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Ongoing contraception after use of emergency contraception from a specialist contraceptive service
Contraception 84 (2011) 368 – 371
Original research article
Ongoing contraception after use of emergency contraception from a specialist contraceptive service☆ Sharon T. Camerona,b,⁎, Anna Glasierb , Anne Johnstoneb , Leanne Raec a Dean Terrace Centre, NHS Lothian, 18 Dean Terrace, Edinburgh, EH4 1NL, Scotland, UK Department of Reproductive and Developmental Sciences, University of Edinburgh, 51 Little France Crescent, Royal Infirmary of Edinburgh, EH16 5SU, Scotland, UK c College of Medicine and Veterinary Medicine, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland, UK Received 24 January 2011; revised 8 February 2011; accepted 24 February 2011 b
Abstract Background: A consultation for emergency contraception (EC) gives way to an opportunity to provide women with an ongoing effective method of contraception. Study Design: A review of the case notes of women seeking EC from a large family planning clinic in Edinburgh, Scotland, was conducted to determine what percentage of women were provided with an effective method of ongoing contraception. Results: Case notes of 460 women presenting for EC over a 2-year period were reviewed. Women were of mean age 26 years (range 15–49 years) and presented because they had used no contraception (47%), experienced condom failure (42%) or missed oral contraceptive pills (9%). Only 2% (n=11) were given an intrauterine device for EC. All women who had missed contraceptive pills prior to taking EC opted to continue this method. Only 23% (n=89) of women using no method or condoms at EC received supplies of an effective contraceptive method (pills, patch, injectable). Two thirds (n=263) of the women chose condoms for ongoing contraception. Conclusion: Research is required to develop strategies to improve the uptake of effective contraception after EC. © 2011 Elsevier Inc. All rights reserved. Keywords: Emergency contraception; Intrauterine device; Hormonal contraception; Quick start
1. Introduction Hormonal emergency contraception (EC) is now available in over 140 countries worldwide, and in 44 of them it is readily available over the counter [1]. Use of EC varies considerably worldwide but in Scotland at least one in 10 women presenting for an abortion has used it to try to prevent a pregnancy [2] and in the general population in Great Britain in 2008/09, 7% of women of reproductive age (and 14% of those aged 16–19 years) had used it in the last year [3]. It is clear from most clinical trials that around 95% of women using EC will not become pregnant and so remain at risk of pregnancy unless they start using another method of ☆
There was no funding provided for this study. ⁎ Corresponding author. Dean Terrace Centre, 18 Dean Terrace, NHS Lothian, Edinburgh EH4 INL, Scotland, UK. Tel.: +44 131 343 0912; fax: 131 332 2391. E-mail address: [email protected] (S.T. Cameron). 0010-7824/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2011.02.012
contraception [4–6]. Results of a recently published metaanalysis, which included nine trials of more than 4500 women who had sexual intercourse after using EC but before return of menses, found that the relative risk of pregnancy was 2.61 (95% confidence intervals of 2.0–3.4) when compared with women who said they did not have sex after using EC [7]. In the UK, the Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit produces clinical guidance for health professionals and has a clinical guidance document for every method of contraception. The recent guidance relating to ‘quick starting’ contraception following EC advises that a regular method of contraception (combined hormonal contraception, progestogen-only pill or implant) can be started immediately if the woman is likely to continue to be at risk of pregnancy [8]. It advises that immediate start of the progestogen-only injectable is acceptable if other methods are not appropriate or acceptable [8]. In the US, the seminal textbook on contraception, Contraceptive
S.T. Cameron et al. / Contraception 84 (2011) 368–371
Technology (19th edition, 2007), clearly states that the woman needs to understand that use of EC will not protect against pregnancy in the days or weeks following use and that combined oral contraceptives (COCs) can be used as an ongoing method the day after EC treatment and that the injectable progestin method, vaginal ring or transdermal patch can also be started immediately after EC [9]. Since there is no evidence that widespread use of EC reduces unintended pregnancy rates [10,11], the public health benefit of a consultation for EC lies in the opportunity to advise women about the importance of using an ongoing effective method of contraception and, wherever possible, to provide such a method. With this in mind, we undertook a case note review in a large specialist family planning clinic in central Edinburgh to determine what percentage of women presenting for EC were provided with an effective method of contraception for ongoing use.
