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Primary care services for an emergency department population: a novel location for contraception
Contraception 71 (2005) 40 – 44
Original research article
Primary care services for an emergency department population: a novel location for contraception Catherine S. Todda,*, Laura C. Plantingab, Richard Lichensteinc a
Department of Obstetrics and Gynecology, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA b Department of Internal Medicine, Johns Hopkins University, Baltimore, MD 21218, USA c Department of Pediatrics, University of Maryland Hospital for Children, Baltimore, MD 20201, USA Received 11 May 2004; revised 24 June 2004; accepted 9 August 2004
Abstract Objective: To assess contraceptive provision site preferences in female urban Baltimore emergency department patients. Methods: This cross-sectional questionnaire study was completed by 790 women, a population sufficient to detect a 10% intersite difference. The results were analyzed with chi-square, univariate and multivariate logistic regression analyses. Results: Obtaining contraception other than from a physician’s office was acceptable to 57.2% of the subjects, particularly those uninsured ( p = .006) and without primary care providers ( p b .001). Contraceptive provision in the emergency department ( ED) was acceptable to 44.0%, particularly those who are frequent ED users ( p = .003) and those at risk for unintended pregnancy ( p = .024; pooled, p b .001). Care in nontraditional settings may preclude pelvic examination; 34.0% of the subjects felt safe obtaining contraception without this examination, significantly for those desiring contraceptive provision in the ED. Conclusion: Contraceptive services are acceptable in nontraditional settings, including the ED, particularly to women of limited resources. This service is acceptable without pelvic examination for a sizable proportion of the women using the ED. D 2005 Elsevier Inc. All rights reserved. Keywords: Emergency department; Primary care; Contraceptive services
1. Introduction Nearly half of all pregnancies in the United States are unintended, and, of these, half result from contraceptive nonuse [1]. It is possible that the inability to obtain reliable contraception contributes to many of these cases; thus, access to contraception and other health care is becoming a pertinent issue. Populations with poor health care access can be characterized by low socioeconomic status and decreased health insurance possession [2,3]. The noninsured rate of poor women with children has grown by half in the last 4 years, with 37% uninsured in 2000. Although there are other contributing factors, altered welfare policies and Medicaid eligibility levels have had negative effects on women’s health coverage [4]. Family planning clinics, serving as a
* Corresponding author. Division of International Health and CrossCultural Medicine, University of California – San Diego, 9500 Gilman Dr., 0622, La Jolla, CA 92093-0622, USA. E-mail addresses: [email protected] (C.S. Todd), [email protected] (R. Lichenstein). 0010-7824/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2004.08.009
contraceptive service provider to 23.8% of American women of reproductive age, primarily those of low socioeconomic status [5,6], have been affected by decreased Title X funding [7]. Consequently, this raises the question of where resource-challenged women may go to receive health care, particularly contraception. To reach populations at increased risk for unintended pregnancy, it seems best to query them about the ideal location for contraceptive service provision. Low-income women, whose socioeconomic status is significantly related to increased unintended pregnancy risk, have been interviewed regarding contraceptive use patterns and satisfaction with care, but care site preference was not assessed [8]. Provision of contraception in sites whose primary purpose is not health care has been demonstrated to be acceptable and effective [9–11]. Women using the emergency department ( ED) for care, particularly those with low income and without a primary health care provider [12], have been identified as a group at increased risk of unintended pregnancy and are disproportionately present in the ED population [13,14]. The purpose of this study is to determine
C.S. Todd et al. / Contraception 71 (2005) 40 – 44
the acceptability of contraceptive provision in nontraditional settings to those presenting to the ED for care.
