Limited impact of an intervention regarding emergency contraceptive pills in Sweden--repeated surveys among abortion applicants.

OBJECTIVE: To evaluate a community-based intervention consisting of an information campaign and advance provision of emergency contraceptive pills (ECP) to abortion applicants. METHODS: Submission of repeated waiting room questionnaires to abortion applicants in two cities in mid-Sweden; one intervention city (IC) and one comparison city (CC) in 2002 (IC = 92, CC = 95) and 2003 (IC = 244, CC = 204). RESULTS: The overall response rate was 90%. The percentage of women who had undergone an abortion within the previous year had decreased in the intervention group but not in the comparison group. Almost two-thirds (63%) of the targeted women had noticed the information campaign and one out of three (33%) who had visited a family planning clinic recalled being given information about ECP. There was a small decline in the use of combined oral contraceptives and intrauterine devices over time. After the intervention, women in the intervention city had better knowledge of ECP and had used it more than women in the comparison city did. CONCLUSIONS: More than half of the targeted women had noticed the information campaign and it may have had a limited impact. Further investigations are needed to determine whether advance supply of ECP to abortion applicants can reduce repeat abortions.     

Advance supply of emergency contraception. effect on use and usual contraception--a randomized trial

OBJECTIVE: To evaluate whether advance provision of emergency contraception increases its use and/or adversely affects usual contraceptive practices. METHODS: We performed a randomized controlled trial comparing advance provision of emergency contraception with usual care in 370 postpartum women from an inner-city public hospital. Participants were followed for 1 year; 85% were available for at least one follow-up session. All participants received routine contraceptive education. The intervention group received a supply of emergency contraception (eight oral contraceptive pills containing 0.15 mg of levonorgestrel and 30 microg of ethinyl estradiol) and a 5-minute educational session. We compared use of emergency contraception and changes in contraceptive behaviors between groups. RESULTS: Women provided with pills were four times as likely to have used emergency contraception as women in the control group over the course of the year (17% versus 4%; relative risk [RR] 4.0; 95% confidence interval [CI] 1.8, 9.0). Women were no more likely to have changed to a less effective method of birth control (30% versus 33%; RR 0.92; 95% CI 0.63, 1.3), or to be using contraception less consistently (18% versus 25%; RR 0.74; 95% CI 0.45, 1.2). About half of each group reported at least one episode of unprotected intercourse during follow-up, but women who received emergency contraception were six times as likely to have used it (25% versus 4%; RR 5.8; 95% CI 2.1, 16.4). CONCLUSION: Advance provision of emergency contraception significantly increased use without adversely affecting use of routine contraception. It is safe and appropriate to provide emergency contraception to all postpartum women before discharge from the hospital.     

Limited impact of an intervention regarding emergency contraceptive pills in Sweden—repeated surveys among abortion applicants

Objective?To evaluate a community-based intervention consisting of an information campaign and advance provision of emergency contraceptive pills (ECP) to abortion applicants.

Methods Submission of repeated waiting room questionnaires to abortion applicants in two cities in mid-Sweden; one intervention city (IC) and one comparison city (CC) in 2002 (IC = 92, CC = 95) and 2003 (IC = 244, CC = 204).

Results?The overall response rate was 90%. The percentage of women who had undergone an abortion within the previous year had decreased in the intervention group but not in the comparison group. Almost two-thirds (63%) of the targeted women had noticed the information campaign and one out of three (33%) who had visited a family planning clinic recalled being given information about ECP. There was a small decline in the use of combined oral contraceptives and intrauterine devices over time. After the intervention, women in the intervention city had better knowledge of ECP and had used it more than women in the comparison city did.

Conclusions?More than half of the targeted women had noticed the information campaign and it may have had a limited impact. Further investigations are needed to determine whether advance supply of ECP to abortion applicants can reduce repeat abortions.     

