Knowledge and use of hormonal emergency contraception in Finland

How does a Belgian health care provider deal with a request for emergency contraception?

OBJECTIVE

To evaluate how Belgian health care providers deal with a request for emergency contraception.

METHOD

In 2002-2003 we conducted 12 focus groups with pharmacists, general practitioners and school physicians. A skilled moderator accompanied by an observer conducted the focus groups using a semi-structured screenplay.

RESULTS

All these health care providers agree with the free access to emergency contraception (EC), but experience considerable frustration with regard to the practical aspects and the legal framework. General practitioners (GPs) claim to spend a lot of time on requests for EC and they are concerned about the quality of the counselling provided in pharmacies. Pharmacists are creative when giving counselling in the pharmacy, but there is, nevertheless, a problem with a lack of privacy. School physicians are frustrated that there is no legal possibility to respond to a request for EC when they feel they are ideally placed to advise adolescents.

CONCLUSION

The over-the-counter sale of EC offers women better access, but many barriers still interfere with optimal care. Pharmacists experience a lack of skills to communicate with adolescents and a lack of privacy to give counselling. GPs have good intentions, but are confronted with a lack of willingness on the part of the patients and also financial barriers. School physicians want more possibilities to help adolescents.

Counseling about and use of emergency contraception in the United States

CONTEXT

Few nationally representative studies have examined the prevalence and predictors of emergency contraception use or of receipt of counseling about the method. The impact of the U.S. Food and Drug Administration's 2006 approval of behind-the-counter sales of the method to women aged 18 and older remains to be seen; therefore, understanding patterns of use and counseling before the 2006 policy change is necessary to assess its impact.

METHODS

Data collected from 7,643 women aged 15-44 participating in the 2002 National Survey of Family Growth were analyzed using multivariable logistic regression to assess predictors of receipt of counseling and use of emergency contraception.

RESULTS

Overall, 3% of women reported that a clinician had discussed emergency contraception with them in the past year, and 4% of those who had ever had sex with a man reported having used the method. Only 4% of those who had seen a gynecologist in the past year reported having received counseling. Women's likelihood of having received counseling was reduced if they were 30 or older (odds ratio, 0.2), and was elevated if they were Hispanic (4.1), black (2.6) or ever-married (2.4). Receipt of counseling in the last 12 months was the strongest predictor of ever-use (11.7).

CONCLUSIONS

Clinicians can play a pivotal role in ensuring that women have accurate information about how to access and use emergency contraception. However, efforts are needed to explore other ways to deliver this counseling.

Emergency contraception

Teen birth rates in the United States have declined during the last decade but remain much higher than rates in other developed countries. Reduction of unintended pregnancy during adolescence and the associated negative consequences of early pregnancy and early childbearing remain public health concerns. Emergency contraception has the potential to significantly reduce teen-pregnancy rates. This policy statement provides pediatricians with a review of emergency contraception, including a definition of emergency contraception, formulations and potential adverse effects, efficacy and mechanisms of action, typical use, and safety issues, including contraindications. This review includes teens' and young adults' reported knowledge and attitudes about hormonal emergency contraception and issues of access and availability. The American Academy of Pediatrics, as well as other professional organizations, supports over-the-counter availability of emergency contraception. In previous publications, the American Academy of Pediatrics has addressed the issues of adolescent pregnancy and other methods of contraception.

Emergency contraception: who are the users?

The objective was to describe the demographic and sexual characteristics of clients attending a Sexual Health Clinic for emergency contraception (EC). Information about women attending the Parramatta Sexual Health Clinic (PSHC) who received EC between January 1999 and July 2002 was derived from the clinic database. Age-matched controls were randomly selected. Univariate and logistic regression analysis was performed to establish which factors were associated with use of EC. Two hundred and sixty-seven women requesting EC, and an equal number of controls, were studied. Factors that were independently associated with EC use were being a student, (OR=1.7 [95% CI 1.02-2.69]) and having a regular sexual partner (OR=2.3 [95% CI 1.14-4.73]). Women requiring EC were significantly less likely to have had a sexually transmitted infection (STI) (OR=0.3 [95% CI 0.16-0.60]) or a previous pregnancy (OR=0.2 [95% CI 0.09-0.67]) than controls. We concluded that users of EC are at low-risk for STIs, but need counselling about safer sex.

