Consultation patterns and provision of contraception in general practice before teenage pregnancy: case-control study.

OBJECTIVES: To determine patterns of consultation in general practice and provision of contraception before teenage pregnancy. DESIGN: Case-control study, with retrospective analysis of case notes. SETTING: 14 general practices in Trent region. SUBJECTS: 240 registered patients (cases) with a recorded conception before the age of 20. Three controls per case were matched by age and practice. MAIN OUTCOME MEASURES: Consultations in general practice and provision of contraception in the 12 months before conception and recorded provision of contraception at any time before conception. RESULTS: Overall, 223 cases (93%) had consulted a health professional at least once in the year before conception, 171 (71%) had discussed contraception in this time, and 121 (50%) had been prescribed oral contraception. Cases were more likely to have consulted in the year before conception than controls (odds ratio 2. 70, 95% confidence interval 1.56 to 4.66). Most of the difference was owing to consultation for contraception. Overall, 53 cases (22%) resulted in a termination of pregnancy. Cases whose pregnancy ended in a termination were more likely to have received emergency contraception than either their controls (3.21, 1.32 to 7.79) or cases resulting in other outcomes (3.01, 1.06 to 8.51). CONCLUSIONS: Most teenagers who became pregnant attended general practice in the year before pregnancy, and many had sought contraceptive advice. The reluctance of teenagers to attend general practice for contraception may be less than previously supposed. The association between provision of emergency contraception and pregnancy ending in termination emphasises the need for continuing follow up of teenagers consulting for this form of contraception.

PIP: In western Europe, UK has the highest teenage pregnancy rate among 15-19 year olds. Although general practice is one source of provision of contraception, it has been suggested that teenagers are reluctant to seek advice because of difficulty in gaining access and fears about confidentiality. This case-control study determined patterns of consultation in general practice and provision of contraception before teenage pregnancy. A total of 240 cases with a recorded conception before age 20 and 719 matched controls were identified. Overall, results show that most teenagers who became pregnant attended a general practice in the year before pregnancy, and many had sought contraceptive advice. Cases were more likely to have consulted a doctor in the year before conception than controls (odds ratio, 2.70; 95% confidence interval, 1.56-4.66). An association between provision of emergency contraception and pregnancy ending in termination was found. This finding emphasizes the need for continuing follow-up of teenagers consulting for this form of contraception.

Knowledge and willingness to use emergency contraception among low-income post-partum women.

We performed a multivariate analysis to determine factors associated with knowledge and willingness to use emergency contraception in a consecutive sample of 371 post-partum women from an inner-city public hospital. Women were queried about previous contraceptive use, pregnancy history including abortions and unplanned pregnancies, and demographic characteristics. Outcomes included knowledge of emergency contraception and willingness to use it. Questionnaires were conducted in person, in English or Spanish.Of 371 women, 3% had used emergency contraception, 36% had heard of it, and 7% knew the correct timing for use. Two-thirds of the population indicated a willingness to use emergency contraception in the future. Factors positively associated with knowledge included being a teenager or more than 30 years old, prior use of condoms, and history of an elective abortion. Being multiparous, monolingual Spanish-speaking, or Asian were negatively associated with knowledge. Willingness to use emergency contraception was positively associated with being multiparous and negatively associated with a higher income, moral or religious objections to the use of emergency contraception, a belief that it is unsafe or a perception that it is an abortificient. Knowledge about emergency contraception, especially correct timing, remains low. Multiparous women should receive increased education given their lack of knowledge but willingness to use emergency contraception. In order to increase the acceptability of emergency contraception, educational efforts must include accurate information about its mechanism of use and safety.

Provision of emergency contraceptive pills to spermicide users in ghana.