2. Materials and methods A review was conducted of the case notes of women who attended Dean Terrace Family Planning Centre, Edinburgh, requesting EC during the 2-year period from 14 January 2007 to 26 January 2009. This family planning center is the main community contraceptive service provider within Edinburgh, Scotland. Data were retrieved from case notes on demographic information, the reason for EC request, time since unprotected sexual intercourse, method of EC used, chosen method of ongoing contraception and whether this was planned to be started immediately (quick start). Women seeking EC during the study period of interest were identified from the log books of a full-time clinical research nurse (AJ) who was responsible for screening the majority of women presenting for EC during this time for their eligibility for participation in a clinical trial of EC that compared the efficacy of ulipristal acetate compared to levonorgestrel. The requirements of the above trial have been previously published, but the eligibility criteria included age 16 years or older, within 120 h of unprotected sex, not using hormonal contraception, not breastfeeding, not wishing to have an intrauterine device (IUD) for EC and willing to wait until their next menstrual period after EC to commence hormonal contraception [4]. In view of these criteria, subjects in the previous trial (n=211) were excluded from the case notes review of this present study. This left a total of 468 women who requested EC during this period who were included in the case notes review. If women did not wish an IUD for EC, they were provided with levonorgestrel (LNG) for EC (if appropriate) by the research nurse. Women were then assessed by a doctor in the clinic for ongoing contraception. Data were entered into the database using Microsoft Excel (LR and AJ) and was verified (AJ) before analysis. Excel was used to perform descriptive statistics.
369
3. Results 3.1. Demographics Case notes were missing in eight of the 468 cases. The mean age of the women was 26 years (range 15–49). Most women (63%; n=178) had never been pregnant before. However, 21% (n=98) of the women had previously had an induced abortion, 14% (n=64) had previously given birth, 3% (n=15) had had a miscarriage in the past and 0.2% (n=1) had previously had an ectopic pregnancy. Five percent (n=25) of the women had used an intrauterine method of contraception at some point in the past. The most common reason for requesting EC was that the woman had had unprotected intercourse (Table 1). Over 80% of the women presented within 48 h of unprotected sex for EC (Table 2). Only 4% of the women attended more than 72 h after sex. Only 2% (n=11) of the women chose to have an IUD for EC, with 91% (n=418) of the women choosing LNG for EC. Seven percent (n=31) of the women were not given any method of EC. All of them had missed oral contraceptive pills but were not deemed to require EC. Of the 11 women choosing an IUD for EC, two women (18%) had used this method of contraception in the past. None of the women who were taking a contraceptive pill at presentation (and had missed pills) chose an IUD for EC. Three (27%) of the 11 women choosing an IUD presented N72 h after sex. Two (18%) of the 11 women choosing an IUD were not able to have this inserted on the day they presented, but were given oral EC and then had the IUD inserted at an arranged clinic visit. 3.2. Ongoing methods All women (n=45) who were using oral pills at presentation opted to continue with this method for contraception. Two women with a suspected ‘lost IUD or IUS’ due to missing threads opted to use condoms, until a subsequent ultrasound confirmed the device was still in situ. Eleven women had an IUD inserted for EC and were planning to continue with this for ongoing contraception. The ongoing contraceptive choices of the remaining women (n=402) are shown in Table 3. Of this group, 23% (n=89) were given hormonal contraceptive supplies (pills, patch or Table 1 Reasons why women (N=460) presented for EC Reason for EC request
n (%)
No method Condom failure Missed oral contraceptive pills Combined pill Progestogen only Antibiotics/diarrhea/vomiting with oral contraceptive pill Othera
218 (47) 192 (42) 41 (9) 30 (7) 11 (2) 4 (1) 5 (1)
a Includes diaphragm slippage (n=1), intrauterine system (IUS) expulsion (n=2), lost threads IUD (n=1), lost threads IUS (n=1).
