Volume 199, Issue 2 , Pages 111.e1-111.e5, August 2008
Characteristics of women who seek emergency contraception and family planning services
Article Outline
Objective
The purpose of this study was to compare the demographic characteristics and sexual risk behaviors of women who seek emergency contraception (EC) and general family planning (FP) services.
Study Design
This cross-sectional study included 227 women aged 17-43 years who were being evaluated for either EC or FP in an outpatient setting from 2003-2004. Descriptive statistics and odds ratios were included.
Results
The EC group, compared with the FP group, had higher proportions of women with education beyond high school (62% vs 52%; P = .02), and not married (79% vs 42%; P < .01). The groups also differed by age, race, and income. The EC group was more likely to have been unprotected at their last intercourse (odds ratio, 5.56; 95% CI, 2.22, 14.29) and less likely to have a previous sexually transmitted infection (odds ratio, 0.41; 95% CI, 0.17, 0.96).
Conclusion
The development of EC education programs for women is important for increasing awareness for diverse groups of women and their healthcare providers.
Key words: contraception, emergency contraception, sexual risk behavior, women's health
Although distinct prepackaged methods of emergency contraception (EC) have been available in the United States only since 1998, hormonal contraceptive pills have been used “off-label” for emergency pregnancy prevention for >30 years. Albert Yuzpe first described this method to decrease the risk of pregnancy that is associated with a single act of unprotected intercourse in 1974.1 “Plan B” (the levonorgestrel regimen) was approved by the US Food and Drug Administration (FDA) for prescription-only use in the United States in 1999. After much deliberation, the FDA approved “Plan B” for nonprescription purchase for women ≥18 years old in August 2006.2 Women <18 years old will continue to need a prescription to gain access to this contraceptive method. Although EC now is available more widely, it is unclear if use will increase.
EC has significant potential to reduce the burden of unintended pregnancy; however, in general, knowledge and use of EC remain relatively low in the United States. Widespread use of EC could prevent an estimated 1.5 million unintended pregnancies that end in childbirth and 700,000 abortions.3, 4 According to a recent review, many women and healthcare providers are unaware that EC is an option or perceive it as unnecessary.5
Debate over increased access to EC continues, including concerns over the reproductive health and sexual risk behaviors of EC users. Several descriptive studies and studies that investigated the advanced provision of EC discount the claim that access to EC will increase risky sexual behaviors.6, 7, 8 Other studies support the notion that EC users are at higher risk for sexually transmitted infections (STIs) and unwanted pregnancy.9, 10 Contributing to the ambiguity of the literature is the absence of a comparison group in some studies, which has limited the interpretation of their findings.
Educational programs to decrease unintended pregnancies will benefit from an understanding of reproductive health and sexual risk behaviors of women who seek EC and women who seek other contraceptive services to prevent pregnancy. In an effort to inform targeted educational programs, this study evaluates characteristics of women who seek EC and women who seek general family planning services in an urban population with respect to previous unprotected intercourse, previous abortions, previous STI, number of lifetime sexual partners, and age at first intercourse. We hypothesize that there are differences in sexual risk behavior between these groups. The goal of this project was to understand characteristics of these different groups to help focus future contraceptive educational campaigns.
Materials and Methods
As part of a larger study to assess contraceptive attitudes and beliefs, this cross-sectional study included 227 women who were at least 17 years old who sought contraceptive services between January 2003 and April 2004. The convenience sample of 227 women consisted of 2 comparison groups. The first group (n = 114) included women who attended a women's emergency facility that specializes in obstetric and gynecologic services (the Triage Unit) who were seeking EC. The second group (n = 113) included women who attended a walk-in family planning clinic open during traditional business hours (the Women's Primary Care Center Family Planning Unit) seeking any family planning services and who had never used EC. The family planning clinic and the emergency facility are available to all women and are within walking distance of each other. Exclusion criteria were current pregnancy, mental illness, inability to read and write in English or Spanish, and inability to sign the informed consent. In the Triage Unit, candidacy for participation was assessed by trained triage nurses or providers, and informed written consent was obtained. In the Family Planning Unit, candidacy for participation was assessed by trained family planning counselors or providers, who then contacted a member of the study team to meet with the potential participant and obtain informed written consent. Participants received a self-administered, anonymous questionnaire that they completed before receiving any contraceptive counseling. They returned the completed questionnaire to the nurse or provider. Women & Infants Hospital Institutional Review Board approval was obtained before the study was initiated.
