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Beyond access: Acceptability, use and nonuse of emergency contraception among young women
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GENERAL GYNECOLOGY
Beyond access: Acceptability, use and nonuse of emergency contraception among young women Corinne H. Rocca, MPH; Eleanor B. Schwarz, MD; Felicia H. Stewart, MD; Philip D. Darney, MD, MSc; Tina R. Raine, MD, MPH; Cynthia C. Harper, PhD OBJECTIVE: This study was undertaken to assess the acceptability of
levonorgestrel emergency contraception (EC). STUDY DESIGN: We examined attitudes and use patterns among 1950 women in a randomized trial evaluating access to EC through advance provision, pharmacies, or clinics. RESULTS: Most women considered EC to be safe (92%) and effective
(98%). Compared with women with clinic access, women with direct pharmacy access were no more likely to use EC within 24 hours (odds ratio [OR] ⫽ 1.65, 95% CI ⫽ 0.82-3.30) or to report it very convenient (OR ⫽ 1.41, 95% CI ⫽ 0.77-2.56). However, women with advance
provisions were more likely to use EC promptly (OR ⫽ 2.43, 95% CI ⫽ 1.24-4.80) and report high convenience (OR ⫽ 4.25, 95% CI ⫽ 2.32-7.76). Advance provision increased use by all women, whereas pharmacy access increased use only among condom users. Inconvenience and fear of side effects were common reasons for nonuse. CONCLUSION: Women viewed EC favorably. Advance provision im-
proved promptness and convenience of use overall, while pharmacy access benefited specific populations. Key words: acceptability, emergency contraception, nonuse, pharmacy access, use
Cite this article as Rocca CH, Schwarz EB, Stewart FH, et al. Beyond access: Acceptability, use, and nonuse of emergency contraception among young women. Am J Obstet Gynecol 2007;196:29.e1-29.e6
S
ince a dedicated emergency contraceptive product became available by prescription in the United States in 1998, various efforts have been made to facilitate access to it. Nine states have policies allowing women of any age to obtain emergency contraception
From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Reproductive Health Research and Policy, (Ms Rocca and Drs Stewart, Darney, Raine, and Harper), and the Department of Medicine, General Internal Medicine Section (Dr Schwarz), School of Medicine, University of California, San Francisco, CA. Reprints: Corinne H. Rocca, University of California, San Francisco, Department of Obstetrics and Gynecology, 50 Beale St, Suite 1200, UCSF Box 0886, San Francisco, CA, 94105. [email protected]. Sources of financial support: William and Flora Hewlett Foundation, Compton Foundation, Inc, Open Society Institute, Wallace Alexander Gerbode Foundation, Women’s Capital Corporation, former distributor of Plan B, donated the emergency contraceptive pills. 0002-9378/$32.00 © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2006.08.024
(EC) directly through pharmacies (AK, CA, HI, MA, ME, NH, NM, VT, and WA).1 In August 2006, the Food and Drug Administration (FDA) approved an application from the marketers of Plan B EC to make the progestin-only product available over-the-counter for those aged 18 or older. The product remains available by prescription only for minors. In the 9 states with pharmacy access legislation, however, minors can optain Plan B directly from the pharmacist. Despite moderate increases in the availability of EC over the past 5 years, use remains low. In 2003, only 6% of US women aged 18-44 years had used EC, a modest increase from 2% in 2000.2 Even in California, where EC has been available directly through pharmacies since 2002 and health plans are required to cover it, only 8% of women had used EC by 2003.3 Furthermore, most studies on access to EC have shown that only a fraction of those who might appropriately use it actually do, even when given a supply in advance.4 – 8 Considering that unintended pregnancy and abortion rates are high in the United States,9,10 and that a mere 1.3% of women undergoing
abortions reported having taken EC,11 many women who could benefit from EC are still not using it. It remains unclear what determines whether women, who know about EC and have access to it, actually use it. Those with an increased perception of their own risk of pregnancy, because of previous pregnancy or abortion, may be more likely to use the method; however, studies have yielded mixed results.12,13 Researchers have begun to identify reasons why some women do not use EC even when it is available without a prescription. European studies of abortion patients have found higher rates of EC use among those who are younger, better educated, and nulliparous, and those who use contraception or have prior experience with EC and abortion.14,15 These studies also indicate that some women do not use EC because they underestimate their risk of pregnancy.14,16 Other studies in the United Kingdom (UK) have shown women to be reluctant to ask for EC because of feelings of shame, fear of side effects, and worry that health professionals will judge them.17,18 Women in an evaluation of direct pharmacy access in the UK lauded the ab-
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sence of judgmental attitudes when accessing EC this way.19 To date, no study has addressed remaining barriers to use in a US population with improved access to EC. EC studies in the United States indicate that women generally view it favorably. One study of women obtaining EC through Kaiser Permanente in San Diego, CA, found extremely high levels of acceptability: almost all women found the pills easy to use; 90% thought EC was effective; 75% were very satisfied with their experience; and 93% would recommend EC to others.20 Other studies have indicated that women who have used EC would use it again and recommend it to friends in need.3,21,22 Most acceptability studies have looked at women requesting EC, and little is known about women who have access to EC but are not necessarily using it. The aim of this analysis is to evaluate the acceptability of EC in young women at high risk of unintended pregnancy. Because the tolerability and side-effect profiles of levonorgestrel EC have been well documented,21,23–26 this study focuses on other aspects of acceptability, such as reasons why some women do not take EC in situations in which they report wanting to use it. In addition, it considers whether increased access to EC leads to more favorable attitudes or prompter and more convenient administration of the method.
M ATERIAL AND M ETHODS Procedures The procedures followed in this randomized study have been described in detail elsewhere.4 Briefly, from July 2001-October 2003, 2117 females aged 15-24 years were recruited from 4 clinics offering family planning services in the San Francisco Bay Area. To participate in the study, women had to speak English or Spanish and had to have had sexual intercourse within the last 6 months. Women who were pregnant or wanted to become pregnant were excluded from participation, as were those using highly effective contraceptive methods such as Depo-Provera, the intrauterine device or sterilization. Women using barrier 29.e2
methods, oral contraceptive pills (OCP), or no method were eligible. Any woman who reported having unprotected intercourse within 3 days before her visit or who was requesting EC at the visit was excluded. The study received approval from the University of California, San Francisco’s Committee on Human Research. All participants gave written informed consent. The enrollment questionnaire asked for demographic characteristics, frequency of unprotected sex, previous pregnancies, and use of contraception and EC. Research assistants conducted a brief educational session on EC and randomly allocated participants to 1 of 3 groups by handing them a preprepared sequential study packet. Participants in the pharmacy access group received directions on how to obtain levonorgestrel EC (Plan B, formerly distributed by Women’s Capital Corporation, Washington, DC) from 13 pharmacies in the neighborhoods served by the recruitment clinics. Women in the advance provision group received 3 packets of EC. Those in the clinic access group (comparison group) were given a card with instructions to return to the clinic for EC if needed. All participants received EC free of charge and could obtain it as needed from the clinic. Recruitment clinic staffs were trained in the study protocol and did not provide advance provisions to patients during enrollment. Six months after enrollment, participants completed an intervieweradministered follow-up questionnaire.