The role of emergency contraception

Emergency contraception is an underused therapeutic option for women in the event of unprotected sexual intercourse. Available postcoital contraceptives include emergency contraceptive pills (ECPs) both with and without estrogen, and copper-bearing intrauterine devices. Each method has its individual efficacy, safety, and side effect profile. Most patients will experience prevention of pregnancy, providing they follow the treatment regimen carefully. There are concerns that women who use ECPs may become lax with their regular birth control methods; however, reported evidence indicates that making ECPs more readily available would ultimately reduce the incidence of unintended pregnancies. In addition, it is typically conscientious contraceptive users who are most likely to seek emergency treatment. Patient education is paramount in the reduction of unintended pregnancies and there are numerous medical resources available to women to assist them in this endeavor. Finally, ECPs are associated with financial and psychologic advantages that benefit both the individual patient and society at large.

Caractéristiques des utilisatrices de pilule du lendemain, en France

OBJECTIVES

Emergency contraception pill (ECP) has recently become available in France without prescription since 1999. The aim of this study was to explore knowledge, attitudes toward, and use of ECP.

PATIENTS AND METHODS

A national sample of 1639 women were interviewed by telephone randomly selected from the telephone directory. After sending a letter to each household to minimize the number of refusals, finally 397 eligible women aged 18-44 years accepted to answer.

RESULTS

Seventy-one percent of women know ECP and 9% had ever used ECP. ECP users were younger, more often single, but no important difference was found with education level, religion and knowledge of ECP between users and non-users. Only 25% of the women knew the exact correct time for using it (within 72 h following an unprotected sex). ECP users had more sexual partners in their life (12 vs. 4, P < 0.05) and 27% vs. 8%, had a previous history of sexual transmitted disease (P < 0.01). ECP users had a different contraceptive profile than non-users; they used less effective methods but the frequency of contraception use was found to be higher. Finally, over 1 year, the percentage of potential ECP users can be estimated at 13% considering women who had reported problems with condom use, forgot their pill once or more.

DISCUSSION AND CONCLUSION

ECP users are different from non-users, but all women are concerned and should receive increased education on ECP use. Making ECP more easily available in population may reduce the rate of unintended pregnancy.

Investigating the knowledge, attitude and its relationship with the mean of using emergency contraception

The aim of this study was to investigate women s knowledge about and attitude toward emergency contraception (EC) in women who referred to health centers of Tehran University of Medical Science. The subjects in this study consisted of 250 married women of fertility age who had been selected randomly and interviewed by the researcher. The majority of the subjects had not used EC. Just 5.2% (13 women) had used this method and 8.31% had knowledge and information about EC. There was a significant correlation between knowledge about and use of this method (p = 0.0001). Although the users of this method were more knowledgeable about EC than nonusers, a majority of subjects (76.57%) had a positive attitude toward EC; however, there was not a significant correlation between positive attitude and use of EC (p = 0.184).

Emergency contraception: knowledge and use among Danish women requesting termination of pregnancy

The aim of this study was to describe knowledge about and use of emergency contraception (EC) among Danish women requesting termination of pregnancy. The study included 1514 women (response rate 83.7%) referred during the period August 2000 to May 2001. Sufficient knowledge of EC was defined as knowledge about both the correct time limit and where to acquire the EC. We found adequate knowledge in 44.7%. These women were typically younger, better educated and more often singles, nulliparae, and users of contraception. No relation was found to the type of contraception used or to previous terminations of pregnancies. EC was used in the actual pregnancy by 6.6% and 24.1% had used it previously. Actual or formers users were characterized in the same way. The general knowledge about EC has not improved significantly during the last few years and there is still need for information about the correct use of EC.

Women's voices about emergency contraceptive pills "over-the-counter": a Swedish perspective

This study aimed to describe women's experiences with the emergency contraceptive pill (ECP) as a prescription-free over-the-counter (OTC) product. Women (median age 24) who had bought ECP as an OTC product were interviewed in focus groups. Data were analyzed by content analysis. All participants appreciated the OTC availability. Timesaving aspects were seen as important benefits and pharmacies were seen as the right place to sell ECP. The media was the main source of information about OTC, probably due to the debates of the introduction of ECP as an OTC product in Sweden. All women discussed the mechanism of action. The women's experiences of interacting with the pharmacists were both positive and negative. Inconsistencies in routines with regard to providing ECP and different attitudes toward use of ECP among the pharmacists, were identified. The women expected up-to-date information about ECP and the OTC availability from gynecologists and other health professionals.

Emergency contraception among teenagers in Switzerland: a cross-sectional survey on the sexuality of 16- to 20-year-olds

PURPOSE

To describe and analyze emergency contraception (EC) awareness and use among sexually active Swiss teenagers.

METHODS

Anonymous computerized questionnaires were distributed to a national representative sample of 4283 in-school adolescents (aged 16 to 20 years) in high schools and professional centers. Young people who were sexually active (51.5% of the sample: 1058 girls and 1073 boys) responded to questions on EC awareness and use and on sexual perception, attitude, and behaviors. Univariate analyses and multiple regression analyses were used to describe EC awareness and use and their correlates.