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S.T. Cameron et al. / Contraception 84 (2011) 368–371
Table 2 Time from unprotected sex to EC Time (h)
n (%) (n=460)
0–24 25–48 49–72 73–96 97–120 N120
219 (48) 157 (34) 64 (14) 12 (2.5) 2 (0.5) 6 (1)
injectable). From the case notes, all (n=83) but six women (all combined pill users) were advised to start the hormonal method immediately. Thus, 93% (83/89) of the women choosing a hormonal method were advised to start this immediately. A further two women who opted for the contraceptive implant (Implanon®) and intrauterine system (IUS) were given an appointment to attend for insertion at a later date. Sixty-five percent (n=263) of women chose condoms as their sole method of ongoing contraception.
4. Discussion This study showed that within a specialist contraceptive service, less than one quarter of women presenting for EC chose an effective method of ongoing contraception. For many experts, this may be viewed as a disappointingly low uptake of ongoing contraception, given the expertise and ready availability of contraceptive supplies on site. Given the significantly higher risk of pregnancy in women who have further sex in the same cycle as EC [7], it is important that women start an effective method of contraception. This low uptake within a specialist setting raises concern that the proportion of women choosing effective ongoing contraception who access EC from a less specialized setting such as general practice may be even lower. In our study only 2% of women opted for an IUD for EC. Once again, this low uptake is disappointing given that this was a specialist contraceptive setting with ready access to trained providers on site. Although an IUD is the most effective method of EC, insertion is invasive and it is not a popular choice of women in the UK, often due to myths and prejudices about the method [12,13]. Furthermore, as observed in our study, it can be difficult even within a specialist contraceptive service to be able to offer immediate IUD insertion to all women requesting an IUD for EC. Clearly, one drawback of this study design is that whilst it informs us of which methods of contraception women chose, it does not tell us the reasons for such choices. Whilst we know that most women used no method or a method of low effectiveness when they presented for EC, and most continued to do so after EC, we have no idea how many women were offered a more effective method of contraception, but declined it. Although published guidance on ‘quick starting’ contraception after EC has only recently become available in the UK [8], our study provides evidence that this approach to
Table 3 Chosen method (main method) of ongoing contraception after oral EC amongst 402 women using no method or a less effective method at presentation [condom failure (n=192), diaphragm slippage (n=1), known IUS expulsion (n=1)] Ongoing contraception
n (%) (n=402)
Condoms (only) Combined pill Progestogen-only pill Combined hormonal contraceptive patch Progestogen-only injectable No method IUS Implant
263 (65) 63 (16) 23 (6) 1 (0.2) 2 (0.5) 48 (12) 1 (0.2) 1 (0.2)
contraception has been promoted for some time within contraceptive services, since the majority of case notes of women choosing to use hormonal contraception after EC had documented evidence of being advised to start their hormonal supplies immediately. This guidance, whilst overdue, will nevertheless be welcomed by contraceptive providers throughout the UK, since it provides detailed advice on additional contraceptive measures to be used when quick starting each contraceptive method [8]. In the UK (and probably elsewhere), increasing numbers of women prefer to attend a pharmacy rather than their family doctor or family planning clinic even if it means paying for the EC [14]. In Scotland in December 2008, EC became freely available (at no cost) to women from the pharmacy. Consequent to this, the numbers of women attending our service requesting EC decreased dramatically. In parallel with this, sales of LNG EC provided from pharmacies have increased [15]. Whilst increasing access to EC from the pharmacy may be desirable, it does mean that contraceptive providers lose the opportunity to initiate women on an effective method of ongoing contraception, which is generally believed to be the greatest advantage of the consultation for EC [10]. Pharmacists are not able to provide any ongoing method apart from