Measures Outcome measures We used a series of outcome measures on acceptability of emergency contraception, including attitudes and patterns of use. To assess attitudes, we asked participants to rate EC safety (very safe, somewhat safe, somewhat unsafe, very unsafe), effectiveness (very effective, somewhat effective, somewhat ineffective, very ineffective), and degree of approval of EC use from people from whom they seek advice (strongly approve, somewhat approve, somewhat disapprove, strongly disapprove). They reported whether they would recom-
American Journal of Obstetrics & Gynecology JANUARY 2007
www.AJOG.org mend EC to a friend in need, if they gave EC to a friend, and how they would prefer to get EC if needed (a clinic/doctor’s office, a supply at home, directly from a pharmacy). We also evaluated patterns of use by using measures of EC use (yes, no), including promptness of use after sex (⬍ 12 hours, 12-24 hours, ⬎ 24 hours), and convenience of use (very convenient, somewhat convenient, somewhat inconvenient, very inconvenient). Women who used EC during the study were asked to provide their reasons for use. Participants could choose a reason, including missing taking birth control pills and not using a condom, or provide open-ended responses. Similarly, women who answered “yes” to the question “Since you entered this study, did you ever want to use EC but didn’t?” were asked to provide their reasons, such as “you didn’t know where to get it” and “it was too inconvenient or too much trouble to get it,” and could also provide other responses. Data for all outcome measures were from the follow-up questionnaire.
Predictor measures We used study arm (pharmacy access, advance provision, clinic access) as the main predictor measure in analyses of acceptability and patterns of use. We also controlled for age, clinic site, race/ethnicity (white, black, Latina, Asian/Pacific Islander, Multiracial/other), median household income (from the 2000 Census with the use of Zip code data), and contraceptive method use (condoms, OCPs, no method). In our analyses of preferred way to access EC and use of EC, we also examined the influence of baseline characteristics that have predicted EC use in previous studies, including prior pregnancy, EC use, and unprotected sex.
Analysis We compared acceptability and use patterns in the pharmacy access and advance provision arms of the study to those of the clinic access group. We conducted contingency table analysis with 2 tests and Student t tests to measure differences in outcomes between groups.
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TABLE 1
Acceptability of EC, by study arm: Frequencies and adjusted ORs, multivariate logistic regression
Gave EC to a friend (n ⫽ 1948)
Pharmacy access
Advance provision
Clinic access (comparison) Total sample
N
%
n
%
n
112
(13.8)
242
(29.3)
% 16
(5.2)
n 370
OR (95% CI)*
%
Pharmacy access
Advance provision
(19.0)
3.26 (1.85-5.74)
9.21 (5.30-15.93)
................................................................................................................................................................................................................................................................................................................................................................................
Would recommend EC to a friend (n ⫽ 1948)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes
777
(95.5)
779
(94.5)
297
(95.8)
1853
(95.1)
.......................................................................................................................................................................................................................................................................................................................................................................
Not sure
22
(2.7)
31
(3.8)
7
(2.3)
60
(3.1)
No
15
(1.8)
14
(1.7)
6
(1.9)
35
(1.8)
0.88 (0.45-1.70)
0.73 (0.39-1.70)
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ †
Promptness of EC use (n ⫽ 563)
.......................................................................................................................................................................................................................................................................................................................................................................
⬍12 h
65
(33.3)
135
(44.4)
20
(31.3)
220
(39.1)
12-24 h
93
(47.7)
129
(42.4)
26
(41.6)
248
(44.1)
⬎24 h
37
(19.0)
40
(13.2)
18
(28.1)
95
(16.9)
.......................................................................................................................................................................................................................................................................................................................................................................
1.65 (0.82-3.30)
2.43 (1.24-4.80)
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ †
Convenience of EC use (n ⫽ 563)
.......................................................................................................................................................................................................................................................................................................................................................................
Very convenient
127
(65.5)
258
(84.6)
36
(56.3)
421
(74.8)
Somewhat convenient
43
(22.2)
33
(10.8)
19
(29.7)
95
(16.9)
Somewhat inconvenient
19
(9.8)
6
(2.0)
4
(6.3)
29
(5.2)
5
(2.6)
8
(2.6)
5
(7.8)
18
(3.2)
.......................................................................................................................................................................................................................................................................................................................................................................
1.41 (0.77-2.56)
4.25 (2.32-7.76)
....................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................
Very inconvenient
................................................................................................................................................................................................................................................................................................................................................................................
* Reference group for ORs is clinic access. ORs compare: promptness (ⱕ24 hours vs ⬎24 hours), convenience (very convenient vs other), gave EC (yes vs no), and would recommend EC (yes vs no/not sure). ORs are adjusted for clinic, age, race/ethnicity, income and contraceptive method. †
Includes only participants who used EC during the study period.
By using multivariate logistic regression models, we calculated odds ratios (ORs) and 95% Confidence Intervals (CIs) for promptness of use (⬍ 24 hours, ⱖ 24 hours), convenience of use (very convenient or not), giving EC to a friend (yes, no), and would recommend EC (yes, no/ not sure). For the preferred way to access EC measure, we calculated relative risks (RRs) and 95% CIs by using multinomial logistic regression, with EC from a clinic/doctor’s office as the base outcome. We used multivariate logistic regression to examine characteristics associated with EC use. To test whether condom users responded any differently than pill users to pharmacy access or advance provision, we created interaction terms for the contraceptive methods (OCP, condom) and modes of access. In assessing reasons why EC was not used by some women who wanted to use it, we used Fisher exact tests to identify whether women in the study arms differed in their likelihood of naming the most common reasons. We used Stata
9.0 (StataCorp, College Park, TX) for analyses, which we performed on an intention-to-treat basis. Although we did not make corrections for multiple comparisons, we repeated all analyses by using Bonferroni corrections to ensure that results were consistent.
