Placing Emergency Contraception in the Hands of Women
Authors: Iris F. Litt
Journal: JAMA (2005)

FOR MORE THAN 50 YEARS, SINCE THE SUCCESSFUL SYNthesis of estrogens and progestins, safe and effective pregnancy prevention has been possible. Nonetheless, in the United States an estimated 3.5 million unwanted pregnancies occur annually, one third of which involve teenagers. Among the many possible explanations for this paradox, barriers to health care figure prominently. For instance, lack of health insurance, an issue for more than 44 million Americans, creates a formidable barrier to access. Religious beliefs, concerns about contraceptive safety, and psychological barriers also contribute. Contraception may not be sought, especially by teens and other women for whom a physician visit and discussion of sexual behavior may prove embarrassing. Women without access to effective contraception were enthusiastic about the discovery that certain formulations of contraceptive hormones or hormone receptor inhibitors could prevent implantation of a fertilized ovum. “Morning after” or “emergency contraception” (EC) provided these women a second chance to prevent an unwanted pregnancy. When taken within 72 hours of an episode of unprotected intercourse, the “Yuzpe” regimen (consisting of 2 doses of combined oral contraceptive pills, with the first taken within 72 hours of unprotected intercourse and the second, 12 hours later [a total of 100-120 mg of estrogen and 1.0-1.2 mg of progestin, depending on the formulation of the oral contraceptive pill]) is effective in preventing pregnancy in 75% of cases. As with regular contraception, however, use of these agents has been less frequent than anticipated, and several other factors appear to restrict EC use. For example, patient knowledge of these agents is limited and some physicians are reluctant to prescribe them citing fears that their availability will lead to increased risktaking behavior, especially among teens. Some countries, including the United Kingdom, have removed some real and potential barriers to EC use by making these drugs available over-the-counter. This approach precludes the need for insurance, offers timely access, and eliminates the need for a physician visit for women who would find seeking EC embarrassing or otherwise difficult to accomplish. Indeed, studies have demonstrated that the rate of EC use is doubled when it is provided in advance of need. In the United States, 6 states (Washington and Maine, with pilot programs in Alaska, California, New Mexico, and Hawaii) have legislatively sanctioned pharmacy access to EC without needing a physician’s prescription, but the effects of this availability on clinical outcomes and rates of use have not yet been evaluated. In this issue of JAMA, Raine and colleagues report important data on the effect of access to EC on clinical outcomes. In their study, 2117 young women 15 to 24 years of age were randomly assigned to pharmacy access without a prescription, advance provision, or usual care that required a clinic visit to obtain EC. The authors assessed the effects of increased access on pregnancy rates, acquisition of new sexually transmitted infections (STIs), contraceptive use, and sexual behaviors. Strengths of this study include the large number of women enrolled and the use of biomarkers, rather than self-report, for most of the outcome measures, including tests for diagnosis of Chlamydia trachomatis and herpes simplex virus type 2 and pregnancy tests. After 6 months of follow-up, the authors documented a near doubling of EC use in the advance access group (37.4%) relative to usual care (21.0%) and comparable rates of use for pharmacy access and usual care (24.2% and 21.0%, respectively). Pregnancy rates were comparable in all groups as was the incidence of new STIs. Easier access to EC did not compromise regular contraceptive use or lead to an increase in risky sexual behaviors. Limitations of the study include self-reported use of EC rather than performance of bioassays of hormone metabolites to verify use. Moreover, the women appear to have selfselected by presenting for care at clinics that provide family planning services. Although women requesting EC were excluded, the authors do not report whether contraception was the reason for their visit. That notwithstanding, the very fact these women sought health care suggests that they are more sophisticated than many young women in need of pregnancy protection. Accordingly, the findings of this study can-