Table 2 Characteristics of those desiring a contraceptive provision source other than a physician’s office Source
All patients, % p, Crude OR, (95% CI)
Overall Risk for unintended pregnancy Pooled risk for unintended pregnancy and dissatisfaction with contraceptive method Uninsured status Low income Young age (15–18 years) Lack of primary care provider Frequent ED use
57.2 52.5
– .880 .263, 0.80 (0.53–1.19) .603
59.2
.605, 1.09 (0.79–1.51) .298
65.8 56.9 62.8
.006, 1.65 (1.15–2.36) .886 .652, 0.92 (0.66–1.30) .963 .207, 1.33 (0.86–2.05) .089
66.9
b .001, 1.99 (1.43–2.77) .153
51.5
.263, 1.20 (0.87–1.65) .919
2. Materials and methods This study was performed at the EDs of the Johns Hopkins Bayview and the University of Maryland medical centers. The descriptions of the study sites and criteria for enrollment are summarized in the first paper written about this study [12]. All procedures were reviewed and approved in advance by the institutional review boards of both study sites. 2.1. Patient questionnaire Subjects completed a self-administered anonymous survey. This survey included questions to elicit socioeconomic and demographic data, health care utilization, contraceptive use and sexual behaviors and the reason for coming to the ED. Socioeconomic status was divided into five categories by income level. Health care utilization was measured by frequent ED use (defined as two or more visits in the last year) and regular source of care. We defined contraceptive access preference from a multiple choice question, bWhere would you like to be able to obtain birth control (circle all that apply)? Q to which the possible answers were bdoctor’s office,Q bpharmacy,Q bschool,Q bemergency room,Q bchurch,Q bcommunity centerQ and bother.Q Acceptability of the ED was retested with a separate question, from which a pooled group was analyzed for indicators of acceptability. Comfort obtaining contraception without a pelvic examination was also assessed. 2.2. Data analysis The sample size at each site was sufficient to detect a 10% intersite difference ( power= 80). Crude odds ratios (ORs) were obtained for alternative contraceptive provision sites, ED acceptability and contraceptive provision without pelvic examination by univariate logistic regression to determine an association between these variables of interest, with the exception of unintended pregnancy risk (pooled). This factor was considered both individually and also pooled with those dissatisfied with their current method to increase capture of those at risk for unintended pregnancy [15]. We then tested
All patients Bayview University n = 628, (%) n = 334, (%) of Maryland n = 294, (%)
Doctor’s office 514 Pharmacy 229 Emergency room 201 School 96 Church 49 Community center 106 Other 15 Total 1210
(42.5) (18.9) (16.6) (7.9) (4.0) (8.8) (1.2) (100)
276 131 99 59 29 64 5 663
Intersite p
the associations for acceptability of contraceptive provision in the ED and obtaining contraception without a pelvic examination by multiple logistic regression analysis, calculating adjusted OR and 95% confidence intervals (CIs); all associated variables were included in this model. Data analysis was performed using a standard statistical software (Stata 7.0, College Station, TX, USA). 3. Results The study populations were compared to assess whether each sample was reflective of its site’s population. For the Bayview sample, there was no difference in the ethnic group (p =.428) but it was more likely to have insurance (31.6% vs. 37.47%; p =.02). For the University of Maryland sample, the proportion of the nonspecified racial group (p b.001) and African Americans (p =.03) was significantly different but insurance possession was not ( p =.97). Some patients approached declined entry or were not eligible (never sexually active or homosexual): 12.4% declined and 13.4% were not eligible. Age was the only Table 3 Univariate analysis of acceptability of contraceptive provision in the ED
Table 1 Contraceptive provision preferences Source
41
(41.6) (19.8) (14.9) (8.9) (4.4) (9.7) (0.8) (100)
238 98 102 37 20 42 10 547
(43.5) (17.9) (18.6) (6.8) (3.7) (7.7) (1.8) (100)
n represents the number of patients contributing to the total number of responses. Figures in parentheses are percentage values.
Variable
Patients, % p, Crude OR, (95% CI)
All patients Risk for unintended pregnancy Pooled risk for unintended pregnancy Uninsured status Low income Young age Lack of primary care provider Frequent ED use
44.0 47.5
N/A .051 .315, 0.83 (0.58 – 1.19) .939
54.1
b .001, 1.94 (1.44 – 2.61) .508
50.6 46.8 46.8 50.2 51.0
.012, .060, .384, .004,
1.49 1.35 0.83 1.53
Intersite p
(1.09–2.03) (0.99–1.85) (0.55–1.25) (1.15–2.05)
.173 .180 .896 .651
b .001, 1.75 (1.31–2.34)
.117
42
C.S. Todd et al. / Contraception 71 (2005) 40 – 44
variable assessed in those approached and not entering the study; those who declined did not differ significantly and those ineligible tended to be of younger age. Contraceptive provision was acceptable at a variety of locations; a doctor’s office was mentioned most frequently as acceptable, with the pharmacy and the ED as the next most acceptable sites (Table 1). The distribution of responses was not significantly different between ED sites by Pearson’s chi-square (p = .147). Patients stating that they desired a source other than a physician’s office were analyzed separately; they composed 57.2% of the study population. Overall, patients desiring an unconventional contraceptive source were significantly more likely to be uninsured and without a regular health care provider (Table 2); the relationship for those without a regular provider remained significant in adjusted logistic regression modeling (OR = 1.93; 95% CI, 1.19 –3.13; p =.008). The ED was acceptable as a source for obtaining contraception or related information to 44.0% of patients. Those who found the ED acceptable were significantly more likely to be at risk for unintended pregnancy ( pooled with those dissatisfied with their contraceptive method), uninsured, without a regular medical provider and frequent ED users (Table 3). In adjusted logistic regression analysis, significant relationships persisted for frequent ED users ( p= .003) and those at pooled risk for unintended pregnancy ( pb .001), while it was emerging for those at risk for unintended pregnancy (p =.024). Patients at the University of Maryland site were marginally more likely to prefer this site (p = .051).