We used a 54-item self-administered questionnaire for both groups that included items on general and gynecologic health history, birth control history, sexual history, and demographic background. Each question was pilot tested and assessed for content validity and comprehension. For this study, we considered the following 6 outcomes as indicators of reproductive health and sexual risk behavior: (1) ever having unprotected intercourse, (2) ever having an STI, (3) ever having an abortion, (4) having a high number of sexual partners, (5) having first intercourse at an early age, and (6) not using any form of birth control at last intercourse. Ever having unprotected intercourse was measured with a yes or no response to the question “Have you ever had unprotected sex (includes: not using any form of birth control, having a condom break, and/or not taking birth control pills for ≥ 2 days in a row) when you were not trying to get pregnant?” Number of lifetime sexual partners was assessed with the question, “How many different men have you had sex with in your life?” The responses were dichotomized into high (≥ 5 partners) and low (< 5 partners) for our analysis. Age at first intercourse was evaluated with the question, “How old were you the first time you had sex with a man?” Responses were categorized into < 15 years old and ≥ 15 years old. Other factors that were considered in these analyses were age, race/ethnicity, relationship status, education, family income, and regular medical care.
Before the study was initiated, a sample-size estimate was calculated using EpiInfo software (version 3.2.2, Statcalc function; Centers for Disease Control and Prevention, Atlanta, GA). The assumptions included an alpha error of .05 with a power of 80%. We assumed a difference in the proportion of sexual risk behaviors between the 2 groups to be 20%; for example, we assumed that 50% of women in the EC group would have a history of a previous STI compared with 30% of the women in the Family Planning group. Using these assumptions, we would need approximately 90-100 women in each group.
Data were analyzed with SAS software (version 8.0; SAS Institute, Inc, Cary, NC). Potential confounders were identified on the basis of published literature and evaluated using the chi-square and Fisher's exact test. The 6 indicators of reproductive health and sexual risk (the outcomes) were then each analyzed separately with the use of logistic regression to assess whether these outcomes were associated independently with the type of contraceptive services (EC or general family planning) while we controlled for factors that were identified as potential confounders. Variables that were included in each model as potential confounding factors were age, race/ethnicity, relationship status, education, family income, and regular medical care.
Results
This study sample consisted of 227 women aged 17-43 years. The comparison groups included 114 women who sought EC from a women's emergency facility and 113 women who had never used EC and who sought family planning services from a walk-in clinic.
The women who sought EC differed in age distribution, race, and socioeconomic factors when compared with women who sought general family planning services (Table 1). Although these proportions differ, they are representative of the distribution of women who sought care at these clinical sites. Compared with those women who sought family planning services, the EC group was considerably younger, with 39% of the sample being 17-19 years old compared with 17% in the family planning group. A higher proportion of women in the EC group were white, non-Hispanic (61%) compared with the general family planning group, which had a higher proportion of Hispanic women (45%) and black, non-Hispanic women (21%). Level of education and family income, which are both indicators of socioeconomic status, were higher among the EC group when compared with the general family planning group. For example, 62% of the EC group reported that they had some college education or above, compared with 52% of the family planning group. Relationship status and regular medical care were also significantly different between the 2 groups (Table 1). Compared with women in the family planning group, women in the EC group were more likely to be single, separated, divorced, or widowed. The EC group also had a lower proportion of women who reported having regular medical care (76%), compared with the family planning group (96%), although the proportion is relatively high for both groups.