R ESULTS A total of 2117 women were enrolled, and 1950 (92%) completed follow-up. Sample characteristics have been described in detail elsewhere.4 The sample had a mean age of 19.9 years and was ethnically diverse. Thirty-two percent of subjects had experienced a pregnancy, and 35% had used EC in the 6 months before enrollment. Almost half of participants (46%) used OCPs for birth control; 47% used condoms; and 7% did not have a method of birth control. Attitudes toward EC were favorable at follow-up. Almost all women (98%) believed that EC was very effective or somewhat effective, and 92% thought that EC was very safe or somewhat safe. Eighty-
nine percent thought that the individuals from whom they seek advice would strongly approve or somewhat approve of their using EC. Attitudes were uniformly positive and did not differ by mode of access to EC or predict use of EC at follow-up. Table 1 displays acceptability and patterns of EC use in this study. Nineteen percent of participants gave EC to a friend during the study. Probability of giving EC to a friend varied significantly between the three modes of access: 29% of women with advance provision, 14% with pharmacy access, and only 5% with clinic access reported giving EC to a friend. The vast majority in all groups (95%) would recommend EC to a friend in need. Among all women who used EC, most took the first dose within 24 hours of unprotected sex (83%) and thought that EC was very convenient to use (75%). Those with advance provisions were more likely to take EC within 24 hours than women in the clinic arm (OR ⫽ 2.43,
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95% CI [1.24-4.80]). They were also more likely to report that obtaining EC was very convenient (OR ⫽ 4.25, 95% CI [2.35-7.76]). Women in the pharmacy access group, on the other hand, did not use EC more promptly than women with clinic access (OR ⫽ 1.65, 95% CI [0.823.30]), nor did they find using it to be more convenient (OR ⫽ 1.41, 95% CI [0.77-2.56]), after adjusting for participant characteristics. Promptness and convenience of use varied only by access to EC and not by any demographic or contraceptive characteristics. When asked how they would prefer to get EC if they were to need it, 53% of all subjects said they would prefer to have a supply at home; 28% would prefer to return to a clinic; and 20% would prefer to get EC directly from a pharmacy. Women in each access group were significantly more likely to prefer their own means of access: women with direct pharmacy access were more likely to prefer obtaining EC directly from a pharmacy (RR ⫽ 2.34, 95% CI [1.56-3.50]) compared with women who had clinic access. Women with advance provisions were more likely to prefer having a dose in advance of need (RR ⫽ 1.48, 95% CI [1.09-2.01]) than women with clinic access. Older women, white women, and women with previous EC use were significantly more likely to prefer either direct pharmacy access or advance provision over clinic access. During the 6-month study period, 29% (n ⫽ 571) of participants used EC. Those who received EC in advance were more likely to use it (37.4%) than women in the pharmacy (24.2%) or clinic (21.0%) arms (P ⬍ .001 for both comparisons); women with direct pharmacy access were no more likely to use EC than women in the clinic arm.4 The most common reason for use overall was that the participant had not used a condom (49%), and 23% used it because a condom broke or slipped. Twenty percent of women who took EC did so because they had missed taking regular birth control pills. Multivariate logistic regression analyses delineate participant characteristics associated with EC use (Table 2). As we have previously reported, younger 29.e4
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TABLE 2
Multivariate logistic regression analysis of use of EC OR
95% CI
P value
Study arm
.....................................................................................................................................................................................................................................
Clinic access
—
—
Pharmacy access
1.05
0.68-1.62
—
.....................................................................................................................................................................................................................................
.83
..................................................................................................................................................................................................................................... †
2.92*
2.09-4.07
⬍.001
Age
0.89
0.85-0.93
⬍.001
Income of Zip code
1.00
0.99-1.01
.49
Advance provision
.............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. ‡ ..............................................................................................................................................................................................................................................
Race/ethnicity
.....................................................................................................................................................................................................................................
White
—
—
Black
0.76
0.51-1.12
—
.17
Latina
1.59
1.15-2.21
⬍.01
Asian/Pacific Islander
1.14
0.83-1.55
.42
Other/multi-racial
1.20
0.82-1.75
.34
..................................................................................................................................................................................................................................... § ..................................................................................................................................................................................................................................... ¶ 㛳 ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Contraceptive method
.....................................................................................................................................................................................................................................
OCPs
—
—
—
Condom
1.48
1.11-1.99
⬍.01
None
..................................................................................................................................................................................................................................... 㛳 .....................................................................................................................................................................................................................................
1.47
0.95-2.28
.08
Unprotected sex
1.75
1.40-2.20
.001
Prior pregnancy
1.31
1.03-1.66
.03**
Prior EC use
2.12
1.70-2.64
⬍.001
Pharmacy access ⫻ condom user
1.72
1.10-2.68
.02**
.............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
No. of observations ⫽ 1938. Area under ROC curve ⫽ 0.73 * Significant difference from pharmacy access at P ⱕ .001. †
P ⱕ .001.
‡
Rescaled by factor of 10,000.
§
Significant difference from Asian/PI at P ⫽ .04 and Multiracial/Other at P ⫽ .03.
¶
Significant difference Blacks at P ⱕ .001 and Asian/PI at P ⫽ .04.
㛳
P ⱕ .01.
** P ⱕ .049.
women were more likely than older women to use EC.27 Latinas, women reporting prior pregnancy, and women with prior EC use were also more likely to use it during the study. Use was higher among women who relied on condoms than women taking OCPs (OR ⫽ 1.48, 95% CI [1.11-2.00]). The effect of the intervention differed by contraceptive method; access to EC through direct pharmacy access resulted in increased use among condom users (OR ⫽ 1.81, 95% CI [1.23-2.65]). Fourteen percent of the participants reported not using emergency contraception on at least 1 occasion when they thought it might be called for (Table 3). The most common reason given was that
American Journal of Obstetrics & Gynecology JANUARY 2007
getting EC was too much trouble or too inconvenient (23%). This response varied significantly between the study arms, with 42%, 30%, and 11% giving this response in the clinic, pharmacy, and advance provision arms, respectively (P ⬍ .001). The second most common reason was concern about side effects (15%). Women in the advance provision group were much more likely to express this concern (25%) than those in the pharmacy (6%) or clinic (4%) groups (P ⬍ .001). Other common barriers to use were not being able to get EC within 3 days (10%) and not knowing where to get it (6%). The third most common reason, provided in open-ended responses,
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TABLE 3
Reasons why EC was not used when wanted Women not using EC despite wanting to (n ⴝ 276)* Reasons for nonuse
n
%
Too inconvenient to get EC†
63
(22.8)
Worried about side effects
41
(14.9)
Did not have or lost EC, prescription, or pharmacy card
35
(12.7)
.............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Unsure if needed EC or didn’t think would get pregnant
29
(10.5)
Wasn’t able to get EC in 3 days
26
(9.4)
Decided didn’t need EC
25
(9.1)
Did not know where to get EC
16
(5.8)
Weekend or evening, clinic was closed
.............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. ..................................................................................................................................................................................................................................... †
.............................................................................................................................................................................................................................................. †
15
(5.5)
Had problem at the pharmacy
9
(3.3)
Forgot to take or get EC
7
(2.5)
Boyfriend was concerned about her taking EC
7
(2.5)
Did not know how to take EC correctly
6
(2.2)
Too nervous or embarrassed to get EC
6
(2.2)
Got period
5
(1.8)
Too nervous or afraid to take EC
4
(1.5)
Worried about EC effectiveness
4
(1.5)
Was just curious about EC, had no real need for it
3
(1.1)
Didn’t want to harm baby
3
(1.0)
Too expensive
1
(0.4)
17
(6.1)
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. † ..............................................................................................................................................................................................................................................