Table 4 Univariate analysis of acceptability of contraception without pelvic examination Variable
Patients, % p, OR, (95% CI)
All patients Risk for unintended pregnancy Pooled risk for unintended pregnancy and dissatisfaction with contraceptive method Uninsured status Low income Young age Lack of primary care provider Frequent ED use Contraception acceptable in ED
34.0 38.6
N/A .706, 0.93 (0.64 –1.36)
.321 .310
40.0
.021, 1.45 (1.06 –1.98)
.645
36.7 35.8 41.2 35.2
.313, .042, .100, .550,
a
35.2 44.9
1.18 1.42 0.70 1.10
Intersite p
(0.85 –1.64) 1.000 (1.01–1.99) .761 (.455 –1.07) .103 (0.81–1.50) .219
.562, 1.10 (0.81–1.49) b .01, 2.33 (1.7–3.2)
.022a .035b
This significant interaction value indicated that the effect of this covariate is different at the two locations. Stratified values are as follows: for Bayview, 0.80 (0.52–1.21); for University of Maryland, 1.66 (1.04 –2.64). b This significant interaction value indicated that the effect of this covariate is different at the two locations. Stratified values are as follows: for Bayview, 2.18 (1.42–3.34); for University of Maryland, 2.72 (1.68 – 4.42).
Of all patients, 34.0% felt safe receiving contraception without a pelvic examination. Those patients were more likely to have low income and be in the pooled risk group (Table 4). However, among patients seen at the University of Maryland, frequent ED users were comfortable receiving contraception without a pelvic examination, differing significantly from the patients seen at the Bayview site (Table 4). Pooled risk for unintended pregnancy remained marginally significant (p =.058) in adjusted logistic regression models. An analysis performed with the subset of patients desiring contraception in the ED found this group significantly more likely to be comfortable receiving contraception without a pelvic examination, a relationship that persisted and strengthened in multivariate analysis (univariate, OR = 2.33, CI, 1.7– 3.2; multivariate, OR = 2.52, CI, 1.68 –3.77). Despite a significant site interaction, the direction of the association was consistent across sites (Table 4). 4. Discussion To our knowledge, there have been no prior published reports on the acceptability of the ED for contraceptive provision. While a bphysician’s officeQ was the most frequent answer provided for individual sites, this location may not be an option for many patients surveyed, as denoted by 57.2% of the subjects who preferred nonconventional sites. This association is further supported by the significant relationship of lack of a care provider with unintended pregnancy risk, the desire for an unconventional contraceptive provision site and the desire for contraceptive provision in the ED. While the relationship of contraceptive provision in the ED has not been supported by other studies, lack of a primary provider and use of a nonconventional site were characteristics of the First Stop population, which was at significantly greater risk for unintended pregnancy (23%) than the general population [11]. This study did not assess whether clients preferred to receive care at the nontraditional provision sites, but 92% of the subjects stated that they would recommend the service [11]. Within the ED population, women at risk for unintended pregnancy were not more likely to prefer a nontraditional contraceptive provision site (although they were more likely to prefer the ED specifically and obtaining contraception without a pelvic examination). Because more than half of the population favored a nonconventional site, the difference between those at risk and those not at risk for unintended pregnancy was less marked, as opposed to preference for the ED. This result may have achieved significance with a larger sample size. Possession of health insurance was not related to increased unintended pregnancy risk but was related to preference of nontraditional contraceptive provision sites, the ED as a provision site and comfort obtaining contraception without a pelvic examination. This disparity may be due to the uninsured individuals’ consciousness of the absence of a regular care site. However, low income was not
C.S. Todd et al. / Contraception 71 (2005) 40 – 44
significantly related to nontraditional sites of contraceptive provision, including the ED, although it was related to unintended pregnancy risk. A study composed solely of low-income women verified increased risk but did not assess whether access affected risk. This study did reveal that a large proportion of low-income women had beliefs interfering with correct contraceptive use [8]. Our study did not assess patient perceptions regarding proper use of contraception or barriers to access. We did assess whether the patients believed that they were at risk for unintended pregnancy, and this did not correlate with their actual risk status (p b.001). It is possible that some of the beliefs of low-income women may prevent them from accepting the concept of obtaining contraception in a nontraditional setting. This topic should be assessed by further research on the ED population. Were contraception to be provided in the ED, one factor influencing its acceptability may be the perceived need for pelvic examination. A pelvic examination does not provide information that precludes many forms of contraception such as highly effective hormonal methods [11,16]. Overall, 34% of the patients, particularly those in the lowest-income group, those at increased unintended pregnancy risk and those of young age (relationships did not persist in the multivariate model), believed that it was safe to obtain contraception without a pelvic examination. Harper et al. [11] found a much higher proportion, particularly composed of older and Hispanic women, supporting contraception without pelvic examination although in a very dissimilar patient population and in a population that was offered contraceptive services at the time of interview. Further studies are needed before definite predictive factors for this preference can be concluded, and these will likely be population dependent. There are some limitations to this study. Bias may have been introduced through the sampling scheme (convenience rather than random sampling) or through some patients’ refusal to participate. We acknowledge that asking the population already in the ED if the ED is an acceptable site may have produced a falsely elevated positive response rate due to the power of suggestion; however, this facility sees a population at greater unintended pregnancy risk in a potential setting for intervention and this choice may be the logical one for this population, regardless of whether a patient had been consciously aware of it. Additionally, the response rate for those feeling safe receiving contraception without a pelvic examination may be falsely elevated as this population has less access to routine services or may have other reasons for wanting to avoid pelvic examination, which were not solicited in this study. The ED was not intended for contraceptive provision but represents a logical choice for this service. Family planning and sexually transmitted infection (STI) needs could be served by a designated care provider in an adjoining facility with hours compatible to those most in need of services. Provision of emergency contraception by other sources has
43
been noted to decrease ED visits for that purpose in one setting [17]; this effect might also be seen for provision of family planning and STI services. The need for STI services in a Baltimore ED setting has been established [18,19], and a program of this nature would make follow-up services possible. Such a program could positively impact both patient overcrowding and reproductive health care for this population and deserves further study.