condoms, and studies have shown that they are not good at giving advice about ongoing methods of contraception [16,17]. It is likely therefore that the proportion of women who commence effective contraception after accessing EC from the pharmacy is even less than that amongst women attending either a general practice or a specialist contraceptive setting. Our study has severable drawbacks. Clearly, as a case notes review, it can only provide descriptive data. Furthermore, it describes contraceptive practice from a specialized contraceptive service in a single clinical setting. In addition, it describes contraceptive use in a subpopulation of EC seekers from this setting (women who chose not to participate in a concurrent clinical trial) and so may not be fully representative of the larger population of women requesting EC. In spite of this, our study does, however, have the strength of including data on large numbers of women. Furthermore, there are no other published studies on the proportion of women who start contraception after EC. Our
S.T. Cameron et al. / Contraception 84 (2011) 368–371
study thus highlights for the first time that use of effective ongoing contraception after EC (even from a specialist service) is not high and justifies the need for further research in this area. Since pharmacy access to EC is likely to continue to be an important and popular setting for accessing EC, we need urgently to develop effective strategies aimed at facilitating access to effective ongoing contraception for women from the pharmacy. In addition, we need to reduce the barriers at both educational and service level that inhibit women from having an IUD, the most effective method of EC and one that provides highly effective ongoing contraception. References [1] International Consortium for Emergency Contraception; 2010. http:// www.cecinfo.org/. (access date 20th January 2011). [2] Lakha F, Glasier A, Lakha F, Glasier A. Unintended pregnancy and use of emergency contraception among a large cohort of women attending for antenatal care or abortion in Scotland. Lancet 2006;368:1782–7. [3] Lader D. Opinions Survey Report No. 41. Contraception and Sexual Health. United Kingdom: Office for National Statistics; 2009. p. 40. http://www.statistics.gov.uk. (access date 8th February 2011). [4] Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised noninferiority trial and meta-analysis. Lancet 2010;375:555–62. [5] Von Hertzen H, Piaggio G, Ding J, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception. Lancet 2002;360:1803–10. [6] Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352:428–33.
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[7] Cheng L, Gulmezoglu AM, Piaggio G, Ezcurra E, Van Look PF. Interventions for emergency contraception. Cochrane Database Syst Rev 2008(2):CD 001324. [8] Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Quick starting contraception. Faculty of sexual and reproductive healthcare. Clinical guidance. Clinical Effectiveness Unit; 2010. http:// www.fsrh.org. (access date 17th January 2011). [9] Stewart F, Trussell J, Van Look PFA. Emergency contraception. In: Hatcher RA, Trussell J, Stewart F, et al., editors. Contraceptive Technology, 19th revised edition. New York: Ardent Media; 2009. p. 107. [10] Raymond EG, Trussell J, Polis CB. Population effect of increasing access to emergency contraceptive pills. A systematic review. Obstet Gynecol 2007;109:181–8. [11] Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007(2):CD005497. [12] Glasier A, Scorer J, Bigrigg A. Attitudes of women in Scotland to contraception: a qualitative study to explore the acceptability of longacting methods. J Fam Plann Reprod Health Care 2008;34:213–7. [13] Schwarz EB, Kavanaugh M, Douglas E, Dubowitz T, Creinin MD. Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol 2009;113: 833–9. [14] Marston C, Meltzer H, Majeed A. Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional studies. BMJ 2005;331: 271–6. [15] Bayer Schering Pharma — from IMS Health Regional Sales Analysis Data, December 2009. [16] Black KI, Mercer CH, Kubba A, Wellings K. Provision of emergency contraception: a pilot study comparing access through pharmacies and clinical settings. Contraception 2008;77:181–5. [17] Glasier A, Manners RJ, Loudon JC, Muir A. Community pharmacists providing emergency contraception give little advice about future contraceptive use: a mystery shopper study. Contraception 2010;82: 538–42.
