What happens the morning after? The costs and benefits of expanding access to emergency contraception

Health insurance and fertility among low-income, childless, single women: evidence from the ACA Medicaid expansions

Expansions of Medicaid family planning services have been associated with decreases in pregnancy rates. Access to a broader range of medical, non-family planning services may influence pregnancy rates as well if the increased exposure to medical services spills over to other kinds of behaviour. Using a difference-in-difference approach, I examine the impact of the Affordable Care Act (ACA) Medicaid expansions on the propensity of low-income, single women to become single mothers. Previous expansions of Medicaid family planning services allow us to also investigate the influence of access to other medical services (i.e. non-family planning). I find that although access to contraceptives is associated with a reduction in the propensity of becoming a single mother among adult, low-income women, medical services beyond access to contraceptives can provide additional impacts.

Subdermal contraceptive implants and repeat teenage motherhood: Evidence from a major maternity hospital-based program in Uruguay

Teenage fertility is a social problem because of its private and public costs in countries of different development levels. Reductions in adolescent birth rates do not necessarily follow drops in overall fertility due to the demographic transition model. This paper analyses the impact of a subdermal contraceptive program on repeat teenage motherhood. Using a regression discontinuity design, we find that the intervention reduced mothers' likelihood of having another child in the next 48 months by 10 percentage points. This reduction is not random, and we also identify small positive selection in subsequent births.

Development of self-care strategies to promote young Iranian women's sexual health: an explanatory sequential mixed method study protocol

BACKGROUND

In contemporary Iran, the nation's traditional and deeply religious society is currently experiencing swift transformations in its moral, cultural, and social aspects. It is, therefore, not surprising to observe shifts in people's attitudes toward sexuality, largely attributed to the profound impact of widespread social networks, the proliferation of information technology, and increased levels of education. Unmarried young women may potentially face adverse consequences from engaging in extramarital sexual relationships across various aspects of their lives. Acknowledging the pivotal role of self-care in influencing the sexual behaviors of young women, the objective of this study is to compile a comprehensive list of self-care strategies aimed at improving the sexual well-being of young, single Iranian women.

METHODS

The research will unfold in three distinct phases: Phase 1: Explanatory Sequential Mixed-Method Study This initial phase encompasses both quantitative and qualitative aspects. It begins with a cross-sectional survey, where we will gather data from 400 unmarried female students aged 18 to 29 years, utilizing a cluster random sampling method at Kerman University of Medical Sciences. Data collection will involve the use of a researcher-designed questionnaire. Subsequently, the qualitative phase will involve conducting in-depth, semi-structured interviews with female students from the University. To analyze this qualitative data, we will employ the content analysis approach. The findings obtained from both phases will be combined. Phase 2: Narrative Review In the second stage of the study, we will conduct an extensive narrative review to explore existing strategies related to the subject matter comprehensively. This review will serve as the foundational basis for our subsequent analysis. Phase 3: Strategy Prioritization In the final phase, we will prioritize the proposed strategies using a nominal group process, soliciting expert advice. This step will result in the definitive list of strategies that emerge from the study.

DISCUSSION

This study pioneers the field of sexual health, with the goal of developing a protocol for creating self-care strategies based on the perspectives of young, unmarried Iranian women. It offers potential evidence-based insights into current developments in the physical, psychological, and social aspects of sexual health within this demographic. Additionally, it aims to furnish essential information to healthcare policymakers regarding the sexual health of young women.

The morning after: Prescription-free access to emergency contraceptive pills

We analyze the introduction of prescription-free access to morning-after pills-emergency contraceptives that aim to prevent unintended pregnancy and subsequent abortion after unprotected sexual intercourse. Exploiting a staggered difference-in-differences setting for Europe combined with randomization inference, we find sharp increases in sales and manufacturers' revenues of more than 90%. However, whilst not reducing abortions significantly, the policy triggers an unexpected increase in fertility of 4%, particularly among women aged 25-34. We elaborate on mechanisms by looking at within-country evidence from several EU countries, which suggests that fertility is driven by decreasing use of birth control pills in response to easier access to morning-after pills.

Impact of contraceptive coverage policies on contraceptive use and risky sexual behavior among adolescent girls in the USA

OBJECTIVE

This study used representative data to examine the impact of changes in contraceptive coverage policies (contraceptive insurance mandates and pharmacy access to emergency contraception) on contraceptive use and risky sexual behavior among adolescent girls.