Acknowledgments We would like to thank Carol Hill (Johns Hopkins Bayview) and Colleen Reilly (University of Maryland) for their assistance with site data procurement, Geoffrey Mountvarner, M.D., for his assistance with data collection and Susan Shappert, M.S., for her assistance with special subsets of National Hospital Ambulatory Medical Care Survey data. We thank Charlotte Ellertson, Ph.D., and Arik Marcell, M.D., M.P.H., for their critical evaluation of presented data. We are deeply grateful to Laurie S. Zabin, Ph.D., for her guidance and shared wisdom throughout this project. We also thank the American College of Obstetrics and Gynecology Development Fund for making this project possible. References [1] Henshaw SK. Unintended pregnancy in the United States. Fam Plan Perspect 1998;30:24 – 29, 46. [2] Kasper JD, Giovannini TA, Hoffman C. Gaining and losing health insurance: strengthening the evidence for effects on access to care and health outcomes. Med Care Res Rev 2000;57:298 – 325. [3] Bloom B, Simpson G, Cohen RA, Parsons PE. Access to health care. Part 2: working-age adults. Vital Health Stat 10 1997;197:1 – 47. [4] Mann C, Hudman J, Salganicoff A, Folsom A. Five years later: poor women’s health care coverage after welfare reform. J Am Med Womens Assoc 2002;57:16 – 22. [5] Finer LB, Darroch JE, Frost JJ. U.S. agencies providing publicly funded contraceptive services in 1999. Perspect Sex Reprod Health 2002;34:15 – 24. [6] Frost JJ. Public or private providers? U.S. women’s use of reproductive health services. Fam Plan Perspect 2001;33:4 – 12. [7] Dailard C. Challenges facing family planning clinics and Title X. Guttmacher Rep Public Policy 2001;4(2). Available at: http:// www.guttmacher.org/pubs/tgr/04/2/gr040208.html. [8] Forrest JD, Frost JJ. The family planning attitudes and experiences of low-income women. Fam Plan Perspect 1996;28:246–55, 277. [9] Philiber S, Williams Kaye J, Herrling S, West E. Preventing pregnancy and improving health care access among teenagers: an evaluation of the Children’s Aid Society– Carrera Program. Perspect Sex Reprod Health 2002;34:244. [10] Zabin LS, Hirsch MB, Street R, Emerson MR, Smith M, Hardy JB, et al. The Baltimore Pregnancy Prevention Program for urban teenagers. I: how did it work? Fam Plan Perspect 1988;20: 182 – 7. [11] Harper C, Balistreri E, Boggess J, Leon K, Darney P. Provision of hormonal contraceptives without a mandatory pelvic examination: the First Stop Demonstration Project. Fam Plan Perspect 2001; 33:13 – 8. [12] Todd CS, Mountvarner G, Lichenstein R. Unintended pregnancy risk in an emergency department population. Contraception 2005; 71:35 – 9.
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[13] O’Brien GM, Stein MD, Zierler S, Shapiro M, O’Sullivan P, Woolard R. Use of the ED as a regular source of care: associated factors beyond lack of health insurance. Ann Emerg Med 1997; 30:286 – 91. [14] Walls CA, Rhodes KV, Kennedy JJ. The emergency department as usual source of medical care: estimates from the 1998 National Health Interview Survey. Acad Emerg Med 2002;9:1140 – 5. [15] Trussell J, Vaughm B. Contraceptive failure, method-related discontinuation and resumption of use: results from the 1995 National Survey of Family Growth. Fam Plan Perspect 1999;31:64 – 72, 93. [16] Stewart FH, Harper CC, Ellertson CE, Grimes DA, Sawaya GF, Trussell J. Clinical breast and pelvic examination requirements for
hormonal contraception: current practice vs evidence. JAMA 2001; 286:671 – 2. [17] Kerins M, Maguire E, Fahey DK, Glucksman E. Emergency contraception. Has over the counter availability reduced attendances at emergency departments? Emerg Med J 2004;21:67 – 8. [18] Mehta SD, Rothman RE, Kelen GD, Quinn TC, Zenilman JM. Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention. Sex Transm Dis 2001;28:33 – 9. [19] Mehta SD, Rothman RE, Kelen GD, Quinn TC, Zenilman JM. Clinical aspects of diagnosis of gonorrhea and Chlamydia infection in an acute care setting. Clin Infect Dis 2001;32:655 – 9.
