overview for Providers

Jennifer Brunton, CNM, MSN; Margaret W. Beal, CNM, PhD

Disclosures

J Midwifery Womens Health. 2006;51(6):457-463. 

In This Article

Women's Knowledge, Attitudes, and Practices

While many studies have tried to investigate women's knowledge, attitudes, and practices regarding EC, these issues have proven difficult to measure. Estimates of how much women know about EC vary greatly. Recent data from the 2004 California Women's Health Study, a study of 6000 randomly selected women in California, showed that 51.7% of women knew that there was something a woman could do after intercourse to prevent pregnancy. When asked the follow-up question, "What can she do?," the most common response (66%) was "take the 'morning after' pill." A 2005 study of women in a Boston neighborhood reported that 82% of all respondents had heard of EC, although a significant difference was noted when responses were analyzed by race and ethnicity. Only 51% of Latina women had heard of EC, as compared with 75% of black women and 99% of white women. Several studies have shown that younger women tend to be better informed about EC than older women.[31,32,33]

Even when women have heard of EC, almost all studies show that they do not have sufficient knowledge to be able to use EC effectively. In particular, many women (presumably because of the misnomer "morning after pill") believe that EC must be taken the morning after an act of unprotected intercourse. They often do not realize that, in fact, EC is better taken as soon as possible after the act rather than waiting until the following morning and that the method can be used up to 5 days after intercourse.

Attitudes toward EC are as varied as women's knowledge of the method. One large study from the United Kingdom reported that women who had a strong desire not to become pregnant were more likely to view EC as a morally acceptable option. A study of Latina women in the United States showed that positive attitudes toward EC were linked with increasing knowledge of its proper use and of its mechanism of action. Moral or religious concerns also affect women's attitudes toward EC, and are commonly cited as reasons why women would not use it.[32,34,35]

Statistics on EC use are difficult to compare, as they are gathered from different populations with different demographics, making it almost impossible to determine the true trend of EC use. A study of college students conducted in 2003 reported a 13.7% use rate.[35] In addition to providing for increased access, in several instances, over-the-counter status has led to greater awareness and use of the method. For example, one year after EC was approved for over-the-counter status in Sweden, a study showed that 98% of women had heard of the method. Over-the-counter access in France has led to greater utilization, particularly among younger women.[36,37,38]

Although younger women tend to be more aware of the availability of EC, users of EC tend to be older. They are also apt to have a higher education level and are more often in stable relationships. Other factors that have been found to be good predictors of EC use are seeing EC use as a responsible action, having the support of the sexual partner for use, understanding the pregnancy risk or having more negative perceived consequences of pregnancy, confidence in requesting EC, and a positive attitude regarding its efficacy.[39,40]

Barriers to Accessing Emergency Contraception

For EC to be an effective means of preventing unintended pregnancies, several conditions must be met: the woman must be aware of her pregnancy risk, she must have some knowledge of EC and how it is used, and she must have access to the medication. In the United States, several barriers that limit access currently exist. One major barrier, as discussed above, is a lack of knowledge on the part of women. One research team concluded that the lack of perceived pregnancy risk was perhaps the most important factor that limited the use of EC.[41] Other knowledge deficits also play a role, including having never heard of EC, not knowing when it can be used, or not knowing where or how to get it. For other women, especially adolescents, access to EC is limited by feelings of embarrassment or shame in asking for it, as well as concerns about confidentiality.[40,41]

If the provider has little knowledge of the method or a negative attitude toward it, the option will likely not be offered. Practices of prescribing EC differ by specialty of provider, with one recent study reporting that 94% of obstetrician/gynecologists had prescribed EC, compared with 76% of family practitioners and 63% of general internists. In a survey of 146 CNMs conducted in 2001, 58% reportedly prescribed EC only a few times a year, and only 7% prescribed it one or more times a week.[42,43]

Another major barrier to easy access of EC is its prescription-only status. This usually requires women to make an appointment with a care provider, a time consuming and often expensive task. For women on a limited budget or those with extremely tight schedules, the prescription requirement can make accessing EC nearly impossible. The requirement for a prescription also poses problems when unprotected intercourse occurs on a weekend when provider offices are likely to be closed. For those women who telephone or see their provider and obtain the necessary prescription, this is only the first step.

More barriers are often encountered while trying to fill the prescription. Some pharmacy chains have adopted policies that prohibit the dispensing of ECPs, or allow pharmacists the option of declining to dispense them. A 2003 study of 315 Pennsylvania pharmacies showed that only 35% were able to give information about the product and also had it in stock, while only 3% of the entire sample stocked Plan B. Of those who said they could not provide the medication, reasons given included no medication in stock, that it was against store policy, or that it conflicted with personal beliefs.[44] A similar study in 2006 showed that only 32% of Pennsylvania pharmacies had EC in stock.[45]

Limited prescribing and dispensing of EC by many practitioners and pharmacists can stem from their lack of knowledge about EC, moral or ethical issues with providing it, as well as worries about efficacy and side effects. Some practitioners also have concerns that provision of EC may cause an increase in risky sexual behaviors and in sexually transmitted infections, although this has not proven to be the case.[32] A 2005 study looked at young women who were given either advance provision or pharmacy access to EC and found that they had no significant increase in sexually transmitted infections nor decrease in regular contraceptive use.[46]

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