Original research article
Ongoing contraception after use of emergency contraception from a specialist contraceptive service☆ Sharon T. Camerona,b,⁎, Anna Glasierb , Anne Johnstoneb , Leanne Raec a Dean Terrace Centre, NHS Lothian, 18 Dean Terrace, Edinburgh, EH4 1NL, Scotland, UK Department of Reproductive and Developmental Sciences, University of Edinburgh, 51 Little France Crescent, Royal Infirmary of Edinburgh, EH16 5SU, Scotland, UK c College of Medicine and Veterinary Medicine, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland, UK Received 24 January 2011; revised 8 February 2011; accepted 24 February 2011 b
Abstract Background: A consultation for emergency contraception (EC) gives way to an opportunity to provide women with an ongoing effective method of contraception. Study Design: A review of the case notes of women seeking EC from a large family planning clinic in Edinburgh, Scotland, was conducted to determine what percentage of women were provided with an effective method of ongoing contraception. Results: Case notes of 460 women presenting for EC over a 2-year period were reviewed. Women were of mean age 26 years (range 15–49 years) and presented because they had used no contraception (47%), experienced condom failure (42%) or missed oral contraceptive pills (9%). Only 2% (n=11) were given an intrauterine device for EC. All women who had missed contraceptive pills prior to taking EC opted to continue this method. Only 23% (n=89) of women using no method or condoms at EC received supplies of an effective contraceptive method (pills, patch, injectable). Two thirds (n=263) of the women chose condoms for ongoing contraception. Conclusion: Research is required to develop strategies to improve the uptake of effective contraception after EC. © 2011 Elsevier Inc. All rights reserved. Keywords: Emergency contraception; Intrauterine device; Hormonal contraception; Quick start
1. Introduction Hormonal emergency contraception (EC) is now available in over 140 countries worldwide, and in 44 of them it is readily available over the counter [1]. Use of EC varies considerably worldwide but in Scotland at least one in 10 women presenting for an abortion has used it to try to prevent a pregnancy [2] and in the general population in Great Britain in 2008/09, 7% of women of reproductive age (and 14% of those aged 16–19 years) had used it in the last year [3]. It is clear from most clinical trials that around 95% of women using EC will not become pregnant and so remain at risk of pregnancy unless they start using another method of ☆
There was no funding provided for this study. ⁎ Corresponding author. Dean Terrace Centre, 18 Dean Terrace, NHS Lothian, Edinburgh EH4 INL, Scotland, UK. Tel.: +44 131 343 0912; fax: 131 332 2391. E-mail address: [email protected] (S.T. Cameron). 0010-7824/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2011.02.012
contraception [4–6]. Results of a recently published metaanalysis, which included nine trials of more than 4500 women who had sexual intercourse after using EC but before return of menses, found that the relative risk of pregnancy was 2.61 (95% confidence intervals of 2.0–3.4) when compared with women who said they did not have sex after using EC [7]. In the UK, the Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit produces clinical guidance for health professionals and has a clinical guidance document for every method of contraception. The recent guidance relating to ‘quick starting’ contraception following EC advises that a regular method of contraception (combined hormonal contraception, progestogen-only pill or implant) can be started immediately if the woman is likely to continue to be at risk of pregnancy [8]. It advises that immediate start of the progestogen-only injectable is acceptable if other methods are not appropriate or acceptable [8]. In the US, the seminal textbook on contraception, Contraceptive
S.T. Cameron et al. / Contraception 84 (2011) 368–371
Technology (19th edition, 2007), clearly states that the woman needs to understand that use of EC will not protect against pregnancy in the days or weeks following use and that combined oral contraceptives (COCs) can be used as an ongoing method the day after EC treatment and that the injectable progestin method, vaginal ring or transdermal patch can also be started immediately after EC [9]. Since there is no evidence that widespread use of EC reduces unintended pregnancy rates [10,11], the public health benefit of a consultation for EC lies in the opportunity to advise women about the importance of using an ongoing effective method of contraception and, wherever possible, to provide such a method. With this in mind, we undertook a case note review in a large specialist family planning clinic in central Edinburgh to determine what percentage of women presenting for EC were provided with an effective method of contraception for ongoing use.