Original research article
Primary care services for an emergency department population: a novel location for contraception Catherine S. Todda,*, Laura C. Plantingab, Richard Lichensteinc a
Department of Obstetrics and Gynecology, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA b Department of Internal Medicine, Johns Hopkins University, Baltimore, MD 21218, USA c Department of Pediatrics, University of Maryland Hospital for Children, Baltimore, MD 20201, USA Received 11 May 2004; revised 24 June 2004; accepted 9 August 2004
Abstract Objective: To assess contraceptive provision site preferences in female urban Baltimore emergency department patients. Methods: This cross-sectional questionnaire study was completed by 790 women, a population sufficient to detect a 10% intersite difference. The results were analyzed with chi-square, univariate and multivariate logistic regression analyses. Results: Obtaining contraception other than from a physician’s office was acceptable to 57.2% of the subjects, particularly those uninsured ( p = .006) and without primary care providers ( p b .001). Contraceptive provision in the emergency department ( ED) was acceptable to 44.0%, particularly those who are frequent ED users ( p = .003) and those at risk for unintended pregnancy ( p = .024; pooled, p b .001). Care in nontraditional settings may preclude pelvic examination; 34.0% of the subjects felt safe obtaining contraception without this examination, significantly for those desiring contraceptive provision in the ED. Conclusion: Contraceptive services are acceptable in nontraditional settings, including the ED, particularly to women of limited resources. This service is acceptable without pelvic examination for a sizable proportion of the women using the ED. D 2005 Elsevier Inc. All rights reserved. Keywords: Emergency department; Primary care; Contraceptive services
1. Introduction Nearly half of all pregnancies in the United States are unintended, and, of these, half result from contraceptive nonuse [1]. It is possible that the inability to obtain reliable contraception contributes to many of these cases; thus, access to contraception and other health care is becoming a pertinent issue. Populations with poor health care access can be characterized by low socioeconomic status and decreased health insurance possession [2,3]. The noninsured rate of poor women with children has grown by half in the last 4 years, with 37% uninsured in 2000. Although there are other contributing factors, altered welfare policies and Medicaid eligibility levels have had negative effects on women’s health coverage [4]. Family planning clinics, serving as a
* Corresponding author. Division of International Health and CrossCultural Medicine, University of California – San Diego, 9500 Gilman Dr., 0622, La Jolla, CA 92093-0622, USA. E-mail addresses: [email protected] (C.S. Todd), [email protected] (R. Lichenstein). 0010-7824/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2004.08.009
contraceptive service provider to 23.8% of American women of reproductive age, primarily those of low socioeconomic status [5,6], have been affected by decreased Title X funding [7]. Consequently, this raises the question of where resource-challenged women may go to receive health care, particularly contraception. To reach populations at increased risk for unintended pregnancy, it seems best to query them about the ideal location for contraceptive service provision. Low-income women, whose socioeconomic status is significantly related to increased unintended pregnancy risk, have been interviewed regarding contraceptive use patterns and satisfaction with care, but care site preference was not assessed [8]. Provision of contraception in sites whose primary purpose is not health care has been demonstrated to be acceptable and effective [9–11]. Women using the emergency department ( ED) for care, particularly those with low income and without a primary health care provider [12], have been identified as a group at increased risk of unintended pregnancy and are disproportionately present in the ED population [13,14]. The purpose of this study is to determine
C.S. Todd et al. / Contraception 71 (2005) 40 – 44
the acceptability of contraceptive provision in nontraditional settings to those presenting to the ED for care.