This study evaluated the effect of two approaches to provision of emergency contraceptive pills (ECPs) on ECP use and unprotected intercourse among women relying on spermicides for contraception. The study enrolled 211 women at 4 family planning clinics in Ghana. At two clinics, participants were advised to return to the clinic within 3 days after unprotected intercourse to obtain ECPs. At the other two clinics, participants were given ECPs to take home for use if unprotected intercourse occurred. All participants were asked to maintain daily diaries for 8 weeks to record information on sexual activity, spermicide use, and ECP use. Women at all clinics used ECPs after at least 78% of unprotected coital acts. ECPs were used more promptly by women who had the pills at home. At three of the clinics, at most 1.3% of the coital acts were unprotected; at the fourth, 6.7% were unprotected. Our data did not suggest that the availability of ECPs increased the frequency of unprotected intercourse.

Emergency contraception: a review of the programmatic and social science literature.

Many biomedical aspects of emergency contraception have been investigated and documented for >30 years now. A large number of social science questions, however, remain to be answered. In this article, we review the rapidly growing but geographically lopsided literature on this topic. Using computer database searches supplemented by reference reviews and professional correspondence with those active in the field, we gathered literature on the social science and service delivery aspects of emergency contraception published in English up through December 1998, as well as a few unpublished papers from the same time and slightly later, representing regions where published material is practically nonexistent. Methodologically acceptable papers are summarized in our tables and text, and form the basis for suggested improvements in existing emergency contraceptive services. The review also offers ideas for designing new emergency contraception services where they do not yet exist. We conclude by proposing an agenda for further social science research in this area.

Bust without boom.

PIP: Just like injectables, oral contraceptives (OCs), including progestin-only ¿minipill¿ and ¿morning-after¿ pill regimens, have experienced a bust without a boom. Fear of political and religious backlash over emergency contraceptives containing estrogen and progestin prompted large companies not to market these regimens. Another major factor in the bust phase of OC use and acceptance has been a small coterie of English and American epidemiologists focused on the adverse effects of Ocs, including risks of thrombotic events, heart attacks, and strokes. The media played a crucial role in the bust phase of these OCs. In the UK, the alleged increase of cancer risk with pill use, which leaked before publication in London newspapers, resulted in 50,000 additional unintended pregnancies. Nevertheless, there is no doubt that boom-and-bust cycles will continue simply because many of the actors in this drama have too great a vested interest to desist. Groups involved in this field must recognize the hazards that come with the territory and be proactive, anticipatory, and well armed with facts--and get good with media access. Drug companies should think on a long-term basis the potential effects of leaving the field, as they have done, or shooting down competitive innovations.^ieng

Provider knowledge about emergency contraception in Ghana.

In 1996, the Ministry of Health in Ghana included emergency contraception (EC) in its newly issued National Reproductive Health Service Policy and Standards. A short survey was conducted in the summer of 1997 to evaluate health providers' knowledge of EC. Of the 325 providers interviewed, about one-third (34%) had heard of EC. No provider had sufficient knowledge to prescribe EC correctly. A well-coordinated training programme for providers will have to precede successful introduction of EC in Ghana. Moreover, a dedicated product may be critical for the successful introduction of EC in a country like Ghana, where provider knowledge is low.

PIP: In 1996, the Ministry of Health in Ghana included emergency contraception (EC) in its newly issued National Reproductive Health Service Policy and Standards. This paper reports a short survey conducted to evaluate the success of these early efforts to introduce EC into Ghana and evaluate health providers' knowledge of EC. Short structured interviews were conducted with health care providers at a sample of family planning outlets in two regions of Ghana. Findings revealed that health providers' knowledge about EC is low. Out of the 325 people interviewed, only about one-third (34%) had heard of EC. Furthermore, no provider had sufficient knowledge to prescribe EC correctly. Two policy implications can be drawn from this research: 1) well coordinated training of providers will have to precede a successful introduction of EC in Ghana; 2) a dedicated product may be critical for the successful introduction of EC, where providers' knowledge is low.

"After the Fact, After the Act" spotlights EC.

PIP: The ¿After the Fact, After the Act¿ campaign in Philadelphia promoted emergency contraception (EC) to women through radio advertisements, and distribution of brochures, fliers, and posters. The program was sponsored by the Reproductive Health Technologies Project (RHTP), a nonprofit organization that helps provide public education and build understanding of safe, effective reproductive health technologies for women. Following the radio advertisement campaign, the hotline call volume increased by 110%, compared with 10 weeks prior to the project, and it remained high for several weeks thereafter. Moreover, RHTP conducted focus groups to examine the effectiveness of its existing EC material. The results led to the development of programs for hard-to-reach populations, including low-income urban African Americans.^ieng

The basics of OCs: your peers share insights.

