Committee Opinion
Number 542, November 2012


Committee on Health Care for Underserved Women
This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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Access to Emergency Contraception

ABSTRACT: Emergency contraception includes contraceptive methods used to prevent pregnancy in the first few days after unprotected intercourse, sexual assault, or contraceptive failure. Although the U.S. Food and Drug Administration approved the first dedicated product for emergency contraception in 1998, numerous barriers to access to emergency contraception remain. The purpose of this Committee Opinion is to examine the barriers to the use of oral emergency contraception methods and to highlight the importance of increasing access.


Background

Emergency contraception may be used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. Emergency contraception is effective in preventing pregnancy within 120 hours after unprotected intercourse but is most effective if used within 24 hours (1, 2). The most common emergency contraceptive method is oral progestin-only pills (levonorgestrel), but use of the antiprogestin ulipristal acetate or use of a combined regimen (high doses of ethinyl estradiol and a progestin) also are effective (3). A copper intrauterine device (IUD) is the most effective form of emergency contraception for medically eligible women and may prevent pregnancy if inserted up to 5 days after unprotected intercourse (4, 5).

Progestin-only emergency contraception is better tolerated and more efficacious than the combined regimen. In the United States, the two levonorgestrel-only regimens include a single-dose regimen (1.5 mg levonorgestrel) and a two-dose regimen (two tablets of 0.75 mg of levonorgestrel taken 12 hours apart). The levonorgestrel-only regimens are available without a prescription to women aged 17 years or older with government-issued photo identification. However, the antiprogestin, a 30-mg tablet of ulipristal acetate, requires a prescription (6). Ulipristal acetate is at least as effective as levonorgestrel in preventing pregnancy up to 72 hours after unprotected intercourse and appears to be more effective than levonorgestrel in preventing pregnancy when used between 72 hours and 120 hours after unprotected intercourse (7).

Barriers to Access

Misconceptions

Mechanism of Action

A common misconception is that emergency contraception causes an abortion. Inhibition or delay of ovulation is the principal mechanism of action (8–13). Review of evidence suggests that emergency contraception cannot prevent implantation of a fertilized egg (1, 12–14). Emergency contraception is not effective after implantation; therefore, it is not an abortifacient.

Effect on Risky Sexual Behavior

Another misconception is that making emergency contraception more readily available promotes risky sexual behavior and increases the rates of unintended pregnancy among adolescents (15). Ready access of adolescents to emergency contraception is not associated with less hormonal contraceptive use, less condom use, or more unprotected sex (16). This misconception also has been raised among adult women. However, numerous studies have shown that this concern is unfounded (3).

Safety of Repeated Use

Data are not available on the safety of current regimens of emergency contraception if used frequently over a long period. However, emergency contraception may be used more than once, even within the same menstrual cycle (3). Information about other forms of contraception and counseling about how to avoid future contraceptive failure should be made available to women who use emergency contraception, especially to those who use it repeatedly.

Financial Barriers

Women’s financial resources and insurance coverage limit access to contraceptive methods. Women who lack health insurance or disposable income, have substantial copayments, deductibles, or both, or do not have coverage for over-the-counter medications may not have access to any method of emergency contraception (17). Out of pocket costs for oral emergency contraception average $25–60 and IUD costs can be more than $500, depending on insurance (18–20). Some insurance companies reimburse women only for the cost of emergency contraception in specific circumstances (eg, in the case of sexual assault if a police report has been filed) and most require a prescription (19).

Education and Practice Barriers

Although use of emergency contraception has increased, many women and health care providers remain unfamiliar with the method or are unaware that a physical examination or testing is not needed before emergency contraception is provided. Women often are reluctant to ask health care providers for an advance prescription because they do not anticipate needing it and then have difficulty locating a provider when a prescription for emergency contraception is needed (21, 22). Health care providers often discuss or provide emergency contraception only on request or when a woman reports an unprotected sexual encounter (21). Some health care providers believe that routine counseling about emergency contraception is too time consuming or have a misperception that the patient is unable to properly use the method (18).

Facilities

Women in underserved communities face additional challenges in obtaining emergency contraception. Some communities simply lack a nearby facility or a health care provider willing to prescribe emergency contraception. In other communities, hospitals and pharmacies affiliated with a religious institution present a further barrier to access (15). Emergency departments affiliated with religious institutions have been the target of legislation and lawsuits seeking to enforce compliance with state laws that require emergency contraception be offered to sexual assault survivors (23). Even within the large network of Title X funded clinics, which provide reproductive health services to approximately 5 million low-income women and adolescents annually, some communities do not have a health care provider willing to prescribe emergency contraception.