Table 2 Characteristics of those desiring a contraceptive provision source other than a physician’s office Source
All patients, % p, Crude OR, (95% CI)
Overall Risk for unintended pregnancy Pooled risk for unintended pregnancy and dissatisfaction with contraceptive method Uninsured status Low income Young age (15–18 years) Lack of primary care provider Frequent ED use
57.2 52.5
– .880 .263, 0.80 (0.53–1.19) .603
59.2
.605, 1.09 (0.79–1.51) .298
65.8 56.9 62.8
.006, 1.65 (1.15–2.36) .886 .652, 0.92 (0.66–1.30) .963 .207, 1.33 (0.86–2.05) .089
66.9
b .001, 1.99 (1.43–2.77) .153
51.5
.263, 1.20 (0.87–1.65) .919
2. Materials and methods This study was performed at the EDs of the Johns Hopkins Bayview and the University of Maryland medical centers. The descriptions of the study sites and criteria for enrollment are summarized in the first paper written about this study [12]. All procedures were reviewed and approved in advance by the institutional review boards of both study sites. 2.1. Patient questionnaire Subjects completed a self-administered anonymous survey. This survey included questions to elicit socioeconomic and demographic data, health care utilization, contraceptive use and sexual behaviors and the reason for coming to the ED. Socioeconomic status was divided into five categories by income level. Health care utilization was measured by frequent ED use (defined as two or more visits in the last year) and regular source of care. We defined contraceptive access preference from a multiple choice question, bWhere would you like to be able to obtain birth control (circle all that apply)? Q to which the possible answers were bdoctor’s office,Q bpharmacy,Q bschool,Q bemergency room,Q bchurch,Q bcommunity centerQ and bother.Q Acceptability of the ED was retested with a separate question, from which a pooled group was analyzed for indicators of acceptability. Comfort obtaining contraception without a pelvic examination was also assessed. 2.2. Data analysis The sample size at each site was sufficient to detect a 10% intersite difference ( power= 80). Crude odds ratios (ORs) were obtained for alternative contraceptive provision sites, ED acceptability and contraceptive provision without pelvic examination by univariate logistic regression to determine an association between these variables of interest, with the exception of unintended pregnancy risk (pooled). This factor was considered both individually and also pooled with those dissatisfied with their current method to increase capture of those at risk for unintended pregnancy [15]. We then tested
All patients Bayview University n = 628, (%) n = 334, (%) of Maryland n = 294, (%)
Doctor’s office 514 Pharmacy 229 Emergency room 201 School 96 Church 49 Community center 106 Other 15 Total 1210
(42.5) (18.9) (16.6) (7.9) (4.0) (8.8) (1.2) (100)
276 131 99 59 29 64 5 663
Intersite p
the associations for acceptability of contraceptive provision in the ED and obtaining contraception without a pelvic examination by multiple logistic regression analysis, calculating adjusted OR and 95% confidence intervals (CIs); all associated variables were included in this model. Data analysis was performed using a standard statistical software (Stata 7.0, College Station, TX, USA). 3. Results The study populations were compared to assess whether each sample was reflective of its site’s population. For the Bayview sample, there was no difference in the ethnic group (p =.428) but it was more likely to have insurance (31.6% vs. 37.47%; p =.02). For the University of Maryland sample, the proportion of the nonspecified racial group (p b.001) and African Americans (p =.03) was significantly different but insurance possession was not ( p =.97). Some patients approached declined entry or were not eligible (never sexually active or homosexual): 12.4% declined and 13.4% were not eligible. Age was the only Table 3 Univariate analysis of acceptability of contraceptive provision in the ED
Table 1 Contraceptive provision preferences Source
41
(41.6) (19.8) (14.9) (8.9) (4.4) (9.7) (0.8) (100)
238 98 102 37 20 42 10 547
(43.5) (17.9) (18.6) (6.8) (3.7) (7.7) (1.8) (100)
n represents the number of patients contributing to the total number of responses. Figures in parentheses are percentage values.
Variable
Patients, % p, Crude OR, (95% CI)
All patients Risk for unintended pregnancy Pooled risk for unintended pregnancy Uninsured status Low income Young age Lack of primary care provider Frequent ED use
44.0 47.5
N/A .051 .315, 0.83 (0.58 – 1.19) .939
54.1
b .001, 1.94 (1.44 – 2.61) .508
50.6 46.8 46.8 50.2 51.0
.012, .060, .384, .004,
1.49 1.35 0.83 1.53
Intersite p
(1.09–2.03) (0.99–1.85) (0.55–1.25) (1.15–2.05)
.173 .180 .896 .651
b .001, 1.75 (1.31–2.34)
.117
42
C.S. Todd et al. / Contraception 71 (2005) 40 – 44
variable assessed in those approached and not entering the study; those who declined did not differ significantly and those ineligible tended to be of younger age. Contraceptive provision was acceptable at a variety of locations; a doctor’s office was mentioned most frequently as acceptable, with the pharmacy and the ED as the next most acceptable sites (Table 1). The distribution of responses was not significantly different between ED sites by Pearson’s chi-square (p = .147). Patients stating that they desired a source other than a physician’s office were analyzed separately; they composed 57.2% of the study population. Overall, patients desiring an unconventional contraceptive source were significantly more likely to be uninsured and without a regular health care provider (Table 2); the relationship for those without a regular provider remained significant in adjusted logistic regression modeling (OR = 1.93; 95% CI, 1.19 –3.13; p =.008). The ED was acceptable as a source for obtaining contraception or related information to 44.0% of patients. Those who found the ED acceptable were significantly more likely to be at risk for unintended pregnancy ( pooled with those dissatisfied with their contraceptive method), uninsured, without a regular medical provider and frequent ED users (Table 3). In adjusted logistic regression analysis, significant relationships persisted for frequent ED users ( p= .003) and those at pooled risk for unintended pregnancy ( pb .001), while it was emerging for those at risk for unintended pregnancy (p =.024). Patients at the University of Maryland site were marginally more likely to prefer this site (p = .051).
