Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Thursday, December 13, 2007

Advance Provision of Emergency Contraception and its effects on Prevention of Unintended Pregnancies- Diego Martinez-Vasquez,M.D

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution—the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and—thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control (1).

The most recent cycle of the National Survey of Family Growth demonstrates that, despite a reduction in unintended pregnancies among adolescents, college-educated, and higher-income women, 49% of all pregnancies in 2001 (3.1 million) were unintended. Of these unintended pregnancies, 42% ended in abortion. Furthermore, 48% of unintended pregnancies occurred in women who were using contraception during the month of conception (2, 3).

Unintended and teenage pregnancies (49%) are major public health concerns in the United States (see above). Emergency contraception (EC) is used to prevent pregnancy after failure of a contraceptive method or after unprotected intercourse. EC can prevent pregnancy when taken within 120 hours of unprotected intercourse (4). Several types of EC regimens exist, including an estrogen-progestin combination (sometimes called "combined regimen" or "Yuzpe regimen"), levonorgestrel alone (plan B), and mifepristone.

Some clinical trials have been studied the benefits of providing EC in and advance manner (AEC) to facilitate females in their use (4). The idea begin was to determine if when giving AEC can reduce the rates of unintended pregnancy when compared to regular EC. These clinical trials did not showed any benefit in reducing unintended pregnancies in females who received AEC compared to EC.

Contraceptive counseling. A Healthy People 2010 objective is to increase the rate of intended pregnancy to at least 70% of all pregnancies (5). One approach to reducing rates of unintended pregnancy is providing contraceptive counseling during primary care visits. The National Survey of Family Growth defines birth control counseling as “counseling about whether to use birth control methods, how to get them, information about different methods, and how they are used.

EC for a woman, who has unprotected intercourse, requires several steps to reduce the risk of unintended pregnancy. She must perceive that her risk of pregnancy is real and must be motivated to prevent it. She must be aware that a post-coital contraceptive method exists that could reduce her risk of conception. She also must have specific knowledge about how to obtain it and time its administration. She must have access to it, including a place to get it, a way to pay for it, and the time to invest in getting it. Any of those steps can be barriers to actually using emergency contraception after unprotected sex.

One of the current and likely been a very significant barrier to making EC part of routine contraceptive counseling is that providers are unlikely to initiate discussions regarding EC or offer an advance prescription (AEC). One particular barrier to the provision of EC information may be lack of a standardized manner in which to deliver information and the option for EC. Major health organizations and groups, such as the World Health Organization, American College of Obstetrics and Gynecology and the International Consortium for Emergency Contraception, have guidelines regarding key points to be included in EC counseling. However, despite increases, knowledge is still limited and EC provision does not occur in a majority of visits(6).

Contraceptive counseling is defined as a form of interpersonal (as opposed to public) communication. It includes information-giving as well as opportunities for clients (patients) to express their concerns, values, and preferences and to ask questions. Information may be provided through multiple communication channels, and using multiple channels may have a synergistic impact, with written or video material reinforcing oral communication. In health care settings, counseling may include face-to-face discussions between the patient and her provider; group discussions; peer counseling; telephone hot lines or information resource lines; print or video materials made available in information kiosks or resource centers; and telephone or mail follow-ups or reminders. In the case of contraceptive counseling, the goal is to empower women to prevent unintended pregnancy (1, 2, 6).

Counseling is conceived as having three dimensions: 1) exposure refers to whether or not any counseling occurs through any communication channels; 2) content refers to the information imparted during counseling; and 3) personalization refers to the degree to which women’s needs and preferences are addressed. Little research on U.S. populations has addressed the relationship between counseling and contraceptive adoption or continued use (7).

The plausibility of the hypothesis that counseling is associated with contraceptive use is supported by evidence that provider counseling influences women’s use of other preventive tests and interventions. Studies of mammography screening find that one of the most common reasons reported by older women for not obtaining mammograms is that their physicians did not recommend it.

Theories of health behavior attempt to explain how individuals adopt or fail to adopt health-promoting behaviors (e.g., exercise, smoking cessation, use of screening mammography) or maintain those behaviors over time. Theories such as the health belief model, the theory of planned behavior, and the transtheoretical model provide a basis for examining the relationship between contraceptive counseling in the health care setting and contraceptive behavior. These theories recognize that knowledge alone is not sufficient to motivate individuals to adopt health-promoting behaviors and that factors such as values, expectations, and social influences also are important determinants of health behaviors. In addition, these theories draw attention to intervening steps between the acquisition of information and health-promoting behavior, such as building self-efficacy and forming behavioral intent.

The function of counseling in the health care setting can provide information and help clarify the options available to the individual, thus empowering individuals to make informed decisions with respect to their health. Counseling can help alleviate fears about specific options or reduce anxiety about social consequences of options, thus addressing some of the nonrational components of health decision making. Providing information and enabling individuals to cope with their concerns help build self-efficacy for behavior change. Counseling also can help individuals move from one stage of behavior change to another—for example, from the precontemplation stage, in which there is no intent to take action, to the contemplation stage, when an intent is formed to change behavior in the near future—or to maintain a health behavior once adopted.

