Patterns of use of emergency and oral contraceptives from an online service in the United Kingdom during the COVID-19 pandemic: A quantitative study of routinely collected data.

OBJECTIVES: Our study aimed to describe users of a free online contraception service, compare online emergency contraceptive pill (ECP) users with online oral contraceptive (OC) users, and describe patterns of use of online ECP and OC over time, including transition from ECP to more effective forms of contraception. STUDY DESIGN: Analysis of routinely collected, anonymized data from a large, publicly funded, online contraceptive service in the United Kingdom from April 1, 2019 to October 31, 2021. RESULTS: The online service provided 77,447 prescriptions during the study period. About 84% for OC and 16% for ECP, of which 89% were ulipristal acetate. ECP users were younger, lived in more deprived areas, and were less likely to be of white ethnicity than OC users. About 53% ordered OC only, but 37% ordered both ECP and OC. Among those prescribed both OC and ECP (n = 1306), 40% had one method as dominant, 25% appeared to move from one method to the other (11% ECP to OC, 14% OC to ECP), and 35% continued to use both methods. CONCLUSIONS: Online services are accessible to diverse young populations. While the majority of users order OC only, our study suggests that where there is free, online access to both OC and ECP, and those ordering ECP are always offered free OC, transition to more effective ongoing forms of contraception is uncommon. Further research is needed to understand whether online access to ECP increases its attractiveness and reduces likelihood of transition to OC. IMPLICATIONS: This study demonstrates that free, online contraceptive services are accessible to ethnically and socioeconomically diverse users. It identifies a subgroup of contraceptive users who combine use of OC and ECPs over time, and suggests that improved access to ECP may alter contraceptive choices.

School-going adolescent girls' preferences and views of family planning services in Phalombe district, Malawi: A descriptive, cross-sectional study.

BACKGROUND: Low uptake of family planning services by adolescent girls remains a public health concern. An estimated 120 out of every 1,000 girls aged 15 to 19 years are having unplanned pregnancies in the sub-Saharan region. Between January and June 2020, the Phalombe District of Malawi reported 3,030 adolescent pregnancies. At this stage, most Malawian schools were closed due to the COVID-19 pandemic. The high rate of adolescent pregnancies prompted the Ministry of Health to provide emergency contraceptives to reduce the number of unplanned pregnancies among adolescents. The provision of emergency contraceptives would be effective if girls were willing and able to access these family planning services. We thus explored the views of school-going adolescent girls regarding their preferences for modern family planning methods including emergency contraceptives in Phalombe, Malawi. METHODS: This was a cross-sectional, descriptive study, where quantitative data were collected using a structured questionnaire. Participants included randomly sampled school-going adolescent girls from eight purposively selected secondary schools and eight randomly selected primary schools. All the schools were sampled from three purposively selected Traditional Authorities namely Nkhulambe, Jenala and Nkhumba which had reported high numbers of adolescent pregnancies. We analyzed the GeoPoints for schools and health facilities using ArcGIS, while adolescent girls' views were analyzed using STATA. RESULTS: Participants included 388 adolescent girls, ranging in age from 10 to 19 years (median age = 15.5 years, SD = 1.9 years). Participants were hesitant to use contraceptives because they were afraid of being stigmatized and embarrassed, had to travel long distances to reach the service center, knew little about modern family planning and were afraid of medical complications. CONCLUSION: The uptake of family planning services by adolescent girls can be improved by bringing healthcare services closer to schools and homes. Family planning services should employ health workers who are non-judgmental and who are able to remove the stigma associated with family planning. Health workers should at any given opportunity, address the misconceptions and beliefs that adolescents have towards contraceptives. Community sensitization and health talks should be done to improve adolescent girls' understanding of family planning services.

Over-the-counter provision of emergency contraceptive pills: a systematic review.

OBJECTIVE: To synthesise evidence around over-the-counter (OTC) emergency contraceptive pills (ECPs) to expand the evidence base on self-care interventions. DESIGN: Systematic review (PROSPERO# CRD42021231625). ELIGIBILITY CRITERIA: We included publications comparing OTC or pharmacy-access ECP with prescription-only ECPs and measuring ECP uptake, correct use, unintended pregnancy, abortion, sexual practices/behaviour, self-efficacy and side-effects/harms. We also reviewed studies assessing values/preferences and costs of OTC ECPs. DATA SOURCES: We searched PubMed, CINAL, LILACS, EMBASE, clinicaltrials.gov, WHO International Clinical Trials Registry Platform, Pan African Clinical Trials Registry, Australian New Zealand Clinical Trials Registry, Cochrane Fertility Regulation and International Consortium for Emergency Contraception through 2 December 2020. RISK OF BIAS: For trials, we used Cochrane Collaboration's tool for assessing risk of bias; for other studies, we used the Evidence Project risk of bias tool. DATA EXTRACTION AND SYNTHESIS: We summarised data in duplicate using Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence Profile tables, reporting findings by study design and outcome. We qualitatively synthesised values/preferences and cost data. RESULTS: We included 19 studies evaluating effectiveness of OTC ECP, 56 on values/preferences and 3 on costs. All studies except one were from high-income and middle-income settings. Broadly, there were no differences in overall ECP use, pregnancy or sexual behaviour, but an increase in timely ECP use, when comparing OTC or pharmacy ECP to prescription-only ECP groups. Studies showed similar/lower abortion rates in areas with pharmacy availability of ECPs. Users and providers generally supported OTC ECPs; decisions for use were influenced by privacy/confidentiality, convenience, and cost. Three modelling studies found pharmacy-access ECPs would lower health sector costs. CONCLUSION: OTC ECPs are feasible and acceptable. They may increase access to and timely use of effective contraception. Existing evidence suggests OTC ECPs do not substantively change reproductive health outcomes. Future studies should examine OTC ECP's impacts on user costs, among key subgroups and in low-resource settings.