Impact of increased access to emergency contraceptive pills: a randomized controlled trial

OBJECTIVE: To assess how a strategy to maximize access to emergency contraceptive pills would affect rates of pregnancy and sexually transmitted infections. METHODS: Sexually active women, 14-24 years old, were randomly assigned to two methods of access to emergency contraceptive pills: increased access (two packages of pills dispensed in advance with unlimited resupply at no charge) or standard access (pills dispensed when needed at usual charges). Participants were followed for 1 year to assess incidence of pregnancy, gonorrhea, chlamydia, and trichomonas. RESULTS: The numbers of women enrolled in the increased and standard access groups were 746 and 744, respectively. More than 93% of participants completed a full year of follow-up. The incidence of pregnancy was similar in both groups (increased access group: 9.9/100 woman years, 95% confidence interval [CI] 7.7-12.6; standard access group: 10.5/100 woman years, 95% CI 8.2-13.2). Aggregate rates of gonorrhea, chlamydia, and trichomonas were also similar in the two groups (increased access group: 6.9/100 woman years, 95% CI 5.1-9.1; standard access group: 7.6/100 woman years, 95% CI 5.7-9.9). The increased access group used emergency contraceptive pills substantially more often and sooner after coitus than the standard access group. No other differences were noted between groups in self-reported measures of sexual behavior and contraceptive use. CONCLUSION: This intensive strategy to enhance access to emergency contraceptive pills substantially increased use of the method and had no adverse impact on risk of sexually transmitted infections. However, it did not show benefit in decreasing pregnancy rates. LEVEL OF EVIDENCE: II-1.     

Increased sexual risk taking behavior among Swedish female university students: repeated cross-sectional surveys

BACKGROUND: The aim of this study was to perform a repeated cross-sectional study of female university students' sexual and contraceptive behavior, as well as experiences of pornography and sexual harassment and compare the findings with those from earlier studies. METHODS: Waiting-room questionnaires to female university students (n = 315) visiting a Student Health Centre in Sweden. Similar investigations had been performed earlier, which enabled comparisons. RESULTS: Almost all women (98%) had experienced intercourse and giving oral sex (94%). Condoms were most often used at first intercourse (72%) and combined oral contraceptives at latest intercourse (67%). The ever use of emergency contraceptive pills had increased from 22% to 52% over five years and there was a tendency towards more risk-taking behavior with more sexual partners (mean 5.4 in 1999 and mean 7.4 in 2004), more experience of first-date intercourse without a condom (37-45%), and more self-reported sexually transmitted infections (14-21%). The proportion of women who had undergone an abortion remained stable (6%) and fewer women reported ever being sexually harassed in 2004 compared to 1999. CONCLUSIONS: In conclusion, contraceptive use remained stable over time, but there was a trend towards more risky sexual behavior with more sexual partners, more unprotected first-date intercourse, and more self-reported sexually transmitted infections. Induced abortions, however, had not increased, but the use of emergency contraceptive pills had more than doubled in the five years between 1999 and 2004.     

A survey of knowledge, attitudes and practices relating to emergency contraception among health workers in Manisa, Turkey

OBJECTIVE: to determine knowledge, attitudes and practices relating to emergency contraception among health-care providers (general practitioners, nurses and midwives). DESIGN: a cross-sectional design using face-to-face interview methods plus questionnaire in the work setting. Researchers were able to maintain privacy by using priority strategies. SETTING: 18 primary health-care units in Manisa, western Turkey. SAMPLE: 182 health-care providers (general practitioners [n = 72]; nurses and midwives [n = 110] were invited to participate in the study, but 26 of them declined. PARTICIPANTS: 156 health-care providers. As 16 participants had not heard of emergency contraception, 140 health-care providers (general practitioners [n = 51] and nurses and midwives [n = 89]) were included. FINDINGS: of the health-care providers, almost one in 10 was unfamiliar with the term 'emergency contraception'. Only a few health-care providers knew how to use the intra-uterine contraceptive device (IUCD) for emergency contraception and the doses of emergency contraceptive pills. Some health-care providers included emergency contraception in routine consultations, but many did not support the use of emergency contraception in Turkey. Many of the providers thought that young people should not know about emergency contraception. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: knowledge among health-care providers about emergency contraception is inadequate. All health-care providers should know about emergency contraception and include it in routine contraceptive consultations. Thus, continuing education information programmes are required. Further research into the knowledge, practices and attitudes of health-care providers is needed to understand the underlying reasons for the hesitant attitudes among health professionals.     