PIP: This article gives basic information about oral contraceptives based on the findings of Contraceptive Technology Update's 2000 Contraception Survey involving family planning providers and clinicians. Most (66%) of the providers surveyed prefer starting patients on pill packs the Sunday after menstruation (¿Sunday start¿ method). A remaining 34% of participants instruct their patients to begin pills on the first day of menses, known as the ¿same day start¿ method. Still others offer their patients the choice: either a ¿same day start¿, a ¿Sunday start¿, or a start on the day of the first visit. In addition, nearly 60% of providers offer printed materials concerning backup contraception to reinforce counseling especially in cases when women experience diarrhea or vomiting. Women should use backup contraception if they: 1) suspect that pills may be less effective; 2) miss taking any of the hormonal pills; 3) are late in starting new pill packs; 4) have severe vomiting or diarrhea; and 5) take medications such as anticonvulsants, that affect absorption of contraceptive hormones. Finally, counseling women on emergency contraception when discussing contraceptive methods is advised.^ieng

Providers make EC readily available.

PIP: This paper presents the findings of the Contraceptive Technology Update 2000 Contraception Survey in the US involving 275 health service providers, which examines the leniency of health care providers in dispensing emergency contraceptive pills (ECPs). According to the survey, three-quarters of the respondents say they prescribe ECPs on-site and provide them at any time. While 41.8% say their facility dispenses standard birth control pills for ECP use, almost 60% say they use products specifically marketed for emergency contraception. In addition, many believe that ECPs should be available over-the-counter (OCT). Advocates for taking emergency contraception OCT are preparing supporting materials for submission to the Food and Drug Administration.^ieng

"EC to go" takes off at Maryland sites.

PIP: Baltimore-based Planned Parenthood of Maryland and the Baltimore City Health Department have joined forces in "EC to Go," which distributes free emergency contraceptive pills (ECPs) through the seven affiliate sites of Planned Parenthood and the three family planning centers of the city. The distribution program was started in October 1999 and funds were provided by an undisclosed area foundation. Although the program is still in its infancy, it has recorded some 800 prescriptions of ECPs in the last fiscal year, and 600 prescriptions have been logged in just the first 6 months of the current fiscal year. To inform the public about the program, Planned Parenthood developed newspaper advertisements, a 60-second radio spot, and coupon distributions, all of which emphasize the fact that emergency contraception is a higher dose of birth control, which can prevent pregnancy if taken within 72 hours of unprotected sex.^ieng

Help patients obtain emergency contraception.

PIP: This article provides a guide to eliminating barriers to women who seek emergency contraception (EC) in health facilities. The guide, intended for health care providers, suggests the use of a role-play staff session to see how the staff will respond when they receive a request for EC over the telephone. It is noted that even if health care providers know about EC, the receptionist and the front-end people do not. Educating patients about how to ask for EC over the telephone is also recommended. Education could be done by giving patients a telephone script which can be included in EC pamphlets so that patients will know how to ask for care when they call the clinic. In addition, patients especially adolescents should be given advance counseling on the common side effects of EC and should be assured of the drug's safety. Aside from making EC available round the clock at health centers, a trial protocol to offer telephone EC prescriptions for new services is also being undertaken.^ieng

Improving access to emergency contraception.

PIP: Reproductive health centers are finding successful ways to improve access to emergency contraceptive pills (ECPs) in an effort to reduce the high rate of unplanned pregnancies in the US. In a study by the Pacific Institute for Women's Health and the Family Planning Council, it was noted that there is a specific need for a clear, concise manual for family planning clinicians that would promote awareness of the method and ease the introduction of ECPs into clinical practice. To this effect, the institute and its partners published the manual, "A Clinician's Guide to Providing Emergency Contraceptive Pills". This manual offers tips on policies, organizational and management issues, staff training, and billing and insurance procedures to clinicians. On the other hand, the Planned Parenthood of Los Angeles designed a campaign in which affiliated clinics offered ECPs to most of their patients to take home with them at the time of their clinic visit. Reports from clinic officials indicate that in the campaign's first month of operation, the number of patients who took home ECPs doubled.^ieng

The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices.