2. Materials and methods A review was conducted of the case notes of women who attended Dean Terrace Family Planning Centre, Edinburgh, requesting EC during the 2-year period from 14 January 2007 to 26 January 2009. This family planning center is the main community contraceptive service provider within Edinburgh, Scotland. Data were retrieved from case notes on demographic information, the reason for EC request, time since unprotected sexual intercourse, method of EC used, chosen method of ongoing contraception and whether this was planned to be started immediately (quick start). Women seeking EC during the study period of interest were identified from the log books of a full-time clinical research nurse (AJ) who was responsible for screening the majority of women presenting for EC during this time for their eligibility for participation in a clinical trial of EC that compared the efficacy of ulipristal acetate compared to levonorgestrel. The requirements of the above trial have been previously published, but the eligibility criteria included age 16 years or older, within 120 h of unprotected sex, not using hormonal contraception, not breastfeeding, not wishing to have an intrauterine device (IUD) for EC and willing to wait until their next menstrual period after EC to commence hormonal contraception [4]. In view of these criteria, subjects in the previous trial (n=211) were excluded from the case notes review of this present study. This left a total of 468 women who requested EC during this period who were included in the case notes review. If women did not wish an IUD for EC, they were provided with levonorgestrel (LNG) for EC (if appropriate) by the research nurse. Women were then assessed by a doctor in the clinic for ongoing contraception. Data were entered into the database using Microsoft Excel (LR and AJ) and was verified (AJ) before analysis. Excel was used to perform descriptive statistics.
369
3. Results 3.1. Demographics Case notes were missing in eight of the 468 cases. The mean age of the women was 26 years (range 15–49). Most women (63%; n=178) had never been pregnant before. However, 21% (n=98) of the women had previously had an induced abortion, 14% (n=64) had previously given birth, 3% (n=15) had had a miscarriage in the past and 0.2% (n=1) had previously had an ectopic pregnancy. Five percent (n=25) of the women had used an intrauterine method of contraception at some point in the past. The most common reason for requesting EC was that the woman had had unprotected intercourse (Table 1). Over 80% of the women presented within 48 h of unprotected sex for EC (Table 2). Only 4% of the women attended more than 72 h after sex. Only 2% (n=11) of the women chose to have an IUD for EC, with 91% (n=418) of the women choosing LNG for EC. Seven percent (n=31) of the women were not given any method of EC. All of them had missed oral contraceptive pills but were not deemed to require EC. Of the 11 women choosing an IUD for EC, two women (18%) had used this method of contraception in the past. None of the women who were taking a contraceptive pill at presentation (and had missed pills) chose an IUD for EC. Three (27%) of the 11 women choosing an IUD presented N72 h after sex. Two (18%) of the 11 women choosing an IUD were not able to have this inserted on the day they presented, but were given oral EC and then had the IUD inserted at an arranged clinic visit. 3.2. Ongoing methods All women (n=45) who were using oral pills at presentation opted to continue with this method for contraception. Two women with a suspected ‘lost IUD or IUS’ due to missing threads opted to use condoms, until a subsequent ultrasound confirmed the device was still in situ. Eleven women had an IUD inserted for EC and were planning to continue with this for ongoing contraception. The ongoing contraceptive choices of the remaining women (n=402) are shown in Table 3. Of this group, 23% (n=89) were given hormonal contraceptive supplies (pills, patch or Table 1 Reasons why women (N=460) presented for EC Reason for EC request
n (%)
No method Condom failure Missed oral contraceptive pills Combined pill Progestogen only Antibiotics/diarrhea/vomiting with oral contraceptive pill Othera
218 (47) 192 (42) 41 (9) 30 (7) 11 (2) 4 (1) 5 (1)
a Includes diaphragm slippage (n=1), intrauterine system (IUS) expulsion (n=2), lost threads IUD (n=1), lost threads IUS (n=1).