No reason, just didn’t take EC, doesn’t remember why
..............................................................................................................................................................................................................................................
* Among women answering “yes” to: Since you entered this study, did you ever want to use emergency contraception but didn’t? Responses do not add to 100% because response categories were not mutually exclusive. †
Response category provided to participant.
was not having a supply of EC (13%). This response did not vary significantly between groups. Responses included “didn’t have it around” or “have it at home but was not home.” Also in open-ended responses, 11% of women said they did not take EC because they did not know if they needed it, giving responses such as “missed a couple of pills and just wasn’t sure if I should take it,” “thought I was just being paranoid,” or “decided to wait it out.” Another 9% said that they realized that EC was not really indicated.
C OMMENT This study examined attitudes toward EC in a clinic population of young women, who had facilitated access to EC as a result of their participation in the
trial. Participants reported that they considered the drug to be safe and effective and that they would recommend it to friends in need. Our finding that many participants gave doses of EC to their friends not only points to the acceptability of EC, but also suggests that getting EC readily from a friend may be preferable or easier for young women than having to locate a clinic and ask a provider for it. We also examined the effect of access to EC on patterns of use. The provision of EC in advance increased the frequency, promptness, and perceived convenience of use. That advance provision fostered prompt use is in agreement with previous findings12,28,29 and extends these results to a young, high-risk, urban population in the United States.
Research
Results show no significant difference in the frequency, promptness or convenience of use between those with access through pharmacies and through clinics. A study in the UK found that the proportion of women who used EC did not grow over the 2 years after EC was made available without a prescription, although the percentage of EC users obtaining it from pharmacies did increase.30 Other studies have found increases in use once EC became available directly from pharmacists31 and prompter use when it is obtained from a pharmacy.32 In light of the fact that study subjects were recruited from family planning clinics and, for that reason, presumably were already accustomed to receiving supplies from a clinic, it is perhaps not surprising that pharmacy access had such a limited impact. A populationbased study might show a more meaningful effect. Condom users were found to be almost twice as likely to use EC if they could get it from a pharmacist instead of a clinic. This lends support to the hypothesis that direct pharmacy access may be more useful for those who do not have an established relationship with a doctor or clinic because they are not using a regular hormonal method.33 The majority of participants said they would prefer to be able to receive EC in advance. Although all women in our study had access to EC, some still found it to be too much trouble to get, did not have time to get it, or did not use it because they did not have it with them at the time they needed it. Women in the clinic access group were 4 times more likely than those in the advance provision arm to name “inconvenience” as a reason why EC was not used when the need arose. These findings underscore the importance of convenient access to the effective use of EC. Several studies have indicated that facilitated availability of EC does not reduce the reported use of ongoing contraceptives and does not increase STI acquisition.4,5,12,30 In light of this, expanding the means of access will only be of benefit to women, who can then access EC in the way that is most convenient and comfortable to them, thereby optimizing use.
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Another important barrier to effective use may be underestimation of probability of pregnancy. Despite the comprehensive education the women in this trial received, 11% of women who wanted to use EC, but did not do so, reported being unsure if EC was needed, thinking that they would not become pregnant, or deciding to “wait it out.” This corroborates findings from other studies showing that misevaluation of pregnancy risk is a key reason why EC is not taken.14,16 Although greater availability of EC through OTC access could alleviate barriers to use for some women, promotion of advance provision will be imperative to improving access and use. Efforts must also focus on personal barriers such as underestimation of risk to help women avoid unintended pregnancy. f ACKNOWLEDGMENTS We are grateful to the San Francisco Department of Public Health for their support of this study. We also thank the Pharmacy Access Partnership for their participation.
REFERENCES 1. Alan Guttmacher Institute. State policies in brief: emergency contraception, as of December 1, 2006. Available at: http://www.guttmacher. org/statecenter/spibs/spib_EC.pdf. Accessed December 1, 2006. 2. Kaiser Family Foundation. SELF Magazine. National survey of women about their sexual health. Available at: http://www.kff.org/womenshealth/ 3341-index.cfm. Accessed September 21, 2005. 3. Salganicoff A, Wentworth B, Ranji U. Emergency contraception in California: findings from a 2003 Kaiser Family Foundation survey. The Henry J. Kaiser Family Foundation. February, 2004. 4. Raine, TR, Harper CC, Rocca CH, Fischer R, Padian N, Klausner JD, Darney PD. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA 2005;293:54-62. 5. Jackson, RA, Schwarz, EB, Freedman L, Darney, P. Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial. Obstet Gynecol 2003;102:8-16. 6. Ellertson C, Ambardekar S, Hedley A, Coyaji K, Trussell J, Blanchard K. Emergency contraception: randomized comparison of advance
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provision and information only. Obstet Gynecol 2001;98:570-5. 7. Raine T, Harper C, Leon K, Darney P. Emergency contraception: advance provision in a young, high-risk clinic population. Obstet Gynecol 2000;96:1-7. 8. Glasier A, Baird D. The effects of self-administering emergency contraception, N Engl J Med 1998;339:1-4. 9. Henshaw SK. Unintended pregnancy in the United States. Fam Plan Perspect 1998; 30:24-9., 46. 10. Finer LB, Henshaw SK. Abortion incidence and services in the United States in 2000, Perspect Sex Reprod Health 2003;35:6-15. 11. Jones RK, Darroch JE, Henshaw DK. Contraceptive use among U.S. women having abortions in 2000-2001. Perspect Sex Reprod Health 2002;34:294-303. 12. Gold, MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women’s sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004;17:87-96. 13. Fox J, Weerasinghe D, Marks C, Mindel A. Emergency contraception: who are the users? Int J STD AIDS 2004;15:309-13. 14. Sorensen MB, Pederson BL, Nyrnberg LE. Differences between users and non-users of emergency contraception after a recognized unprotected intercourse. Contraception 2000;62:1-3. 15. Perslev A, Rorbye C, Boesen HC, Norgaard M, Nilas L. Emergency contraception: knowledge and use among Danish women requesting termination of pregnancy. Contraception 2002;66:427-31. 16. Moreau, C Bouyer J, Goulard H, Bajos N. The remaining barriers to the use of emergency contraception: perception of pregnancy risk by women undergoing induced abortions. Contraception 2005;71:202-7. 17. Fairhurst K, Ziebland S, Wyke S, Seaman P, Glasier A. Emergency contraception: why can’t you give it away? Qualitative findings from an evaluation of advance provision of emergency contraception. Contraception 2004;70:25-9. 18. Free C, Lee RM, Ogden J. Young women’s accounts of factors influencing their use and non-use of emergency contraception: in-depth interview study. BMJ 2002;325:1393-6. 19. Bissell P, Anderson C. Supplying emergency contraception via community pharmacies in the UK: reflections on the experiences of users and providers. Soc Sci Med 2003; 57:2367-78. 20. Harvey SM, Beckman LJ, Sherman C, Petitti D. Women’s experience and satisfaction with emergency contraception. Fam Plan Perspect 1999;31:237-40., 260. 21. Hamoda H. Ashok PW, Stalder C, Flett GM, Kennedy E, Templeton A. A randomized trial of