Modern hormonal contraceptives and intrauterine contraceptive devices have multiple biologic effects. Some of them may be the primary mechanism of contraceptive action, whereas others are secondary. For combined oral contraceptives and progestin-only methods, the main mechanisms are ovulation inhibition and changes in the cervical mucus that inhibit sperm penetration. The hormonal methods, particularly the low-dose progestin-only products and emergency contraceptive pills, have effects on the endometrium that, theoretically, could affect implantation. However, no scientific evidence indicates that prevention of implantation actually results from the use of these methods. Once pregnancy begins, none of these methods has an abortifacient action. The precise mechanism of intrauterine contraceptive devices is unclear. Current evidence indicates they exert their primary effect before fertilization, reducing the opportunity of sperm to fertilize an ovum.

PIP: The mechanism of action of contraceptive method is essential for the development of new methods. It also influences cultural and individual acceptability of a contraceptive method. Modern hormonal contraceptives and intrauterine contraceptive devices have multiple biologic effects. Some of them may be the primary mechanism of contraceptive action, whereas others are secondary. For the combined oral contraceptives and progestin-only methods, the main mechanism of action are the inhibition of follicular development, ovulation, and as consequence, corpus luteum formation. Further, it is also involved in the alteration of the cervical mucus that inhibit sperm penetration. For hormonal methods, particularly the low-dose progestin-only products and emergency contraceptive pills have effects on the endometrium that, theoretically, could affect implantation. However, no scientific evidence will indicate that prevention of implantation actually results from the use of these methods. Once implantation has taken place, none of these methods are effective and pregnancy proceeds normally. The precise mechanism of IUDs remains unclear because of difficulties in carrying out relevant investigations in humans and the limitations of extrapolating findings from animal studies. However, several studies evidenced that IUDs exert their primary effect before fertilization, by impeding the ascent of sperm to the fallopian tubes or by reducing the ability of sperm to fertilize an ovum.

Project makes emergency pill more available.

PIP: More than 100 general medical practices in Lothian, Scotland, have agreed to take part in the 2-year research project designed to see if improving the availability of emergency contraception will reduce unplanned pregnancies and lower the abortion rate. At the end of 2 years, the change in the abortion and unplanned pregnancy rate of women attending the 100 general practices will be compared with any change in rates among other practices in the region. Both the BMA and the Royal College of Obstetricians and Gynaecologists have supported moves to make emergency contraception available over the counter in pharmacies. However, this has been strongly resisted in Great Britain by anti-abortion groups and the Catholic Church. Expectations are bright that the project will reduce the number of abortion cases in Lothian by about 15%.^ieng

Knowledge of emergency contraception amongst female patients attending a department of genitourinary medicine.

The aim of the study was to assess the knowledge of emergency contraception amongst new female patients attending an inner-city department of genitourinary medicine. Information was also sought about use of regular contraception and demography. Three hundred and ninety nine questionnaires were suitable for analysis. Half of the sample answered that the latest a woman could take emergency contraception after unprotected sex was three days. None of the sample knew that emergency contraception could be obtained up to five days. Twenty nine per cent of the sample reported sex without contraception during the menstrual cycle preceding attendance. Women who had ever used regular contraception in the past were statistically less likely to have reported unprotected sex in the menstrual cycle preceding attendance (p=0.0000068). Professional women were statistically less likely to have reported unprotected sex in the menstrual cycle preceding the clinic visit. Fourteen per cent of the sample had genital warts at this first clinic visit, 10 per cent had Chlamydia trachomatis, seven per cent had herpes simplex infection, six per cent had gonococcal infection and five per cent had trichomonal infection. Women who reported unprotected sex during the preceding menstrual cycle were not statistically more likely to have a sexually transmitted infection at this first clinic visit. A large number of women attending departments of genitourinary medicine are at risk of both pregnancy and also sexually transmitted infection. Staff working in all areas of sexual health need to have a good knowledge of both contraception and sexually transmitted infections in order to educate the clients on both aspects of unprotected sex.