Ectopic gestation following emergency contraception with levonorgestrel

Reports of ectopic gestation after failure of emergency contraceptive pills have thus far been rare, although the use of various types of emergency contraceptive pills is becoming more and more popular world-wide. We report two cases of ectopic gestation following failure of levonorgestrel as over-the-counter emergency contraceptive pills. The women personally purchased the pills over-the-counter at a drugstore and took them routinely. Clinicians should be aware of the possibility of an ectopic gestation when an emergency contraceptive pill fails. We recommend to women the full use of established service networks to enhance education and dissemination of information on emergency contraception. Additionally, health providers should advise women very clearly that, if treatment fails, pregnancy could occur, including ectopic gestation.     

Ectopic gestation following emergency contraception with levonorgestrel.

Reports of ectopic gestation after failure of emergency contraceptive pills have thus far been rare, although the use of various types of emergency contraceptive pills is becoming more and more popular world-wide. We report two cases of ectopic gestation following failure of levonorgestrel as over-the-counter emergency contraceptive pills. The women personally purchased the pills over-the-counter at a drugstore and took them routinely. Clinicians should be aware of the possibility of an ectopic gestation when an emergency contraceptive pill fails. We recommend to women the full use of established service networks to enhance education and dissemination of information on emergency contraception. Additionally, health providers should advise women very clearly that, if treatment fails, pregnancy could occur, including ectopic gestation.     

Attitudes towards contraception in three different populations

OBJECTIVE: To investigate contraceptive behavior of women belonging to three different ethnic and/or socioeconomic populations as well as to evaluate the main sources of information concerning contraception in each population. METHODS: 150 Muslim women living in Germany (group A), 120 Muslim women living in Thrace, Greece (group B) and 140 Christian Orthodox women living in Thrace, Greece were enrolled in the study. Attitudes concerning contraceptive practices were assessed by means of a questionnaire. Demographic and socioeconomic characteristics of each group were compared with the method of contraception used. Statistical analysis was performed using one-way analysis of variance (ANOVA), followed by Turkey's test, chi-square test and multiple logistic regression analysis. RESULTS: The contraceptive pill (41.7%), the condom (35.1%), periodic abstinence (24.4%) and interrupted coitus were the most common methods of contraception. The gynecologist (23.4%), the family consultant (12.0%) and the sexual partner (10.2%) were the most usual sources of information. The use of contraceptive pills was more frequent among Muslims from Germany and Christians from Greece (p < 0.001), while the use of condoms was more frequent among Christians from Greece (p = 0.019). The use of IUDs was more frequent among Muslims from Germany and Greece (p = 0.039). CONCLUSIONS: Our study results reveal that there are behavioral differences between race/ethnic groups and minorities regarding contraceptive practices, probably due to different cultural, socioeconomic and educational factors.     

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

Objective To investigate the knowledge, experiences and attitudes towards emergency contraceptive pills (ECP) among women presenting for induced abortion.
Design Survey by self-administered waiting room questionnaires.
Setting Three large hospitals in the cities of Uppsala, Västerås and Örebro in Sweden.
Population 591 Swedish-speaking women consecutively attending the clinics for an induced abortion during a four-month period in 2000.
Results The response rate was 88% (   n = 518  ). As many as 43% had a history of one or more previous abortions and 43% were daily smokers. Four out of five women, 83%, were aware of ECP, but only 15 women used it to prevent this pregnancy. Fewer, 38%, knew the recommended timeframes for use and 54% had knowledge of the mode of action. The two most common sources of information about ECP were media and friends. One out of five, 22%, had previously used the method, and at the time of conception, 55% would have taken ECP if it had been available at home, and 52% were positive to having ECP available over the counter.
Conclusions Emergency contraception is well known but is still underused. Lack of awareness of pregnancy risk may be one limiting factor for its use. Making ECP available over the counter may be an important measure towards better availability. Information strategies to the public are needed before ECP will be a widely used back-up method.     