American Journal of Obstetrics & Gynecology JANUARY 2007
www.AJOG.org mifepristone (10 mg) and levonorgestrel for emergency contraception. Obstet Gynecol 2004;104:1307-13. 22. Breitbart V, Castle MA, Walsh K, Casanova C. The impact of patient experience on practice: the acceptability of emergency contraceptive pills in inner-city clinics. JAMA 1998;53:255-8. 23. Harper CC, Rocca CH, Darney PD, von Hertzen H, Raine TR. Tolerability of levonorgestrel emergency contraception in adolescents. Am J Obstet Gynecol 2004;191:1158-63. 24. Von Hertzen H, Piaggio G, Ding J, Chen S, Song S, Bartfai G. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomized trial. Lancet 2002;360:1803-10. 25. Gainer E, Mery C, Ulmann A. Levonorgestrel-only emergency contraception: realworld tolerance and efficacy. Contraception 2001;64:17-21. 26. WHO Task Force on Post-ovulatory Methods for Fertility Regulation. Randomized controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352: 428-33. 27. Harper, CC, Cheong M, Rocca C, Darney P, Raine T. Increased access to emergency contraception among young adolescents in the United States. Obstet Gynecol 2005;106: 483-91. 28. Glasier A, Fairhurst K, Wyke S, Ziebland S, Seaman P, Walker J, Lakha F. Advanced provision of emergency contraception does not reduce abortion rates. Contraception 2004; 69:361-6. 29. Lovvorn A, Nerquaye-Tetteh J, Glover EK, Amankwah-Poku A, Hays M, Raymond E. Provision of emergency contraceptive pills to spermicide users in Ghana. Contraception 2000; 61:287-93. 30. Marston C, Meltzer M, Majeed A. Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional surveys. BMJ 2005;331:271. EPub: July 2005. 31. Soon JA, Levin M, Osmond BL, Ensom MH, Fielding DW. Effects of making emergency contraception available without a physician’s prescription: a population-based study. Can Med Assoc J 2005;172:878-83. 32. Killick SR, Irving G. A national study examining the effect of making emergency hormonal contraception available without prescription. Hum Reprod 2004;19:553-7. 33. Boggess JE. How can pharmacies improve access to emergency contraception? Perspect Sex Reprod Health 2002;34:162-5.
www. AJOG.org
GENERAL GYNECOLOGY
Beyond access: Acceptability, use and nonuse of emergency contraception among young women Corinne H. Rocca, MPH; Eleanor B. Schwarz, MD; Felicia H. Stewart, MD; Philip D. Darney, MD, MSc; Tina R. Raine, MD, MPH; Cynthia C. Harper, PhD OBJECTIVE: This study was undertaken to assess the acceptability of
levonorgestrel emergency contraception (EC). STUDY DESIGN: We examined attitudes and use patterns among 1950 women in a randomized trial evaluating access to EC through advance provision, pharmacies, or clinics. RESULTS: Most women considered EC to be safe (92%) and effective
(98%). Compared with women with clinic access, women with direct pharmacy access were no more likely to use EC within 24 hours (odds ratio [OR] ⫽ 1.65, 95% CI ⫽ 0.82-3.30) or to report it very convenient (OR ⫽ 1.41, 95% CI ⫽ 0.77-2.56). However, women with advance
provisions were more likely to use EC promptly (OR ⫽ 2.43, 95% CI ⫽ 1.24-4.80) and report high convenience (OR ⫽ 4.25, 95% CI ⫽ 2.32-7.76). Advance provision increased use by all women, whereas pharmacy access increased use only among condom users. Inconvenience and fear of side effects were common reasons for nonuse. CONCLUSION: Women viewed EC favorably. Advance provision im-
proved promptness and convenience of use overall, while pharmacy access benefited specific populations. Key words: acceptability, emergency contraception, nonuse, pharmacy access, use
Cite this article as Rocca CH, Schwarz EB, Stewart FH, et al. Beyond access: Acceptability, use, and nonuse of emergency contraception among young women. Am J Obstet Gynecol 2007;196:29.e1-29.e6
S
ince a dedicated emergency contraceptive product became available by prescription in the United States in 1998, various efforts have been made to facilitate access to it. Nine states have policies allowing women of any age to obtain emergency contraception
From the Department of Obstetrics, Gynecology, and Reproductive Sciences, Bixby Center for Reproductive Health Research and Policy, (Ms Rocca and Drs Stewart, Darney, Raine, and Harper), and the Department of Medicine, General Internal Medicine Section (Dr Schwarz), School of Medicine, University of California, San Francisco, CA. Reprints: Corinne H. Rocca, University of California, San Francisco, Department of Obstetrics and Gynecology, 50 Beale St, Suite 1200, UCSF Box 0886, San Francisco, CA, 94105. [email protected]. Sources of financial support: William and Flora Hewlett Foundation, Compton Foundation, Inc, Open Society Institute, Wallace Alexander Gerbode Foundation, Women’s Capital Corporation, former distributor of Plan B, donated the emergency contraceptive pills. 0002-9378/$32.00 © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2006.08.024
(EC) directly through pharmacies (AK, CA, HI, MA, ME, NH, NM, VT, and WA).1 In August 2006, the Food and Drug Administration (FDA) approved an application from the marketers of Plan B EC to make the progestin-only product available over-the-counter for those aged 18 or older. The product remains available by prescription only for minors. In the 9 states with pharmacy access legislation, however, minors can optain Plan B directly from the pharmacist. Despite moderate increases in the availability of EC over the past 5 years, use remains low. In 2003, only 6% of US women aged 18-44 years had used EC, a modest increase from 2% in 2000.2 Even in California, where EC has been available directly through pharmacies since 2002 and health plans are required to cover it, only 8% of women had used EC by 2003.3 Furthermore, most studies on access to EC have shown that only a fraction of those who might appropriately use it actually do, even when given a supply in advance.4 – 8 Considering that unintended pregnancy and abortion rates are high in the United States,9,10 and that a mere 1.3% of women undergoing
abortions reported having taken EC,11 many women who could benefit from EC are still not using it. It remains unclear what determines whether women, who know about EC and have access to it, actually use it. Those with an increased perception of their own risk of pregnancy, because of previous pregnancy or abortion, may be more likely to use the method; however, studies have yielded mixed results.12,13 Researchers have begun to identify reasons why some women do not use EC even when it is available without a prescription. European studies of abortion patients have found higher rates of EC use among those who are younger, better educated, and nulliparous, and those who use contraception or have prior experience with EC and abortion.14,15 These studies also indicate that some women do not use EC because they underestimate their risk of pregnancy.14,16 Other studies in the United Kingdom (UK) have shown women to be reluctant to ask for EC because of feelings of shame, fear of side effects, and worry that health professionals will judge them.17,18 Women in an evaluation of direct pharmacy access in the UK lauded the ab-
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sence of judgmental attitudes when accessing EC this way.19 To date, no study has addressed remaining barriers to use in a US population with improved access to EC. EC studies in the United States indicate that women generally view it favorably. One study of women obtaining EC through Kaiser Permanente in San Diego, CA, found extremely high levels of acceptability: almost all women found the pills easy to use; 90% thought EC was effective; 75% were very satisfied with their experience; and 93% would recommend EC to others.20 Other studies have indicated that women who have used EC would use it again and recommend it to friends in need.3,21,22 Most acceptability studies have looked at women requesting EC, and little is known about women who have access to EC but are not necessarily using it. The aim of this analysis is to evaluate the acceptability of EC in young women at high risk of unintended pregnancy. Because the tolerability and side-effect profiles of levonorgestrel EC have been well documented,21,23–26 this study focuses on other aspects of acceptability, such as reasons why some women do not take EC in situations in which they report wanting to use it. In addition, it considers whether increased access to EC leads to more favorable attitudes or prompter and more convenient administration of the method.