PIP: 399 questionnaires were analyzed to evaluate the knowledge of emergency contraception among female patients in a genitourinary medicine (GUM) department. The use of regular contraception and demography was also examined. 50% of the sample stated that the latest a woman could take emergency contraception after unprotected sex was 3 days, while none of them knew that emergency contraception could be taken up to 5 days afterwards. 29% admitted having engaged in unprotected sex during the menstrual cycle preceding their clinic visit. On the other hand, women who had ever used regular contraception in the past showed low incidence of unprotected sex in the menstrual cycle prior to attendance at the clinic. Among the sample, 14% had genital warts, 10% had Chlamydia trachomatis, 7% had herpes simplex infection, 6% had gonococcal infection, and 5% had trichomonal infection. This study has revealed that several women attending GUM departments are at risk of both pregnancy and sexually transmitted infection. Therefore, there is a need to provide intensive education regarding contraception and sexually transmitted infections among the female patients attending GUM departments.

Questionnaire study of use of emergency contraception among teenagers.

PIP: This is a report of a survey on the use of emergency contraception among teenagers in Finland. The school health promotion study provided data on adolescent health behaviors. Each of the 52,700 respondents from comprehensive schools and upper secondary schools answered a structured questionnaire. Findings showed that adolescent girls were widely aware of emergency contraception. Only a small proportion of teenagers had actually used emergency contraception. The proportion of girls who had used emergency contraception increased in proportion with age, but among multiple users, there was no evidence that multiple use increased systematically with age. The survey results suggest that accessibility of contraception and intensive sex education has not increased the level of adolescent sexual activity.^ieng

The risk of venous thromboembolism in users of postcoital contraceptive pills.

Postcoital contraceptive pills (PCP) have recently been approved for use as emergency contraception in the United States. The objective of this study was to assess the risk of idiopathic venous thromboembolism (VTE) in relation to exposure to PCP, and to better quantify the risk of idiopathic VTE associated with current oral contraceptive (OC) use and pregnancy. A population-based cohort study with a nested case-control analysis was conducted using women from the General Practice Research Database. There were no women with an outcome of idiopathic VTE with current exposure to PCP. The incidence rates for various exposures were 3.0/100,000 person-years for the unexposed, 5.3/100,000 person-years for second generation OC, 10.7/100,000 person-years for third generation OC, and 15.5/100,000 person-years in pregnant (or postpartum) women. The relative risk estimates were 1.7 (95% CI 0.3-10.5) for second generation OC, 4.4 (95% CI 1.0-18.7) for third generation OC, and 6.3 (95% CI 1.2-33.5) for pregnancy. Short-term use of PCP is not associated with a substantially increased risk for developing VTE.

PIP: A population-based cohort study with a nested case-control analysis was conducted to assess the risk of idiopathic venous thromboembolism (VTE) in relation to exposure to postcoital contraceptive pills (PCP) and to better quantify the risk of idiopathic VTE associated with current oral contraceptive (OC) use and pregnancy. The subjects were women less than 50 years of age who received PCP prescriptions at some time between January 1, 1989, and October 31, 1996. All subjects in the cohort of PCP users had a computer-recorded diagnosis from the General Practice Research Database. The results of the study indicate that there were no women currently exposed to PCP who had an outcome of idiopathic VTE. The incidence rates for various exposures were 3.0/100,000 person-years for those unexposed, 5.3/100,000 person-years for second-generation OCs, 10.7/100,000 person-years for third-generation OCs, and 15.5/100,000 person-years for pregnant (or postpartum) women. The relative risk estimates were 1.7 (95% CI, 0.3-10.5) for second-generation OCs and 4.4 (95% CI, 1.2-33.5) for pregnancy. Thus, the risk of VTE attributable to PCP is not substantially higher than it is for the risk for traditional OCs, despite the higher content of both estrogen and progesterone present in PCP.