STUDY DESIGN

Using 2003-17 Youth Risk Behavior Survey data on 116 180 adolescent girls from 34 states, we conducted difference-in-differences models to examine changes in contraceptive use and unprotected sexual intercourse with the implementation of contraceptive coverage policies. We also tested interactions between age and pharmacy access to emergency contraception.

RESULTS

Findings indicate that contraceptive insurance mandates and pharmacy access to emergency contraception were not associated with changes in contraceptive use or unprotected sexual intercourse among adolescent girls, although some changes were observed in specific age groups. Despite this, our results show an overall increase in reported use of birth control pills and longer-acting methods from 2003 through 2017.

CONCLUSIONS

Using representative data, this study lends support to existing evidence that increased access to emergency contraception does not impact contraceptive method used or unprotected sexual intercourse among adolescent girls. The results underscore the need for expanding access to a wide range of contraceptive options for adolescents, with a focus on safer and more effective longer-acting methods.

Pharmacy-based initiatives to reduce unintended pregnancies: A scoping review

BACKGROUND

Community pharmacy contraception services are thought to improve access, with the potential to reduce the persistent sexual and reproductive health inequities observed globally.

OBJECTIVES

We aimed to identify the range of pharmacy-based initiatives addressing unintended pregnancy in the primary literature and examine their feasibility, acceptability and effectiveness.

METHOD

Using the Joanna Briggs Institute Methodology for Scoping Reviews, we searched seven bibliographic databases using combinations of keywords and subject headings for related to contraception and community pharmacy. Studies of any design undertaken in high income countries for reproductive-aged women were eligible provided they evaluated intervention or legislation after the implementation of these initiatives. Included articles were critically appraised and findings summarised narratively.

RESULTS

We identified 49 articles, 80% of which involved pharmacist supply of emergency contraception (EC), 14% of regular contraception methods, and 6% involved adjuncts of EC dispensing: counselling (2%) and bridging initiatives to link clients with regular contraception (4%). EC initiatives were perceived as feasible and were facilitated by interdisciplinary partnerships but there are persistent barriers to the provision of initiatives congruous with the retail pharmacy setting. Furthermore, consumers may be reluctant to receive contraceptive counselling from pharmacists but often value the convenience and anonymity pharmacy services offer. Overall, interventions improved access to contraceptive products but did not consistently reduce inequities, and the health benefits of pharmacy initiatives are either small (EC) or lacking description in the literature (other contraceptive methods and contraceptive counselling).

CONCLUSIONS

Pharmacy initiatives may not negate all barriers to access or reduce unintended pregnancy rates, however they are valued by pharmacists and consumers. Evidence gaps including the lack of description of health outcomes of regular contraception provision, contraceptive counselling and the perceived barriers and facilitators of access and provision from end-user perspectives, should be pursued in future research, to establish initiatives' utility and effectiveness.

A Comparative Study of the Cost and Uptake of Community Pharmacy "Stop Smoking and Emergency Contraception" Services from the Perspective of the National Health Service

Objective:

The objective was to explore if the community pharmacy (CP) stop smoking service (SSS) and emergency hormonal contraception patient group direction (EHC PGD) meet the needs of the English population and are cost-effective.

Methods:

This research was completed over 2 years. Public health resources provided details of CPs and provision of SSS and EHC PGD. Questionnaires were sent to smoking cessation/sexual health leads in local authorities to obtain information not available elsewhere. Questionnaires inquired about CP payment for provision of SSS and EHC PGD, overhead costs, successful outcomes, and validation methods. Quit rates at 4-weeks, 52-weeks, and lifetime determined SSS effectiveness. The effectiveness of EHC PGD was based on the probability of unintended pregnancy with/without levonorgestrel. Incremental cost-effectiveness ratio and cost of quality-adjusted life years (QALYs) gained were calculated. Descriptive statistics were determined. A priori of less than 0.05 (P < 0.05) was significant.

Findings:

SSS provision and uptake did not match local needs (smoking prevalence) even though increased CP SSS provision correlated with increased SSS success. Similarly, the need (based on teenage pregnancy rates) for EHC PGD did not correlate with the rate of CP provision but only with the uptake. Nevertheless, the provision of SSS and EHC PGD from CPs was cost-effective from an NHS perspective. Various assumptions were tested, but in all cases fell well below NICE QALY recommendations for cost-effectiveness.