RESULTS

Most of the sexually active girls (89.3%) and boys (75.2%) knew of the existence of EC. Of girls, 20% reported having used EC, and the majority of them used it only once (64.1%) or twice (18.5%). EC awareness was positively associated with the father's level of education (girls: odd ratio 5.18) and the scholastic curriculum of the respondent. Gender differences in the correlates of EC awareness demonstrate that girls who had a confidant or a group of friends or boys of Swiss nationality and those who have had the opportunity to discuss the issue of contraception declare greater awareness of EC. EC use was higher among girls who lived in urban areas (odds ratio 1.91) and occasionally had unprotected intercourse. We did not find any significant difference in the profile of multiple vs. one-time users.

CONCLUSION

EC awareness and use should be improved through better information and accessibility, especially among teenagers who place themselves in at-risk situations.

Emergency contraception

The last decade has seen a huge interest in emergency contraception (EC) because of the potential it has to reduce abortion rates. A variety of hormonal methods is available although mifepristone-arguably the best method-is only licensed in China. The intrauterine device is highly effective but its use is limited because of the technical skill required for successful insertion. The mechanism of action of both the Yuzpe regimen of EC and of levonorgestrel is poorly understood and for all methods there are serious methodological difficulties involved with calculating efficacy. Nevertheless the risks and side-effects of EC are negligible and the practicalities of prescribing it are extremely simple. Research and programmatic efforts should concentrate on improving availability if EC is to fulfil its promise as a public health intervention to reduce unwanted pregnancy.

Knowledge, use and attitudes towards emergency contraceptive pills among Swedish women presenting for induced abortion

OBJECTIVE

To investigate the knowledge, experiences and attitudes towards emergency contraceptive pills (ECP) among women presenting for induced abortion.

DESIGN

Survey by self-administered waiting room questionnaires.

SETTING

Three large hospitals in the cities of Uppsala, Västerås and Orebro in Sweden.

POPULATION

591 Swedish-speaking women consecutively attending the clinics for an induced abortion during a four-month period in 2000.

RESULTS

The response rate was 88% (n = 518). As many as 43% had a history of one or more previous abortions and 43% were daily smokers. Four out of five women, 83%, were aware of ECP, but only 15 women used it to prevent this pregnancy. Fewer, 38%, knew the recommended timeframes for use and 54% had knowledge of the mode of action. The two most common sources of information about ECP were media and friends. One out of five, 22%, had previously used the method, and at the time of conception, 55% would have taken ECP if it had been available at home, and 52% were positive to having ECP available over the counter.

CONCLUSIONS

Emergency contraception is well known but is still underused. Lack of awareness of pregnancy risk may be one limiting factor for its use. Making ECP available over the counter may be an important measure towards better availability. Information strategies to the public are needed before ECP will be a widely used back-up method.

Reasons for pregnancy termination, contraceptive habits and contraceptive failure among Swedish women requesting an early pregnancy termination

BACKGROUND

More than 30 000 legal abortions are performed every year in Sweden despite sexual education in schools, widespread youth-clinics and family planning services that are free of charge. The aim of this study was to investigate reasons for induced abortion, contraceptive habits and reasons for contraceptive failure among women presenting for induced abortion.

METHODS

A questionnaire was administered to 591 Swedish-speaking women consecutively attending three different health care providers concerning an induced abortion during spring 2000.

RESULTS

The response rate was 88% (n = 518). As many as 43%, among daily smokers 53%, had experienced one or more previous legal abortions. The majority of the women (97%) had discussed the decision about abortion with someone. The most cited reasons contributing to their decision were financial concerns, worries about the relationship and bad timing of the pregnancy. Though 85% had used contraception during the previous year, 36% of the women had not used any contraceptive method at the time of conception. The main reason given for not using contraception was the belief that they could not at that time become pregnant (35%). Ninety percent of the women planned to use contraception after the abortion.

CONCLUSION

Women's decisions regarding induced abortion are multifactorial. One important reason was "poor economy". One out of three did not use any contraception, as they believed they could not become pregnant. Women presenting for induced abortion are a risk-group for further terminations. Counseling must include information about the fertile window, effective contraceptives and the emergency contraceptive pill.

Emergency contraception knowledge and prescribing practices: a comparison of primary care residents at a teaching hospital

STUDY OBJECTIVE

To determine knowledge, opinion, and experience concerning emergency postcoital contraception in primary care physicians who are in training.