Review of newer contraceptive agents.

Advances in contraceptive technology have made birth control more effective, convenient, and safe. We review the newer products and some under development, including the latest oral contraceptives, injectable progesterone, subdermal progestin implants, progesterone-releasing IUDs, emergency contraception, and male contraception.

PIP: This paper reviews the latest developments in oral contraceptives (OCs), long-acting contraceptives such as injectable progesterone, subdermal progestin implants, progesterone-releasing IUDs, emergency contraception, and male contraception. Latest developments of OCs contain much lower doses of estradiol than the older preparations and uses newer progestins with less androgenic activity, thus causing fewer side effects. Depot-medroxyprogesterone acetate injections every 3 months prevent conception by suppressing the luteinizing hormone surge, thereby inhibiting ovulation. These contraceptive options are good for women in whom compliance may be low. Subdermal progestin implants have a failure rate of 0.8/100 woman-years for the first 5 years of use, increasing to 2/100 woman-years by the 6th year. They acts primarily by rendering the cervical mucus impenetrable to sperm. The progesterone-releasing IUDs, on the other hand, induce decidualization of the endometrium, thus inhibiting implantation. Among the postcoital contraceptives briefly discussed in this paper are the combined OCs (ethinyl estradiol and norgestrel), progestin-only compounds, the copper IUD, and mifepristone. The new developments of condoms, which are the mainstay of male contraception, include the new polyurethane condom, which is thinner, stronger, and less allergenic.

Levonorgestrel versus the "Yuzpe" regimen. New choices in emergency contraception.

PIP: A double-blind, randomized controlled trial conducted at 21 centers in 14 countries compared the effectiveness and side effects of the traditional Yuzpe method of emergency contraception (200 mcg of ethinyl estradiol and 1 mg of levonorgestrel divided into 2 equal doses) and levonorgestrel alone (2 doses of 0.75 mg each). 1955 women (979 in the Yuzpe group and 976 in the levonorgestrel group) completed the study. 42 women had subsequent pregnancies, although at least 4 women were pregnant at the time of treatment. The pregnancy rate was 1.1% (95% confidence interval [CI], 0.6-2.0) for the levonorgestrel group and 3.2% (95% CI, 2.2-3.5) for the Yuzpe regimen. The relative risk of pregnancy was 0.36 (95% CI, 0.18-0.70). Levonorgestrel prevented 85% of expected pregnancies while the Yuzpe method prevented only 57%. Efficacy increased when the regimen was initiated within 24 hours and decreased as the time after unprotected intercourse approached 72 hours. Women in the levonorgestrel group reported less nausea, vomiting, dizziness, and fatigue than their counterparts in the Yuzpe group. Overall, 57% of women started bleeding within 3 days of their expected menses and the mean duration of menses of 4.7 days in both groups. Results of this study support use of levonorgestrel alone as an alternative for emergency contraception.^ieng

Emergency contraception: is it time to change method?

PIP: The Yuzpe method of using combined oral contraceptives for emergency contraception has been available for 25 years; prevents 75% of pregnancies that would have occurred if no treatment were used; has an excellent safety record; and is contraindicated only in patients with a history of thromboembolism, migraine at presentation, or a history of migraine with aura. However, this method has side effects of nausea and vomiting, and the World Health Organization recently reported that use of levonorgestrel alone is effective and associated with fewer side effects. No additional research has been conducted on the timing or dosage of the estrogen-progestogen method, but some dose-effectiveness studies have been performed on mifepristone. Mifepristone, however, is not widely available. The levonorgestrel studies found a negative correlation between the interval from unprotected intercourse to treatment and effectiveness but concluded that levonorgestrel was more effective than the combined method (this study found a lower effectiveness for the combined method than previously reported). Given that each method is effective, consideration of whether the new one should be adopted must take into account the fact that the levonorgestrel is currently not licensed for this use, is not prepared in convenient dosages, and is more expensive and less available. Introduction of new methods of emergency contraception should augment choices rather than replace other methods.^ieng