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Table 2 Time from unprotected sex to EC Time (h)
n (%) (n=460)
0–24 25–48 49–72 73–96 97–120 N120
219 (48) 157 (34) 64 (14) 12 (2.5) 2 (0.5) 6 (1)
injectable). From the case notes, all (n=83) but six women (all combined pill users) were advised to start the hormonal method immediately. Thus, 93% (83/89) of the women choosing a hormonal method were advised to start this immediately. A further two women who opted for the contraceptive implant (Implanon®) and intrauterine system (IUS) were given an appointment to attend for insertion at a later date. Sixty-five percent (n=263) of women chose condoms as their sole method of ongoing contraception.
4. Discussion This study showed that within a specialist contraceptive service, less than one quarter of women presenting for EC chose an effective method of ongoing contraception. For many experts, this may be viewed as a disappointingly low uptake of ongoing contraception, given the expertise and ready availability of contraceptive supplies on site. Given the significantly higher risk of pregnancy in women who have further sex in the same cycle as EC [7], it is important that women start an effective method of contraception. This low uptake within a specialist setting raises concern that the proportion of women choosing effective ongoing contraception who access EC from a less specialized setting such as general practice may be even lower. In our study only 2% of women opted for an IUD for EC. Once again, this low uptake is disappointing given that this was a specialist contraceptive setting with ready access to trained providers on site. Although an IUD is the most effective method of EC, insertion is invasive and it is not a popular choice of women in the UK, often due to myths and prejudices about the method [12,13]. Furthermore, as observed in our study, it can be difficult even within a specialist contraceptive service to be able to offer immediate IUD insertion to all women requesting an IUD for EC. Clearly, one drawback of this study design is that whilst it informs us of which methods of contraception women chose, it does not tell us the reasons for such choices. Whilst we know that most women used no method or a method of low effectiveness when they presented for EC, and most continued to do so after EC, we have no idea how many women were offered a more effective method of contraception, but declined it. Although published guidance on ‘quick starting’ contraception after EC has only recently become available in the UK [8], our study provides evidence that this approach to
Table 3 Chosen method (main method) of ongoing contraception after oral EC amongst 402 women using no method or a less effective method at presentation [condom failure (n=192), diaphragm slippage (n=1), known IUS expulsion (n=1)] Ongoing contraception
n (%) (n=402)
Condoms (only) Combined pill Progestogen-only pill Combined hormonal contraceptive patch Progestogen-only injectable No method IUS Implant
263 (65) 63 (16) 23 (6) 1 (0.2) 2 (0.5) 48 (12) 1 (0.2) 1 (0.2)
contraception has been promoted for some time within contraceptive services, since the majority of case notes of women choosing to use hormonal contraception after EC had documented evidence of being advised to start their hormonal supplies immediately. This guidance, whilst overdue, will nevertheless be welcomed by contraceptive providers throughout the UK, since it provides detailed advice on additional contraceptive measures to be used when quick starting each contraceptive method [8]. In the UK (and probably elsewhere), increasing numbers of women prefer to attend a pharmacy rather than their family doctor or family planning clinic even if it means paying for the EC [14]. In Scotland in December 2008, EC became freely available (at no cost) to women from the pharmacy. Consequent to this, the numbers of women attending our service requesting EC decreased dramatically. In parallel with this, sales of LNG EC provided from pharmacies have increased [15]. Whilst increasing access to EC from the pharmacy may be desirable, it does mean that contraceptive providers lose the opportunity to initiate women on an effective method of ongoing contraception, which is generally believed to be the greatest advantage of the consultation for EC [10]. Pharmacists are not able to provide any ongoing method apart from condoms, and studies have shown