DESIGN

Cross-sectional survey using a questionnaire survey distributed to primary care specialty housestaff.

SETTING

Questionnaire surveys were distributed to all active primary care housestaff in training and Obstetrics and Gynecology attendings at the University of Kentucky.

PARTICIPANTS

The study surveyed all primary care specialty housestaff. Specialties included family practice (FP), internal medicine (IM), pediatrics (PD), and obstetrics and gynecology (OG). The attending faculty in Obstetrics and Gynecology (OGA) were also surveyed as a comparison group.

MAIN OUTCOME MEASURES

Study variables were compared between specialty of training, year of training, and abortion opinion. ANOVA or Student's t tests were used, with statistical significance defined as P <.05. Each questionnaire was scored 0 to 9 based on knowledge and utilization questions. Overall response rate was 48%, 90 out of 189 surveyed. Response rates per specialty are as follows: FP = 51%, IM = 37%, PD = 48%, OG = 65%, and OGA = 69%.

RESULTS

The average score on the survey was significantly different based on specialty of training (P value <. 0001). Scores were not significantly different based on year of training. However, the average attending OG's score was significantly higher than for all the housestaff (P value <.0001).

CONCLUSION

Knowledge and utilization of postcoital contraception is dependent on specialty. Unfortunately, this knowledge does not appear to increase with year of training, suggesting that there is a lack of education during the years of training.

Differences between users and non-users of emergency contraception after a recognized unprotected intercourse

Knowledge of emergency contraception is crucial but might not transform into use. Factors influencing decision-making related to use of emergency contraception after an unprotected intercourse and the characteristics of users of emergency contraception (EC) were assessed. In an abortion clinic setting, 217 women referred for termination of pregnancy were asked to fill in a questionnaire. Of the 217 women, 139 (64%) were aware of pregnancy risk but only 9 (4%) had used EC after the unprotected intercourse. 42% were estimated to have sufficient knowledge to use hormonal emergency contraception. In a larger background population, a calculated 29% used EC after a recognized unprotected intercourse. EC users were older, better educated, more often in stable relationships, had experienced more abortions, and gestation age was less. However, younger women were in general better informed of EC. Knowledge of EC does not necessarily transform into action. Neglect of risk after an unprotected intercourse is frequent in younger well-informed women and information has to be better targeted.

Knowledge and use of emergency postcoital contraception by female students at a high school in Nova Scotia

PURPOSE

This study was performed in the context of a sexual health promotion project in a Nova Scotia community. Community members wanted information about adolescent females' knowledge and use of emergency contraception (EC). The study was done to meet this need.

METHODS

Female high school students aged 14 to 19 were administered a self-completion survey asking about their knowledge of EC, the time frame for its use, its effectiveness, their personal use of EC, unsuccessful attempts to obtain EC, and sources of knowledge of EC.

RESULTS

Eighty-five percent of 411 female students participated. Eighty percent knew about EC, though few (8%) knew the time frame for EC use. Most (42%) heard of EC at school. Eighteen percent used no contraception at last intercourse. Only 2% ever had used EC.

CONCLUSIONS

Adolescent women know about EC but use it infrequently, even though they frequently lack contraception. These findings raise questions about alternative methods for providing EC to young women.

Provision of emergency contraceptive pills to spermicide users in ghana

This study evaluated the effect of two approaches to provision of emergency contraceptive pills (ECPs) on ECP use and unprotected intercourse among women relying on spermicides for contraception. The study enrolled 211 women at 4 family planning clinics in Ghana. At two clinics, participants were advised to return to the clinic within 3 days after unprotected intercourse to obtain ECPs. At the other two clinics, participants were given ECPs to take home for use if unprotected intercourse occurred. All participants were asked to maintain daily diaries for 8 weeks to record information on sexual activity, spermicide use, and ECP use. Women at all clinics used ECPs after at least 78% of unprotected coital acts. ECPs were used more promptly by women who had the pills at home. At three of the clinics, at most 1.3% of the coital acts were unprotected; at the fourth, 6.7% were unprotected. Our data did not suggest that the availability of ECPs increased the frequency of unprotected intercourse.

Emergency contraception: a review of the programmatic and social science literature

Many biomedical aspects of emergency contraception have been investigated and documented for >30 years now. A large number of social science questions, however, remain to be answered. In this article, we review the rapidly growing but geographically lopsided literature on this topic. Using computer database searches supplemented by reference reviews and professional correspondence with those active in the field, we gathered literature on the social science and service delivery aspects of emergency contraception published in English up through December 1998, as well as a few unpublished papers from the same time and slightly later, representing regions where published material is practically nonexistent. Methodologically acceptable papers are summarized in our tables and text, and form the basis for suggested improvements in existing emergency contraceptive services. The review also offers ideas for designing new emergency contraception services where they do not yet exist. We conclude by proposing an agenda for further social science research in this area.