M ATERIAL AND M ETHODS Procedures The procedures followed in this randomized study have been described in detail elsewhere.4 Briefly, from July 2001-October 2003, 2117 females aged 15-24 years were recruited from 4 clinics offering family planning services in the San Francisco Bay Area. To participate in the study, women had to speak English or Spanish and had to have had sexual intercourse within the last 6 months. Women who were pregnant or wanted to become pregnant were excluded from participation, as were those using highly effective contraceptive methods such as Depo-Provera, the intrauterine device or sterilization. Women using barrier 29.e2
methods, oral contraceptive pills (OCP), or no method were eligible. Any woman who reported having unprotected intercourse within 3 days before her visit or who was requesting EC at the visit was excluded. The study received approval from the University of California, San Francisco’s Committee on Human Research. All participants gave written informed consent. The enrollment questionnaire asked for demographic characteristics, frequency of unprotected sex, previous pregnancies, and use of contraception and EC. Research assistants conducted a brief educational session on EC and randomly allocated participants to 1 of 3 groups by handing them a preprepared sequential study packet. Participants in the pharmacy access group received directions on how to obtain levonorgestrel EC (Plan B, formerly distributed by Women’s Capital Corporation, Washington, DC) from 13 pharmacies in the neighborhoods served by the recruitment clinics. Women in the advance provision group received 3 packets of EC. Those in the clinic access group (comparison group) were given a card with instructions to return to the clinic for EC if needed. All participants received EC free of charge and could obtain it as needed from the clinic. Recruitment clinic staffs were trained in the study protocol and did not provide advance provisions to patients during enrollment. Six months after enrollment, participants completed an intervieweradministered follow-up questionnaire.
Measures Outcome measures We used a series of outcome measures on acceptability of emergency contraception, including attitudes and patterns of use. To assess attitudes, we asked participants to rate EC safety (very safe, somewhat safe, somewhat unsafe, very unsafe), effectiveness (very effective, somewhat effective, somewhat ineffective, very ineffective), and degree of approval of EC use from people from whom they seek advice (strongly approve, somewhat approve, somewhat disapprove, strongly disapprove). They reported whether they would recom-
American Journal of Obstetrics & Gynecology JANUARY 2007
www.AJOG.org mend EC to a friend in need, if they gave EC to a friend, and how they would prefer to get EC if needed (a clinic/doctor’s office, a supply at home, directly from a pharmacy). We also evaluated patterns of use by using measures of EC use (yes, no), including promptness of use after sex (⬍ 12 hours, 12-24 hours, ⬎ 24 hours), and convenience of use (very convenient, somewhat convenient, somewhat inconvenient, very inconvenient). Women who used EC during the study were asked to provide their reasons for use. Participants could choose a reason, including missing taking birth control pills and not using a condom, or provide open-ended responses. Similarly, women who answered “yes” to the question “Since you entered this study, did you ever want to use EC but didn’t?” were asked to provide their reasons, such as “you didn’t know where to get it” and “it was too inconvenient or too much trouble to get it,” and could also provide other responses. Data for all outcome measures were from the follow-up questionnaire.
Predictor measures We used study arm (pharmacy access, advance provision, clinic access) as the main predictor measure in analyses of acceptability and patterns of use. We also controlled for age, clinic site, race/ethnicity (white, black, Latina, Asian/Pacific Islander, Multiracial/other), median household income (from the 2000 Census with the use of Zip code data), and contraceptive method use (condoms, OCPs, no method). In our analyses of preferred way to access EC and use of EC, we also examined the influence of baseline characteristics that have predicted EC use in previous studies, including prior pregnancy, EC use, and unprotected sex.
Analysis We compared acceptability and use patterns in the pharmacy access and advance provision arms of the study to those of the clinic access group. We conducted contingency table analysis with 2 tests and Student t tests to measure differences in outcomes between groups.
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TABLE 1
Acceptability of EC, by study arm: Frequencies and adjusted ORs, multivariate logistic regression
Gave EC to a friend (n ⫽ 1948)
Pharmacy access
Advance provision
Clinic access (comparison) Total sample
N
%
n
%
n
112
(13.8)
242
(29.3)
% 16
(5.2)
n 370
OR (95% CI)*
%
Pharmacy access
Advance provision
(19.0)
3.26 (1.85-5.74)
9.21 (5.30-15.93)
................................................................................................................................................................................................................................................................................................................................................................................
Would recommend EC to a friend (n ⫽ 1948)
.......................................................................................................................................................................................................................................................................................................................................................................
Yes
777
(95.5)
779
(94.5)
297
(95.8)
1853
(95.1)
.......................................................................................................................................................................................................................................................................................................................................................................
Not sure
22
(2.7)
31
(3.8)
7
(2.3)
60
(3.1)
No
15
(1.8)
14
(1.7)
6
(1.9)
35
(1.8)
0.88 (0.45-1.70)
0.73 (0.39-1.70)
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ †
Promptness of EC use (n ⫽ 563)
.......................................................................................................................................................................................................................................................................................................................................................................
⬍12 h
65
(33.3)
135
(44.4)
20
(31.3)
220
(39.1)
12-24 h
93
(47.7)
129
(42.4)
26
(41.6)
248
(44.1)
⬎24 h
37
(19.0)
40
(13.2)
18
(28.1)
95
(16.9)
.......................................................................................................................................................................................................................................................................................................................................................................