Pharmacy Barriers

Some pharmacists refuse to dispense emergency contraception and some pharmacies refuse to stock emergency contraception (17). The prescription requirement for females younger than 17 years of age and pharmacy hours are additional barriers. One study found that pharmacy-related barriers occurred 30% of the time when patients called to obtain emergency contraception, including the need to call more than one pharmacy, wrong numbers given by pharmacy staff, delays in speaking with a knowledgeable staff member, being asked unnecessary embarrassing questions, and disconnection while on a phone referral to another facility (24). Another study found that pharmacists gave inaccurate information regarding the correct age threshold for over-the-counter access by adolescents, especially in low-income neighborhoods (25). Pharmacists are key members of our health care system and could be instrumental in improving access to emergency contraception (22). For example, nine states allow pharmacists to dispense emergency contraception without a physician’s prescription under certain conditions (26).

Special Populations

Access to emergency contraception remains difficult for adolescents, immigrants, non-English speaking women, survivors of sexual assault, those living in areas with few pharmacy choices, and poor women. The barriers most frequently cited by teens are confidentiality concerns, embarrassment, and lack of transportation to a health care provider or a pharmacy. Because nonprescription access to emergency contraception is restricted by age, pharmacies must keep emergency contraception behind the counter and request proof of age before dispensing it, thus restricting access for females aged 17 years or older who do not have government-issued identification. Although more than one half of pharmacies offer Spanish language services, expansion of Spanish and other language services could improve timely access to emergency contraception (18).

Up to 5% of sexual assault survivors become pregnant (27). A 2003 survey of Oregon hospitals found that only 61% of hospitals routinely offered emergency contraception to sexual assault survivors (28). Almost one half of health care providers in emergency departments did not prescribe emergency contraception 48 hours after an assault despite proven efficacy up to 120 hours after unprotected intercourse. Thirty percent of hospitals that provide emergency contraception to sexual assault survivors prescribe combined oral contraceptive pills instead of the more effective and tolerated dedicated progestin-only product, ulipristal acetate, or insertion of an IUD (29).

Recommendations

  • Remove the age restriction (prescription only for females younger than 17 years) to create true over-the-counter access to emergency contraception for all women.
     
  • Encourage federal agencies to meet the Healthy People 2020 goal to increase to 87.7% (a 10% improvement) the proportion of publicly funded family planning clinics that offer methods of emergency contraception approved by the U.S. Food and Drug Administration on site (30).
     
  • Support media campaigns clarifying that emergency contraception will not terminate an established pregnancy.
     
  • Encourage private and public insurers to provide coverage for both prescription and nonprescription emergency contraception and to publicize this coverage to their clients (22). According to an analysis by the Kaiser Foundation Health Plan in California, the distribution of both effective contraceptive methods and of emergency contraception increased once universal contraceptive coverage was offered to its members (31).
     
  • Amplify education campaigns that target health care providers and their staff. Health care providers should have refresher training sessions regarding contraceptive counseling and the effectiveness of each method of emergency contraception. They should be reminded that emergency contraception can be offered up to 5 days after unprotected intercourse; however, the sooner it is taken, the more effective it is (11). Most health care providers consider education essential for increasing acceptance and provision of emergency contraception (21).
     
  • Emphasize that a copper IUD is the most effective form of emergency contraception (32).
     
  • Write advance prescriptions for emergency contraception, particularly for females younger than 17 years, to increase awareness and reduce barriers to immediate access (24).
     
  • Integrate counseling about emergency contraception into all clinical visits of reproductive-aged women, including provision of written information and creation of forms that remind clinic staff to address emergency contraception during the visit (21).
     
  • Provide referrals to women who desire emergency contraception if a health care provider has an objection to providing it.
     
  • Support legislation to increase access to emergency contraception by requiring that it be dispensed confidentially by all pharmacies and by requiring provision of emergency contraception for survivors of sexual assault. Collaborate with pharmacies to avoid confusion and misinformation and to ensure timely access to emergency contraception.
     
  • Use social media to conduct campaigns regarding access to emergency contraception (eg, practices that have Facebook and Twitter accounts could provide links to information about emergency contraception).

Resources

ACOG Resources

The limits of conscientious refusal in reproductive medicine. ACOG Committee Opinion No. 385. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1203–8.

Understanding and using the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Committee Opinion No. 505. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:754–60.

Emergency contraception. Practice Bulletin No. 112. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;115:1100–9.

Additional Resources

The following resources are for informational purposes only. Referral to these sources and web sites does not imply the endorsement of the American College of Obstetricians and Gynecologists. This list is not meant to be comprehensive. The exclusion of a source or web site does not reflect the quality of that source or web site. Please note that web sites are subject to change without notice.

Emergency Contraception Hotline (Available in English and Spanish 24 hours a day)
1-888-NOT-2-LATE (1-888-668-2528)

Emergency Contraception Web Site
ec.princeton.edu

Reproductive Health Technologies Project: Emergency Contraception
www.rhtp.org/contraception/emergency

International Consortium for Emergency Contraception
www.cecinfo.org

References

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  2. Office of Population Research at Princeton University. Answers to frequently asked questions about effectiveness. Available at: http://ec.princeton.edu/questions/eceffect.html. Retrieved August 3, 2012.
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Copyright November 2012 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.

ISSN 1074-861X

Access to emergency contraception. Committee Opinion No. 542. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1250–3.