Emergency contraception: randomized comparison of advance provision and information only

OBJECTIVE: To determine whether multiple courses of emergency contraceptive therapy supplied in advance of need would tempt women using barrier methods to take risks with their more effective ongoing contraceptive methods. METHODS: We randomly assigned 411 condom users attending an urban family planning clinic in Pune, India, to receive either information about emergency contraception along with three courses of therapy to keep in case of need, or to receive only information, including that about the locations where they could obtain emergency contraception if needed. For up to 1 year, women returned quarterly for follow-up, answering questions about unprotected intercourse, emergency contraceptive use, pregnancies, sexually transmitted infections, and acceptability. RESULTS: Women given advance supplies reported unprotected intercourse at rates nearly identical to those among women given only information (0.012 versus 0.016 acts per month). Among those who did have unprotected intercourse, however, supply recipients were nearly twice as likely (79% versus 44%) to have taken emergency contraception, although numbers were too small to permit statistically significant inferences. No women used emergency contraception more than once during the study, even though everyone in the advance-supplies group had extra doses available. All women found knowing about emergency contraception useful, and all those receiving only information wished they had received supplies as well. CONCLUSION: Multiple emergency contraception doses supplied in advance did not tempt condom users to risk unprotected intercourse. After unprotected intercourse, however, those with pills on hand used them more often. Women found advance provision useful.     

"Actual use" study of emergency contraceptive pills provided in a simulated over-the-counter manner

OBJECTIVE: To evaluate use of an emergency contraceptive pill product dispensed under simulated over-the-counter conditions. Secondary objectives were to assess repeat use, pregnancy, and adverse events. METHODS: The study was conducted at family planning clinics and pharmacies in the United States. During enrollment, these facilities did not provide unsolicited counseling about or evaluations for emergency contraceptive pills. Women who requested emergency contraception were asked to examine a package that was modified for over-the-counter use. A package (levonorgestrel, two 0.75-mg tablets) was provided to each woman who met study criteria and indicated that she wished to receive one. Each subject paid the amount normally charged by the facility for emergency contraceptive pills. Subjects were contacted 1 and 4 weeks later and asked about use of the product, side effects, and pregnancy. RESULTS: Of 665 women screened for the study, 585 received at least one package, and 540 reported having used the product. Of classifiable first uses, 1.3% (97.5% confidence interval [CI] 0.5%, 3%) were contraindicated and 28% (97.5% CI 23%, 32%) were incorrect by strict primary definitions of these inappropriate use patterns, based on the label instructions. Only 6.6% (97.5% CI 4.3%, 9.5%) of classifiable first uses were incorrect by a reasonable alternate definition. Ten subjects received the product more than once, and ten were found to be pregnant during the study. The pattern of adverse events was consistent with findings of previous studies. CONCLUSION: Most women used emergency contraceptive pills appropriately without provider evaluation and counseling.     

Experience with self-administered emergency contraception in a low-income, inner-city family planning program