Increase risky sexual behavior, increasing the risk of pregnancy or sexually transmitted diseases. Several studies have looked into AEC in effort to circumvent some of these obstacles. (8, 9). The studies showed that there is no evidence that suggests that providing AEC causes adolescents to have more unprotected intercourse or less consistent contraceptive use. Indeed, contrary to many health care providers and the public's views, the AEC group participants reported significantly higher condom use. The problem with this studies is that these studies failed to showed reduction in unintended pregnancies when compared to standard access situations (defined as routine contraceptive counseling, provision of information on emergency contraception, or emergency contraception on request) (4).

These trials share a common weakness. Reported information on use of emergency contraception, frequency of unprotected intercourse, and changes in contraceptive patterns was of unknown validity. Since these self reports lacked objective verification, this information should be viewed with caution. Objective evidence indicates that self reports on use of contraceptives other medications are inaccurate, and that self-report of unprotected intercourse is inferior to other ascertainment methods. Some degree of underreporting of pregnancies may have occurred in both the advance provision and control groups in these trials, particularly those trials using only self-reported data. Unintended pregnancies terminated by induced abortion are routinely underreported. However, results from the trials relying on pregnancy testing were consistent with results from the trials using self-reports of pregnancy(4).

None of the adequately powered trials showed difference in pregnancy rates, despite increased use, multiple use and faster use of AEC (4).

This conclusion conflicts with earlier optimistic projections of the potential public health impact of improved access. This intervention could have failed because the way women perceives pregnancy risk or because concerns about side effects, and inconvenience(10, 11).

Health care coverage or insurance. Although men and women have some similar challenges with regard to health insurance, women face unique barriers to becoming insured. More significantly, women have greater difficulty affording health care services even once they are insured. On average, women have lower incomes than men and therefore have greater difficulty paying premiums. Women also are less likely than men to have coverage through their own employer and more likely to obtain coverage through their spouses; are more likely than men to have higher out-of-pocket health care expenses; and use more healthcare services than men and consequently are in greater need of comprehensive coverage. Moreover some females don’t have coverage of prescription contraceptives. The direct medical costs of unintended pregnancies were US$5 billion in 2002 and direct medical cost savings due to contraceptive use were US$19 billion (12, 13).

In summary, advance provision of emergency contraception does not decrease unintended pregnancies nor increase sexual risking behaviors or sexual transmitted diseases. In order to decrease unintended pregnancies using advance provision of emergency contraception, routine and consistent counseling by health providers (physicians, pharmacists, nurse practitioners and physician assistant) in emergency contraception has to be provide to any female who is sexually active. Health behavior models like the health belief model, the theory of planned behavior, the transtheoretical have to be use in combination to assess the specific needs of each patient. Health coverage and insurance has to be taken in account when prescribing or recommending AEC. Overall not having access to medical coverage directly impacts the availability of physicians and health care providers. Moreover new programs have to be implemented to increase access of this population to health care.

Finally more studies need to be performed to asses the use of advance provision of emergency contraception. These studies need to be conducted looking at counseling and behavior model as described above. Nevertheless new programs that facilitated easy access to AEC for uninsured sexually active females have to be implemented through out the federal or state level.

References:

1. Benagiano G, Bastianelli C, Farris M. Contraception today. Ann N Y Acad Sci 2006;1092:1-32.

2. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23 2005(25):1-160.

3. Martinez GM, Chandra A, Abma JC, Jones J, Mosher WD. Fertility, contraception, and fatherhood: data on men and women from cycle 6 (2002) of the 2002 National Survey of Family Growth. Vital Health Stat 23 2006(26):1-142.

4. Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007(2):CD005497.

5. Services DoHAH. Healthy People 2010; 2007 October.

6. Petersen R, Albright JB, Garrett JM, Curtis KM. Acceptance and use of emergency contraception with standardized counseling intervention: results of a randomized controlled trial. Contraception 2007;75(2):119-25.

7. Pisaniello ML. Importance of counseling patients about contraception. Am Fam Physician 2007;75(5):624; author reply 624.

8. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004;17(2):87-96.

9. Raymond EG, Stewart F, Weaver M, Monteith C, Van Der Pol B. Impact of increased access to emergency contraceptive pills: a randomized controlled trial. Obstet Gynecol 2006;108(5):1098-106.

10. Adler NE. Contraception and unwanted pregnancy. Behav Med Update 1984;5(4):28-34.

11. Moreau C, Bouyer J, Goulard H, Bajos N. The remaining barriers to the use of emergency contraception: perception of pregnancy risk by women undergoing induced abortions. Contraception 2005;71(3):202-7.

12. Lindrooth RC, McCullough JS. The effect of Medicaid family planning expansions on unplanned births. Womens Health Issues 2007;17(2):66-74.

13. Trussell J. The cost of unintended pregnancy in the United States. Contraception 2007;75(3):168-70.

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7 Comments:

  • At December 18, 2007 at 6:59 PM , Anonymous Sarah said...

    Diego, this was a really well-written article. I completely agree with the need for doctors to actually counsel patients, this can make a huge difference in a number of health behaviors. But how do you reconcile that with the 8 minute doctor visit? Do you feel rushed in your own practice, and do you counsel your female patients on AEC?

     
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