Table 4 Univariate analysis of acceptability of contraception without pelvic examination Variable
Patients, % p, OR, (95% CI)
All patients Risk for unintended pregnancy Pooled risk for unintended pregnancy and dissatisfaction with contraceptive method Uninsured status Low income Young age Lack of primary care provider Frequent ED use Contraception acceptable in ED
34.0 38.6
N/A .706, 0.93 (0.64 –1.36)
.321 .310
40.0
.021, 1.45 (1.06 –1.98)
.645
36.7 35.8 41.2 35.2
.313, .042, .100, .550,
a
35.2 44.9
1.18 1.42 0.70 1.10
Intersite p
(0.85 –1.64) 1.000 (1.01–1.99) .761 (.455 –1.07) .103 (0.81–1.50) .219
.562, 1.10 (0.81–1.49) b .01, 2.33 (1.7–3.2)
.022a .035b
This significant interaction value indicated that the effect of this covariate is different at the two locations. Stratified values are as follows: for Bayview, 0.80 (0.52–1.21); for University of Maryland, 1.66 (1.04 –2.64). b This significant interaction value indicated that the effect of this covariate is different at the two locations. Stratified values are as follows: for Bayview, 2.18 (1.42–3.34); for University of Maryland, 2.72 (1.68 – 4.42).
Of all patients, 34.0% felt safe receiving contraception without a pelvic examination. Those patients were more likely to have low income and be in the pooled risk group (Table 4). However, among patients seen at the University of Maryland, frequent ED users were comfortable receiving contraception without a pelvic examination, differing significantly from the patients seen at the Bayview site (Table 4). Pooled risk for unintended pregnancy remained marginally significant (p =.058) in adjusted logistic regression models. An analysis performed with the subset of patients desiring contraception in the ED found this group significantly more likely to be comfortable receiving contraception without a pelvic examination, a relationship that persisted and strengthened in multivariate analysis (univariate, OR = 2.33, CI, 1.7– 3.2; multivariate, OR = 2.52, CI, 1.68 –3.77). Despite a significant site interaction, the direction of the association was consistent across sites (Table 4). 4. Discussion To our knowledge, there have been no prior published reports on the acceptability of the ED for contraceptive provision. While a bphysician’s officeQ was the most frequent answer provided for individual sites, this location may not be an option for many patients surveyed, as denoted by 57.2% of the subjects who preferred nonconventional sites. This association is further supported by the significant relationship of lack of a care provider with unintended pregnancy risk, the desire for an unconventional contraceptive provision site and the desire for contraceptive provision in the ED. While the relationship of contraceptive provision in the ED has not been supported by other studies, lack of a primary provider and use of a nonconventional site were characteristics of the First Stop population, which was at significantly greater risk for unintended pregnancy (23%) than the general population [11]. This study did not assess whether clients preferred to receive care at the nontraditional provision sites, but 92% of the subjects stated that they would recommend the service [11]. Within the ED population, women at risk for unintended pregnancy were not more likely to prefer a nontraditional contraceptive provision site (although they were more likely to prefer the ED specifically and obtaining contraception without a pelvic examination). Because more than half of the population favored a nonconventional site, the difference between those at risk and those not at risk for unintended pregnancy was less marked, as opposed to preference for the ED. This result may have achieved significance with a larger sample size. Possession of health insurance was not related to increased unintended pregnancy risk but was related to preference of nontraditional contraceptive provision sites, the ED as a provision site and comfort obtaining contraception without a pelvic examination. This disparity may be due to the uninsured individuals’ consciousness of the absence of a regular care site. However, low income was not
C.S. Todd et al. / Contraception 71 (2005) 40 – 44
significantly related to nontraditional sites of contraceptive provision, including the ED, although it was related to unintended pregnancy risk. A study composed solely of low-income women verified increased risk but did not assess whether access affected risk. This study did reveal that a large proportion of low-income women had beliefs interfering with correct contraceptive use [8]. Our study did not assess patient perceptions regarding proper use of contraception or barriers to access. We did assess whether the patients believed that they were at risk for unintended pregnancy, and this did not correlate with their actual risk status (p b.001). It is possible that some of the beliefs of low-income women may prevent them from accepting the concept of obtaining contraception in a nontraditional setting. This topic should be assessed by further research on the ED population. Were contraception to be provided in the ED, one factor influencing its acceptability may be the perceived need for pelvic examination. A pelvic examination does not provide information that precludes many forms of contraception such as highly effective hormonal methods [11,16]. Overall, 34% of the patients, particularly those in the lowest-income group, those at increased unintended pregnancy risk and those of young age (relationships did not persist in the multivariate model), believed that it was safe to obtain contraception without a pelvic examination. Harper et al. [11] found a much higher proportion, particularly composed of older and Hispanic women, supporting contraception without pelvic examination although in a very dissimilar patient population and in a population that was offered contraceptive services at the time of interview. Further studies are needed before definite predictive factors for this preference can be concluded, and these will likely be population dependent. There are some limitations to this study. Bias may have been introduced through the sampling scheme (convenience rather than random sampling) or through some patients’ refusal to participate. We acknowledge that asking the population already in the ED if the ED is an acceptable site may have produced a falsely elevated positive response rate due to the power of suggestion; however, this facility sees a population at greater unintended pregnancy risk in a potential setting for intervention and this choice may be the logical one for this population, regardless of whether a patient had been consciously aware of it. Additionally, the response rate for those feeling safe receiving contraception without a pelvic examination may be falsely elevated as this population has less access to routine services or may have other reasons for wanting to avoid pelvic examination, which were not solicited in this study. The ED was not intended for contraceptive provision but represents a logical choice for this service. Family planning and sexually transmitted infection (STI) needs could be served by a designated care provider in an adjoining facility with hours compatible to those most in need of services. Provision of emergency contraception by other sources has
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been noted to decrease ED visits for that purpose in one setting [17]; this effect might also be seen for provision of family planning and STI services. The need for STI services in a Baltimore ED setting has been established [18,19], and a program of this nature would make follow-up services possible. Such a program could positively impact both patient overcrowding and reproductive health care for this population and deserves further study.