OBJECTIVE: To evaluate women's use, knowledge of and attitudes toward self-administered emergency contraceptive pills (ECP) at the University of Pennsylvania family planning clinic (FPC). STUDY DESIGN: The University of Pennsylvania FPC is a Title X, publicly funded clinic serving urban, low-income women. All women attending the clinic were offered ECP packets. Exclusion criteria for ECP were current pregnancy or newly diagnosed hypertension. Women signed consent forms and were given specific instructions on using ECP with the standard Yuzpe method. Women were contacted for a phone interview after they had the ECP packets at home for six to eight months. RESULTS: One hundred ninety-two women received the ECP packets. Forty-eight were contacted and completed the survey. One hundred forty-four women had moved, no longer had phone service or were unreachable after three or more attempts. Eleven of the 48 women (22.9%) used the ECP, but only 2 of 11 (18.2%) took the pills correctly. One of these two women became pregnant. Of the women who had not used the ECP packets, only 25 of 37 (67.6%) could locate them, and only 9 of 37 (24%) could recall how to use them correctly. Four of 37 (10.8%) experienced an unplanned pregnancy. CONCLUSION: Emergency contraception utilization was far lower than anticipated, suggesting that ready access is not the only issue. Many of the women did not administer ECP correctly or could not state how they would use it in the future despite extensive instruction. Patients will require new and creative approaches to encourage their appropriate use of emergency contraception.     

Contraceptive applications of estrogen

Estrogens are a primary component of several contraceptive methods: combined oral contraceptive pills, a combined injectable contraceptive, the combined contraceptive vaginal ring, the combination transdermal contraceptive patch, and combined emergency contraceptive pills. Contraceptive formulations that contain estrogen are referred to as combined contraceptives because they also contain some form of progestin. This article reviews the contraceptive methods containing estrogen, beginning with a discussion of combined oral contraceptive pills. Formulations and clinical management, mechanisms of action, noncontraceptive benefits of use, therapeutic uses in addition to contraception, side effects, contraindications to use, and drug-drug interactions are described. Information follows about the newer combined contraceptive products including the injection, vaginal ring, and patch. Finally, combined emergency contraceptive pills are reviewed. Thorough knowledge of the contraceptive methods containing estrogen enables clinicians to provide expert care for women using these products.     

Contraceptive behaviour of teenagers requesting abortion

OBJECTIVE: To examine the contraceptive use of teenage girls requesting abortion. STUDY DESIGN: A questionnaire survey was made concerning contraceptive use, awareness and the attitude toward contraceptives. The Mantel-Haenszel test was applied to compare contraceptive determinants between teenagers (<20 years old) and older women. RESULTS: The use of reliable contraceptive methods was significantly less frequent among the teenagers than among the older counterparts, but this difference was much more significant (P<0.001) between those who requested abortion (OR=0.44) than between the controls (OR=0.51). The knowledge about emergency contraceptive pills was similarly significantly poorer between the teenagers in the abortion group (P<0.001) relative to the older women (OR=0.07) and the teenagers in the control group (OR=0.10). Financial means was not a significant determinant in the choice of contraceptives. CONCLUSION: To prevent unwanted pregnancy among teenagers, the media, the family, the school and health-care providers should focus on sexual education and information.     

Knowledge of emergency contraception among pharmacists and doctors in Durban, South Africa.

OBJECTIVE: To determine the level of knowledge of emergency contraception among private-sector pharmacists and doctors. METHOD: This hand-delivered, confidential questionnaire survey was undertaken in North and South Central Durban, Kwazulu-Natal, South Africa. The main outcome measures were frequency of demand for emergency contraception and knowledge of its dosing schedule, side-effects and contraindications. RESULTS: Ninety-six per cent of pharmacists and 93% of doctors had received requests for emergency contraceptive pills within the past year. Thirty-two per cent of pharmacists and 28% of doctors prescribed the Yuzpe regimen correctly. Only 23 (27%) doctors and 25 (22%) pharmacists were able to identify three common side-effects associated with emergency contraceptive pills. Forty-six per cent of pharmacists and 49% of doctors correctly indicated that there are no absolute contraindications to emergency contraceptive pills other than a contraindication to contraceptive pills. Fifty-four per cent of pharmacists and 35% of doctors agreed that the multiple use of emergency contraceptive pills is risky. CONCLUSION: There is an urgent need to improve the knowledge of health-care workers regarding emergency contraception, which forms an important back-up method when existing contraception fails or is not used.