1.65 (0.82-3.30)
2.43 (1.24-4.80)
....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ †
Convenience of EC use (n ⫽ 563)
.......................................................................................................................................................................................................................................................................................................................................................................
Very convenient
127
(65.5)
258
(84.6)
36
(56.3)
421
(74.8)
Somewhat convenient
43
(22.2)
33
(10.8)
19
(29.7)
95
(16.9)
Somewhat inconvenient
19
(9.8)
6
(2.0)
4
(6.3)
29
(5.2)
5
(2.6)
8
(2.6)
5
(7.8)
18
(3.2)
.......................................................................................................................................................................................................................................................................................................................................................................
1.41 (0.77-2.56)
4.25 (2.32-7.76)
....................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................
Very inconvenient
................................................................................................................................................................................................................................................................................................................................................................................
* Reference group for ORs is clinic access. ORs compare: promptness (ⱕ24 hours vs ⬎24 hours), convenience (very convenient vs other), gave EC (yes vs no), and would recommend EC (yes vs no/not sure). ORs are adjusted for clinic, age, race/ethnicity, income and contraceptive method. †
Includes only participants who used EC during the study period.
By using multivariate logistic regression models, we calculated odds ratios (ORs) and 95% Confidence Intervals (CIs) for promptness of use (⬍ 24 hours, ⱖ 24 hours), convenience of use (very convenient or not), giving EC to a friend (yes, no), and would recommend EC (yes, no/ not sure). For the preferred way to access EC measure, we calculated relative risks (RRs) and 95% CIs by using multinomial logistic regression, with EC from a clinic/doctor’s office as the base outcome. We used multivariate logistic regression to examine characteristics associated with EC use. To test whether condom users responded any differently than pill users to pharmacy access or advance provision, we created interaction terms for the contraceptive methods (OCP, condom) and modes of access. In assessing reasons why EC was not used by some women who wanted to use it, we used Fisher exact tests to identify whether women in the study arms differed in their likelihood of naming the most common reasons. We used Stata
9.0 (StataCorp, College Park, TX) for analyses, which we performed on an intention-to-treat basis. Although we did not make corrections for multiple comparisons, we repeated all analyses by using Bonferroni corrections to ensure that results were consistent.
R ESULTS A total of 2117 women were enrolled, and 1950 (92%) completed follow-up. Sample characteristics have been described in detail elsewhere.4 The sample had a mean age of 19.9 years and was ethnically diverse. Thirty-two percent of subjects had experienced a pregnancy, and 35% had used EC in the 6 months before enrollment. Almost half of participants (46%) used OCPs for birth control; 47% used condoms; and 7% did not have a method of birth control. Attitudes toward EC were favorable at follow-up. Almost all women (98%) believed that EC was very effective or somewhat effective, and 92% thought that EC was very safe or somewhat safe. Eighty-
nine percent thought that the individuals from whom they seek advice would strongly approve or somewhat approve of their using EC. Attitudes were uniformly positive and did not differ by mode of access to EC or predict use of EC at follow-up. Table 1 displays acceptability and patterns of EC use in this study. Nineteen percent of participants gave EC to a friend during the study. Probability of giving EC to a friend varied significantly between the three modes of access: 29% of women with advance provision, 14% with pharmacy access, and only 5% with clinic access reported giving EC to a friend. The vast majority in all groups (95%) would recommend EC to a friend in need. Among all women who used EC, most took the first dose within 24 hours of unprotected sex (83%) and thought that EC was very convenient to use (75%). Those with advance provisions were more likely to take EC within 24 hours than women in the clinic arm (OR ⫽ 2.43,
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95% CI [1.24-4.80]). They were also more likely to report that obtaining EC was very convenient (OR ⫽ 4.25, 95% CI [2.35-7.76]). Women in the pharmacy access group, on the other hand, did not use EC more promptly than women with clinic access (OR ⫽ 1.65, 95% CI [0.823.30]), nor did they find using it to be more convenient (OR ⫽ 1.41, 95% CI [0.77-2.56]), after adjusting for participant characteristics. Promptness and convenience of use varied only by access to EC and not by any demographic or contraceptive characteristics. When asked how they would prefer to get EC if they were to need it, 53% of all subjects said they would prefer to have a supply at home; 28% would prefer to return to a clinic; and 20% would prefer to get EC directly from a pharmacy. Women in each access group were significantly more likely to prefer their own means of access: women with direct pharmacy access were more likely to prefer obtaining EC directly from a pharmacy (RR ⫽ 2.34, 95% CI [1.56-3.50]) compared with women who had clinic access. Women with advance provisions were more likely to prefer having a dose in advance of need (RR ⫽ 1.48, 95% CI [1.09-2.01]) than women with clinic access. Older women, white women, and women with previous EC use were significantly more likely to prefer either direct pharmacy access or advance provision over clinic access. During the 6-month study period, 29% (n ⫽ 571) of participants used EC. Those who received EC in advance were more likely to use it (37.4%) than women in the pharmacy (24.2%) or clinic (21.0%) arms (P ⬍ .001 for both comparisons); women with direct pharmacy access were no more likely to use EC than women in the clinic arm.4 The most common reason for use overall was that the participant had not used a condom (49%), and 23% used it because a condom broke or slipped. Twenty percent of women who took EC did so because they had missed taking regular birth control pills. Multivariate logistic regression analyses delineate participant characteristics associated with EC use (Table 2). As we have previously reported, younger 29.e4
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TABLE 2
Multivariate logistic regression analysis of use of EC OR
95% CI
P value
Study arm
.....................................................................................................................................................................................................................................
Clinic access
—
—
Pharmacy access
1.05
0.68-1.62
—
.....................................................................................................................................................................................................................................
.83
..................................................................................................................................................................................................................................... †
2.92*
2.09-4.07
⬍.001
Age
0.89
0.85-0.93
⬍.001
Income of Zip code
1.00
0.99-1.01
.49
Advance provision
.............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. ‡ ..............................................................................................................................................................................................................................................
Race/ethnicity
.....................................................................................................................................................................................................................................
White
—
—
Black
0.76
0.51-1.12
—
.17
Latina
1.59
1.15-2.21
⬍.01
Asian/Pacific Islander
1.14
0.83-1.55
.42
Other/multi-racial
1.20
0.82-1.75
.34
..................................................................................................................................................................................................................................... § ..................................................................................................................................................................................................................................... ¶ 㛳 ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Contraceptive method
.....................................................................................................................................................................................................................................
OCPs
—
—
—
Condom
1.48
1.11-1.99
⬍.01
None
..................................................................................................................................................................................................................................... 㛳 .....................................................................................................................................................................................................................................