TABLE 1. Demographic characteristics of women who were evaluated for EC (n = 114) vs general family planning services (n = 113)
| Variable | Comparison group (n) | ||
|---|---|---|---|
| EC | Family planning | P value | |
| Age (y) | |||
 17-19 | 44(39%) | 19(17%) | <.01 |
| 20-24 | 41(36%) | 53(47%) | |
| ≥25 | 20(17%) | 38(33%) | |
| Missing | 9(8%) | 3(3%) | |
| Race | |||
| White, non-Hispanic | 70(61%) | 30(27%) | <.01 |
| Black, non-Hispanic | 11(10%) | 24(21%) | |
| Other, non-Hispanic | 11(10%) | 6(5%) | |
| Hispanic | 17(15%) | 51(45%) | |
| Missing | 5(4%) | 2(2%) | |
| Education | |||
| Less than high school | 10(9%) | 21(24%) | .02 |
| Completed high school | 26(23%) | 21(19%) | |
| Some college and above | 71(62%) | 59(52%) | |
| Missing | 7(6%) | 6(5%) | |
| Income | |||
| ≤ $20,000 | 32(28%) | 56(50%) | <.01 |
| > $20,000 | 66(58%) | 43(38%) | |
| Missing | 16(14%) | 14(12%) | |
| Relationship status | |||
| Married | 5(4%) | 25(22%) | <.01 |
| Cohabitating relationship | 12(11%) | 35(31%) | |
| Single/widowed/separated/divorced | 90(79%) | 47(42%) | |
| Missing | 7(6%) | 6(5%) | |
| Regular medical care | |||
| Yes | 87(76%) | 109(96%) | <.01 |
| No | 25(22%) | 4(4%) | |
| Missing | 2(2%) | 0 | |
A high proportion of women in both the EC and the general family planning services groups had unprotected sex in the past (83% vs 73%, respectively). Additionally, nearly one-half of this study population reported ≥ 5 past sexual partners. Although the EC group had a higher proportion of women who had had unprotected sex in the past and a greater number of sexual partners, when compared with the group seeking family planning services, these differences were not statistically significant (Table 2). The general family planning group had a higher proportion of women who had an STI in the past and who started having intercourse at < 15 years old, compared with the EC group. These differences remained significant, even after we adjusted for age, race, marital status, education, income, and regular medical care in the regression analysis.
TABLE 2. Comparison of sexual risk factors between women who sought EC and women who sought family planning services
| Risk factor | Comparison group (n) | Odds ratioa | ||
|---|---|---|---|---|
| EC | Family planning | Crude (95% CI) | Adjusted (95% CI)b | |
| Unprotected sex ever | ||||
| Yes | 95(83%) | 82(73%) | 1.89(0.99-3.59) | 2.27(0.84-6.11) |
| No | 19(17%) | 31(27%) | ||
| Previous STI | ||||
| Yes | 19(17%) | 50(44%) | 0.25(0.14-0.47) | 0.41(0.17-0.96) |
| No | 95(83%) | 63(56%) | ||
| Previous abortion | ||||
| Yes | 22(20%) | 33(30%) | 0.58(0.31-1.07) | 1.43(0.55-3.73) |
| No | 90(80%) | 78(70%) | ||
| Sex partners (n) | ||||
| High(≥ 5) | 56(49%) | 44(39%) | 1.51(0.89-2.56) | 1.62(0.70-3.80) |
| Low (< 5) | 59(51%) | 69(61%) | ||
| Age at first intercourse (y) | ||||
| ≤ 15 | 12(11%) | 38(34)% | 0.24(0.12-0.49) | 0.33(0.12-0.89) |
| ≥ 16 | 98(89%) | 74(66%) | ||
| Birth control at last intercourse | ||||
| No | 54(48%) | 26(23%) | 3.03(1.64-5.56) | 5.56(2.22-14.29) |
| Yes | 59(52%) | 86(77%) | ||
aThe referent group for the odds ratio calculations is the family planning group |
bAdjusted for age, race, marital status, education, income, and regular medical care. |
Comment
This study was performed to better understand whether there are differences between women who know how to access EC and those who have never used EC and who are seeking general family planning services. Although the women in this study who sought EC needed to attend an urgent care facility (open 24 hours a day), the system for obtaining EC is similar to what will be done in the pharmacy setting. Similar to the pharmacy setting, women are able to attend the women's urgent care facility to request EC and pay for the medication (they are not charged for an emergency room visit); they are then interviewed briefly, counseled, and given the medication. This system for accessing EC has been available for > 5 years. With the recent FDA decision to make EC available without a prescription, understanding the differences between women who access EC and women who have never used EC will help us to develop broad and effective strategies to increase awareness and access to EC and to improve overall reproductive health.