Emergency contraception: an anomalous position in the family planning repertoire?

Emergency contraception (EC) can be used up to 72 h after sex to prevent pregnancy. Internationally there is wide variation in the availability of EC. In the USA it has only recently (1997) won approval from the FDA, while the UK and New Zealand have seen calls for over the counter availability. In recent years surveys, editorials and opinion pieces in medical journals have pointed out that increased access to EC could help to tackle the unwanted pregnancy rate, especially among teenagers, and concluded that lack of knowledge of EC is the major barrier to use. However, women in a UK study have expressed concerns that it is not safe to use the method repeatedly and cited general practitioners (GPs) as one of the sources of this belief, which contradicts the professional guidelines and the rationale for de-regulation. A subsequent study sought to seek the views of GPs about prescribing EC and explored reasons for the gap between the views of women using UK family planning services, GPs and professionals at the public policy level. Data from two studies are presented. In the first study, 53 women seeking emergency contraception were interviewed at two family planning clinics. In the second, semi-structured telephone interviews were completed with a random sample of 76 GPs from three English health authorities. Interviews were recorded, transcribed and thematic analysis was conducted using the constant comparative method. EC was rarely described, by users or GPs, as an acceptable contraceptive option. Consultations for emergency contraception were viewed by GPs as an important opportunity to discuss the woman's future contraceptive needs. Repeated use of EC was not encouraged and a discussion of contraceptive needs could range from a mild enquiry to quite forceful messages contrasting EC to 'regular' and 'proper' methods. The medical literature suggests that EC is underused because of a lack of awareness. Commentators have recommended educating health professionals and women about EC and increasing availability through de-regulation. The data presented in this paper show that British GPs are not enthusiastic about the de-regulation of EC, but the reasons are complex and related to concerns about planned contraception and sexual behaviour. It is suggested that it may be because EC is used after sex that it seems to occupy an uncomfortable place within the contraceptive repertoire.

Reproductive health: an international perspective

The twentieth century began with approximately 1.6 billion human beings in the world and, with an increase of 96 million people per year, will end with over 6 billion people. Unless this trend is directly confronted by the world governments and their citizens, there will be nearly 8 billion by 2025 and over 11 billion by 2050. Thus, reproductive health is and will remain an issue of critical importance for all countries to realize and study. Part of this trend is because of the many pregnancies which occur in adolescents around the world. A number of issues have developed this century contributing to the many pregnant teenagers. For example, India has one of the world's largest populations of teenagers--over 23 million, representing over 26% of the total in the world. Effective methods for contraception and sexually transmitted diseases prevention are available, but not to all sexually active humans. However, many barriers to effective contraception exist around the globe. This article discusses some of them and also reviews use of contraceptive methods in various countries. These include oral contraceptives, emergency contraceptives, injectable and implantable contraceptives, intrauterine devices, barrier contraceptives and others. Reproductive health remains a critical, universal issue for all humans in the world. We all must examine the many pitfalls to controlling the world's populations, including lack of sex education, limited access to effective contraceptives, and others. We cannot afford to let the population continue unchecked. Effective strategies are needed at this time; otherwise, the population will continue to run out of control, negatively damaging the world for the coming generations. There is need to leave a positive, and not negative legacy for the next generation.

Knowledge, attitudes, and practices regarding emergency contraception among nurses and nursing students in two hospitals in Nairobi, Kenya

A cross-sectional descriptive study on knowledge, attitudes, and practice about emergency contraception (EC) was conducted among nurses and nursing students using a self-administered questionnaire. One-hundred-sixty-seven qualified nurses and 63 nursing students completed the questionnaire. Over 95% listed at least one regular contraceptive method but only 2.6% spontaneously listed EC as a contraceptive method, whereas 48% of the respondents had heard of EC. Significantly more nursing students than qualified nurses were familiar with EC. Knowledge about the types of EC, applications, and side effects was poor and 49% of the respondents considered EC as an abortifacient. Of those familiar with EC, 77% approved its use for rape victims and 21% for adolescents and schoolgirls. Only 3.5% of all respondents had personally used EC in the past, 23% of those familiar with EC intend to use it in the future, whereas 53% intend to provide or promote it. The view that EC was abortifacient negatively influenced the decision to use or provide EC in the future. The present findings suggest that the level of knowledge of EC is poor and more information is needed. These findings indicate the potential to popularize emergency contraception in Kenya among nurses and nursing students.