1.47
0.95-2.28
.08
Unprotected sex
1.75
1.40-2.20
.001
Prior pregnancy
1.31
1.03-1.66
.03**
Prior EC use
2.12
1.70-2.64
⬍.001
Pharmacy access ⫻ condom user
1.72
1.10-2.68
.02**
.............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
No. of observations ⫽ 1938. Area under ROC curve ⫽ 0.73 * Significant difference from pharmacy access at P ⱕ .001. †
P ⱕ .001.
‡
Rescaled by factor of 10,000.
§
Significant difference from Asian/PI at P ⫽ .04 and Multiracial/Other at P ⫽ .03.
¶
Significant difference Blacks at P ⱕ .001 and Asian/PI at P ⫽ .04.
㛳
P ⱕ .01.
** P ⱕ .049.
women were more likely than older women to use EC.27 Latinas, women reporting prior pregnancy, and women with prior EC use were also more likely to use it during the study. Use was higher among women who relied on condoms than women taking OCPs (OR ⫽ 1.48, 95% CI [1.11-2.00]). The effect of the intervention differed by contraceptive method; access to EC through direct pharmacy access resulted in increased use among condom users (OR ⫽ 1.81, 95% CI [1.23-2.65]). Fourteen percent of the participants reported not using emergency contraception on at least 1 occasion when they thought it might be called for (Table 3). The most common reason given was that
American Journal of Obstetrics & Gynecology JANUARY 2007
getting EC was too much trouble or too inconvenient (23%). This response varied significantly between the study arms, with 42%, 30%, and 11% giving this response in the clinic, pharmacy, and advance provision arms, respectively (P ⬍ .001). The second most common reason was concern about side effects (15%). Women in the advance provision group were much more likely to express this concern (25%) than those in the pharmacy (6%) or clinic (4%) groups (P ⬍ .001). Other common barriers to use were not being able to get EC within 3 days (10%) and not knowing where to get it (6%). The third most common reason, provided in open-ended responses,
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TABLE 3
Reasons why EC was not used when wanted Women not using EC despite wanting to (n ⴝ 276)* Reasons for nonuse
n
%
Too inconvenient to get EC†
63
(22.8)
Worried about side effects
41
(14.9)
Did not have or lost EC, prescription, or pharmacy card
35
(12.7)
.............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Unsure if needed EC or didn’t think would get pregnant
29
(10.5)
Wasn’t able to get EC in 3 days
26
(9.4)
Decided didn’t need EC
25
(9.1)
Did not know where to get EC
16
(5.8)
Weekend or evening, clinic was closed
.............................................................................................................................................................................................................................................. † .............................................................................................................................................................................................................................................. ..................................................................................................................................................................................................................................... †
.............................................................................................................................................................................................................................................. †
15
(5.5)
Had problem at the pharmacy
9
(3.3)
Forgot to take or get EC
7
(2.5)
Boyfriend was concerned about her taking EC
7
(2.5)
Did not know how to take EC correctly
6
(2.2)
Too nervous or embarrassed to get EC
6
(2.2)
Got period
5
(1.8)
Too nervous or afraid to take EC
4
(1.5)
Worried about EC effectiveness
4
(1.5)
Was just curious about EC, had no real need for it
3
(1.1)
Didn’t want to harm baby
3
(1.0)
Too expensive
1
(0.4)
17
(6.1)
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. † ..............................................................................................................................................................................................................................................
No reason, just didn’t take EC, doesn’t remember why
..............................................................................................................................................................................................................................................
* Among women answering “yes” to: Since you entered this study, did you ever want to use emergency contraception but didn’t? Responses do not add to 100% because response categories were not mutually exclusive. †
Response category provided to participant.
was not having a supply of EC (13%). This response did not vary significantly between groups. Responses included “didn’t have it around” or “have it at home but was not home.” Also in open-ended responses, 11% of women said they did not take EC because they did not know if they needed it, giving responses such as “missed a couple of pills and just wasn’t sure if I should take it,” “thought I was just being paranoid,” or “decided to wait it out.” Another 9% said that they realized that EC was not really indicated.
C OMMENT This study examined attitudes toward EC in a clinic population of young women, who had facilitated access to EC as a result of their participation in the
trial. Participants reported that they considered the drug to be safe and effective and that they would recommend it to friends in need. Our finding that many participants gave doses of EC to their friends not only points to the acceptability of EC, but also suggests that getting EC readily from a friend may be preferable or easier for young women than having to locate a clinic and ask a provider for it. We also examined the effect of access to EC on patterns of use. The provision of EC in advance increased the frequency, promptness, and perceived convenience of use. That advance provision fostered prompt use is in agreement with previous findings12,28,29 and extends these results to a young, high-risk, urban population in the United States.
Research
Results show no significant difference in the frequency, promptness or convenience of use between those with access through pharmacies and through clinics. A study in the UK found that the proportion of women who used EC did not grow over the 2 years after EC was made available without a prescription, although the percentage of EC users obtaining it from pharmacies did increase.30 Other studies have found increases in use once EC became available directly from pharmacists31 and prompter use when it is obtained from a pharmacy.32 In light of the fact that study subjects were recruited from family planning clinics and, for that reason, presumably were already accustomed to receiving supplies from a clinic, it is perhaps not surprising that pharmacy access had such a limited impact. A populationbased study might show a more meaningful effect. Condom users were found to be almost twice as likely to use EC if they could get it from a pharmacist instead of a clinic. This lends support to the hypothesis that direct pharmacy access may be more useful for those who do not have an established relationship with a doctor or clinic because they are not using a regular hormonal method.33 The majority of participants said they would prefer to be able to receive EC in advance. Although all women in our study had access to EC, some still found it to be too much trouble to get, did not have time to get it, or did not use it because they did not have it with them at the time they needed it. Women in the clinic access group were 4 times more likely than those in the advance provision arm to name “inconvenience” as a reason why EC was not used when the need arose. These findings underscore the importance of convenient access to the effective use of EC. Several studies have indicated that facilitated availability of EC does not reduce the reported use of ongoing contraceptives and does not increase STI acquisition.4,5,12,30 In light of this, expanding the means of access will only be of benefit to women, who can then access EC in the way that is most convenient and comfortable to them, thereby optimizing use.
JANUARY 2007 American Journal of Obstetrics & Gynecology
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Research
General Gynecology
Another important barrier to effective use may be underestimation of probability of pregnancy. Despite the comprehensive education the women in this trial received, 11% of women who wanted to use EC, but did not do so, reported being unsure if EC was needed, thinking that they would not become pregnant, or deciding to “wait it out.” This corroborates findings from other studies showing that misevaluation of pregnancy risk is a key reason why EC is not taken.14,16 Although greater availability of EC through OTC access could alleviate barriers to use for some women, promotion of advance provision will be imperative to improving access and use. Efforts must also focus on personal barriers such as underestimation of risk to help women avoid unintended pregnancy. f ACKNOWLEDGMENTS We are grateful to the San Francisco Department of Public Health for their support of this study. We also thank the Pharmacy Access Partnership for their participation.
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