A descriptive study that characterized a population of women who sought EC in the United Kingdom found that most EC seekers were white women aged 16-19 years, 17.5% of whom have had a previous abortion and 45% of whom were not using contraception for the episode of intercourse that lead them to seek EC.11 Another study from the United Kingdom also found that single women were more likely than married or cohabitating women to have used EC.12 Other studies on sexual behavior and EC have investigated sexual risk-taking after women were provided with varying access to EC (pharmacy access, clinic access, or advanced provision).7, 8, 13, 14, 15, 16 With the exception of 1 study,14 these previous studies have shown that risky sexual behavior did not increase the number of women who were provided with EC.
Access is important because, the sooner after intercourse EC is taken, the more effective it is at preventing unplanned pregnancy. Nonprescription pharmacy availability of EC will not likely solve the complex issue of access by itself.13, 17 Wide-spread educational campaigns are necessary to increase knowledge about EC and its appropriate use. Only 52% of women surveyed in a California study were aware that there was something that could be done after intercourse to prevent a pregnancy.18 Overall, only 38% of women correctly identified a method of EC to be used for this purpose. In another survey of women who sought care in a general emergency department, only 9.8% of women who were at risk for pregnancy had ever used EC.19 Given these findings, understanding differences in behaviors between women who seek EC and women who seek general family planning should enhance the development of much needed educational programs.
This study showed that women who seek EC have a relatively high prevalence of high-risk sexual behaviors, as did those seeking other family planning services. Given that this is a high-risk population, pharmacist training should include education about overall reproductive health and safe sex. In contrast to condoms and other contraceptive methods such as spermicides and the sponge that have been widely available over the counter, EC requires an interaction at the pharmacy to receive the medication. It is unclear what type or if any training is being given to pharmacists at this point; therefore, an evaluation of the current knowledge and attitudes of pharmacists may be important to increasing accessibility of EC. In addition, materials on safe sex, STI prevention, and local reproductive health services that are available at pharmacies should be considered to be part of the procedure for dispensing EC without a prescription. Educating pharmacists increases availability for women who know about EC and those who do not. In addition to pharmacist training, women's healthcare providers must continue educating women about EC during annual examinations, family planning visits, follow-up after a spontaneous or induced abortion, and treatment for STIs. Supporting media campaigns that have the capacity to reach a broad audience of women may increase the use of comprehensive family planning services, including EC.
One potential limitation of this study is that the outcomes, unprotected sex, previous STI, previous abortion, number of sexual partners, and age at first intercourse were all obtained by participant recall and self-report. Additionally, an important variable (level of education) was indicative of cumulative knowledge rather than appropriateness of education for age. It is possible that less than a high school education was appropriate for participants who were 17-19 years of age. Any educational campaign would need to pay attention to health literacy concerns.
The overall proportion of women who had ever had unprotected intercourse or had a previous abortion were relatively high in this study population. Although, the 2 study groups were being evaluated for different solutions to prevent pregnancy (the EC group was seeking to prevent a pregnancy after an act of intercourse, and the general family planning group was seeking to prevent pregnancy before future acts of intercourse), their sexual risk behaviors were similar. Understanding the demographic and health characteristics of women who seek family planning services and EC will help inform meaningful education programs to increase awareness of EC and to encourage safe sex practices for all women. Future directions should include an evaluation of access and use of EC over-the-counter and the effectiveness of educational campaigns that are targeted toward patients, pharmacists, and women's healthcare providers.
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- Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. [see comment] JAMA. 2005;293:54–62
- . Emergency contraception: advance provision in a young, high-risk clinic population. Obstet Gynecol. 2000;96:1–7
- . Advance supply of emergency contraception (effect on use and usual contraception: a randomized trial). [see comment] Obstet Gynecol. 2003;102:8–16
- . Effect of advanced provision of emergency contraception on women's contraceptive behaviour: a randomized controlled trial. Hum Reprod. 2004;19:2404–2410
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- Knowledge of emergency contraception among women aged 18 to 44 in California. Am J Obstet Gynecol. 2004;191:150–156
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Cite this article as: Phipps MG, Matteson KA, Fernandez GE, et al. Characteristics of women who seek emergency contraception and family planning services. Am J Obstet Gynecol 2008;199:111.e1-111.e5.
PII: S0002-9378(08)00161-0
doi:10.1016/j.ajog.2008.02.019
© 2008 Mosby, Inc. All rights reserved.
Volume 199, Issue 2 , Pages 111.e1-111.e5, August 2008