Conclusion:

Provision of SSS and EHC PGD from CP does not meet the needs of the population even though the delivery of these services is cost-effective.

Unintended consequences of health insurance: Affordable Care Act's free contraception mandate and risky sex

Health insurance is a primary driver of rising medical expenditures. Economic theory suggests that insurance induces an increase in risky behaviors, but previous empirical evidence is mixed. I use a mandate in the Affordable Care Act in which contraceptives were covered at zero cost to consumers to test for unintended effects of insurance on risky sex. Leveraging mandated zero cost-sharing for contraception and pre-policy insured rates as a measure of treatment intensity, I provide evidence that this 2012 policy reduced fertility but caused unintended consequences: a decline in condom use and a subsequent increase in sexually transmitted infections (STIs). I discuss shortcomings of controlling for nonparallel pre-trends using state-trends, and I suggest an alternative to control for pre-trends directly in the context of dose-response difference-in-differences. Finally, estimates based on the 2010 dependent coverage mandate indicate health insurance provides an overall net positive effect on insurance and STI prevention.

Graduated driver licensing and teen fertility

This paper evaluates the effect of implementing nighttime driving curfews and passenger restrictions mandated by graduated driver licensing (GDL) on teen fertility. Both components of GDL potentially restrict the freedom and mobility of minor drivers by requiring adult supervision, and therefore reduces opportunities to become pregnant. Using birth data from the National Vital Statistics (NVSS) and a triple differences approach, I find that the implementation of "tough" GDL decreased fertility by 3-4% among mothers between the ages of 16 and 18. This effect is driven by the states that require driving curfews for at least a year before teenagers can obtain their unrestricted drivers license.

Behind-the-Counter, but Over-the-Border? The Assessment of the Geographical Spillover Effects of Emergency Contraception on Abortions

Washington was the first state to ease the prescription requirements making emergency contraception (EC) available behind-the-counter at pharmacies to women of any age in 1998. Using county-level vital statistics data in conjunction with the pharmacy specific location data from the Not-2-Late Hotline database, I study whether the increased access to EC affects fertility rates within the state and beyond the borders of the state that allows it. Unlike other studies that rely on geographic variations in access, I show that increased availability of EC in Washington, measured by the distance to the closest 'no-prescription EC pharmacy', is associated with a statistically significant albeit economically moderate decrease in abortion rates in Washington counties where women had access to 'no-prescription EC'. These effects are localized (i.e., decrease with travel distance) and robust in a number of specifications. Finally, I find some evidence in support of geographical spillover effects in Idaho, but not in Oregon. However, after accounting for the availability of abortion services, the decrease in 'treated' Idaho counties is rather small. Copyright © 2016 John Wiley & Sons, Ltd.

"I don't know what I would have done." Women's experiences acquiring ulipristal acetate emergency contraception online from 2011 to 2015

OBJECTIVES

This study describes women's reasons for seeking ulipristal acetate (UPA) for emergency contraception (EC) through the only authorized online retailer for UPA EC in the US.

STUDY DESIGN

Women aged 14 to 59 years, living in states that allow prescription medications to be shipped from out-of-state, accessed the KwikMed online pharmacy between January 2011 and December 2015. After completing a medical eligibility screener, women answered optional multiple-choice questions. To obtain UPA through KwikMed, individuals must be female, 50 years of age or younger, not currently pregnant or breastfeeding and not attempting to order UPA more than once within 30 days or more than four times per year.

RESULTS

Over the 5-year period, KwikMed provided 8019 prescriptions for UPA, and the number of women using this service more than tripled over time. Among women who responded to the survey questions (n=7133; response rate = 89%), most sought EC because of a condom failure (45.3%) or because they did not use regular contraception (41.2%). More than half (53.5%) of women reported that they chose UPA because of its effectiveness compared to levonorgestrel EC pills, and 58.9% preferred ordering UPA online because they found it easier than getting it from a doctor, clinic or pharmacy.

CONCLUSIONS

This study documents the importance of providing confidential services for acquiring EC online. Benefits of online access include convenience, less embarrassment, avoiding situations in which a provider might refuse to provide EC because of their own ideological belief and more reliable availability for this time-sensitive contraceptive.

IMPLICATIONS

Though physical, logistical and societal barriers can restrict women's access to EC, this study demonstrates that providing access to UPA online empowers women to obtain EC when they need it.