that they are not good at giving advice about ongoing methods of contraception [16,17]. It is likely therefore that the proportion of women who commence effective contraception after accessing EC from the pharmacy is even less than that amongst women attending either a general practice or a specialist contraceptive setting. Our study has severable drawbacks. Clearly, as a case notes review, it can only provide descriptive data. Furthermore, it describes contraceptive practice from a specialized contraceptive service in a single clinical setting. In addition, it describes contraceptive use in a subpopulation of EC seekers from this setting (women who chose not to participate in a concurrent clinical trial) and so may not be fully representative of the larger population of women requesting EC. In spite of this, our study does, however, have the strength of including data on large numbers of women. Furthermore, there are no other published studies on the proportion of women who start contraception after EC. Our
S.T. Cameron et al. / Contraception 84 (2011) 368–371
study thus highlights for the first time that use of effective ongoing contraception after EC (even from a specialist service) is not high and justifies the need for further research in this area. Since pharmacy access to EC is likely to continue to be an important and popular setting for accessing EC, we need urgently to develop effective strategies aimed at facilitating access to effective ongoing contraception for women from the pharmacy. In addition, we need to reduce the barriers at both educational and service level that inhibit women from having an IUD, the most effective method of EC and one that provides highly effective ongoing contraception. References [1] International Consortium for Emergency Contraception; 2010. http:// www.cecinfo.org/. (access date 20th January 2011). [2] Lakha F, Glasier A, Lakha F, Glasier A. Unintended pregnancy and use of emergency contraception among a large cohort of women attending for antenatal care or abortion in Scotland. Lancet 2006;368:1782–7. [3] Lader D. Opinions Survey Report No. 41. Contraception and Sexual Health. United Kingdom: Office for National Statistics; 2009. p. 40. http://www.statistics.gov.uk. (access date 8th February 2011). [4] Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised noninferiority trial and meta-analysis. Lancet 2010;375:555–62. [5] Von Hertzen H, Piaggio G, Ding J, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception. Lancet 2002;360:1803–10. [6] Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352:428–33.
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[7] Cheng L, Gulmezoglu AM, Piaggio G, Ezcurra E, Van Look PF. Interventions for emergency contraception. Cochrane Database Syst Rev 2008(2):CD 001324. [8] Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Quick starting contraception. Faculty of sexual and reproductive healthcare. Clinical guidance. Clinical Effectiveness Unit; 2010. http:// www.fsrh.org. (access date 17th January 2011). [9] Stewart F, Trussell J, Van Look PFA. Emergency contraception. In: Hatcher RA, Trussell J, Stewart F, et al., editors. Contraceptive Technology, 19th revised edition. New York: Ardent Media; 2009. p. 107. [10] Raymond EG, Trussell J, Polis CB. Population effect of increasing access to emergency contraceptive pills. A systematic review. Obstet Gynecol 2007;109:181–8. [11] Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007(2):CD005497. [12] Glasier A, Scorer J, Bigrigg A. Attitudes of women in Scotland to contraception: a qualitative study to explore the acceptability of longacting methods. J Fam Plann Reprod Health Care 2008;34:213–7. [13] Schwarz EB, Kavanaugh M, Douglas E, Dubowitz T, Creinin MD. Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol 2009;113: 833–9. [14] Marston C, Meltzer H, Majeed A. Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional studies. BMJ 2005;331: 271–6. [15] Bayer Schering Pharma — from IMS Health Regional Sales Analysis Data, December 2009. [16] Black KI, Mercer CH, Kubba A, Wellings K. Provision of emergency contraception: a pilot study comparing access through pharmacies and clinical settings. Contraception 2008;77:181–5. [17] Glasier A, Manners RJ, Loudon JC, Muir A. Community pharmacists providing emergency contraception give little advice about future contraceptive use: a mystery shopper study. Contraception 2010;82: 538–42.