Acknowledgments We would like to thank Carol Hill (Johns Hopkins Bayview) and Colleen Reilly (University of Maryland) for their assistance with site data procurement, Geoffrey Mountvarner, M.D., for his assistance with data collection and Susan Shappert, M.S., for her assistance with special subsets of National Hospital Ambulatory Medical Care Survey data. We thank Charlotte Ellertson, Ph.D., and Arik Marcell, M.D., M.P.H., for their critical evaluation of presented data. We are deeply grateful to Laurie S. Zabin, Ph.D., for her guidance and shared wisdom throughout this project. We also thank the American College of Obstetrics and Gynecology Development Fund for making this project possible. References [1] Henshaw SK. Unintended pregnancy in the United States. Fam Plan Perspect 1998;30:24 – 29, 46. [2] Kasper JD, Giovannini TA, Hoffman C. Gaining and losing health insurance: strengthening the evidence for effects on access to care and health outcomes. Med Care Res Rev 2000;57:298 – 325. [3] Bloom B, Simpson G, Cohen RA, Parsons PE. Access to health care. Part 2: working-age adults. Vital Health Stat 10 1997;197:1 – 47. [4] Mann C, Hudman J, Salganicoff A, Folsom A. Five years later: poor women’s health care coverage after welfare reform. J Am Med Womens Assoc 2002;57:16 – 22. [5] Finer LB, Darroch JE, Frost JJ. U.S. agencies providing publicly funded contraceptive services in 1999. Perspect Sex Reprod Health 2002;34:15 – 24. [6] Frost JJ. Public or private providers? U.S. women’s use of reproductive health services. Fam Plan Perspect 2001;33:4 – 12. [7] Dailard C. Challenges facing family planning clinics and Title X. Guttmacher Rep Public Policy 2001;4(2). Available at: http:// www.guttmacher.org/pubs/tgr/04/2/gr040208.html. [8] Forrest JD, Frost JJ. The family planning attitudes and experiences of low-income women. Fam Plan Perspect 1996;28:246–55, 277. [9] Philiber S, Williams Kaye J, Herrling S, West E. Preventing pregnancy and improving health care access among teenagers: an evaluation of the Children’s Aid Society– Carrera Program. Perspect Sex Reprod Health 2002;34:244. [10] Zabin LS, Hirsch MB, Street R, Emerson MR, Smith M, Hardy JB, et al. The Baltimore Pregnancy Prevention Program for urban teenagers. I: how did it work? Fam Plan Perspect 1988;20: 182 – 7. [11] Harper C, Balistreri E, Boggess J, Leon K, Darney P. Provision of hormonal contraceptives without a mandatory pelvic examination: the First Stop Demonstration Project. Fam Plan Perspect 2001; 33:13 – 8. [12] Todd CS, Mountvarner G, Lichenstein R. Unintended pregnancy risk in an emergency department population. Contraception 2005; 71:35 – 9.
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hormonal contraception: current practice vs evidence. JAMA 2001; 286:671 – 2. [17] Kerins M, Maguire E, Fahey DK, Glucksman E. Emergency contraception. Has over the counter availability reduced attendances at emergency departments? Emerg Med J 2004;21:67 – 8. [18] Mehta SD, Rothman RE, Kelen GD, Quinn TC, Zenilman JM. Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention. Sex Transm Dis 2001;28:33 – 9. [19] Mehta SD, Rothman RE, Kelen GD, Quinn TC, Zenilman JM. Clinical aspects of diagnosis of gonorrhea and Chlamydia infection in an acute care setting. Clin Infect Dis 2001;32:655 – 9.