Making it easier to obtain emergency contraception would not increase unprotected intercourse, lead to abandonment of regular contraception, or increase the risk of sexually transmitted infections (STIs), according to a study in the January 5 issue of JAMA.
It is estimated that half of the 3.5 million unintended pregnancies that occur each year in the United States could be averted if emergency contraception (EC) were easily accessible and used, according to background information in the article. In efforts to increase access to EC, six states (Alaska, California, Hawaii, Maine, New Mexico, and Washington) have implemented pharmacy access legislation whereby women can obtain EC directly from pharmacists without having to see a clinician or obtain a prescription first. An important element in policy debates over making EC more widely available is the concern that it will lead to increased risk-taking, that women would have more unprotected intercourse, increase their risk for STIs, and abandon more effective forms of regular contraception.
Tina R. Raine, M.D., M.P.H., of the University of California, San Francisco, and colleagues
conducted a randomized controlled trial to evaluate the effect on pregnancy and STIs of access to EC through pharmacies on receiving the medication in advance. The trial included 2,117 women, ages 15 to 24 years, attending 4 California clinics providing family planning services, who were not desiring pregnancy, using long-term hormonal contraception, or requesting EC. The participants were assigned to one of the following groups: (1) pharmacy access to EC; (2) advance provision of 3 packs of levonorgestrel EC; or (3) clinic access (control).
The researchers found that women in the pharmacy access group were no more likely to use EC (24.2 percent) than controls (21.0 percent). Women in the advance provision group (37.4 percent) were almost twice as likely to use EC than controls (21.0 percent) even though their reported frequency of unprotected intercourse was similar (39.8 percent vs. 41.0 percent, respectively). Only half (46.7 percent) of study participants who had unprotected intercourse used EC over the study period. Eight percent of participants became pregnant and 12 percent acquired an STI; compared with controls, women in the pharmacy access and advance provision groups did not experience a significant reduction in pregnancy rate or increase in STIs. There were no differences in patterns of contraceptive or condom use or sexual behaviors by study group.
“… in our study population, direct pharmacy access did not appear to be any more useful than access through clinics. While study participants had a choice of 13 pharmacies, they could have been reluctant to go to a pharmacy or experienced difficulty getting to a pharmacy or finding a pharmacist on duty who was trained to dispense EC. The requirement to go through pharmacists or clinics to obtain EC appears to be a barrier that limits use. Even though rates of unprotected intercourse were similar across study groups, women in the advance provision group were still almost twice as likely to use EC than women in the clinic access group. Furthermore, contrary to concerns that increased access to EC will entice women to use EC repeatedly, only a small fraction of women in the pharmacy access and advance provision groups used EC more than once over the 6-month period, even though EC was supplied at no cost,” the authors write.
“These data support the previous scientific literature that indicates that among young sexually active women, unprotected intercourse leads to EC use, not the converse,” they add.
“… our study has important public health implications. While removing the requirement to go through pharmacists or clinics to obtain EC increases use, the public health impact may be negligible because of high rates of unprotected intercourse and relative underutilization of the method. Given that there is clear evidence that neither pharmacy access nor advance provision compromises contraceptive or sexual behavior, it seems unreasonable to restrict access to EC through clinics,” the researchers conclude.
In an accompanying editorial, Iris F. Litt, M.D., of the Stanford University School of Medicine, Palo Alto, Calif., writes that the report by Raine et al makes an important contribution to current knowledge of EC use and should help dispel concerns that easier access to EC increases the risk of STIs or leads to abandonment of regular contraception.
“The finding that women who were provided EC at a clinic visit prior to the time of need were almost twice as likely to use EC than women in the clinic access control group is critically important, even though a reduction in pregnancy was not demonstrated. Several explanations for this finding, which could not be assessed within the context of the study, include timing of unprotected intercourse in relationship to ovulation, as well as the timing and accuracy of use of EC. The fact remains that women are more likely to use EC if it is readily available. It is similarly significant that no apparent downside of EC was demonstrated in the study. There was no evidence of a decrement in use of other methods of contraception such as oral contraceptives or condoms. Equally important, to counter the frequent argument that provision of EC will increase high-risk behavior, this study demonstrated no increase in STIs or reports of unprotected intercourse.”
“The task remains to improve access to EC by expanding the number and types of facilities where it can be obtained. Education about EC for both physicians and the public should be improved, especially now that other agents (including RU-486 [mifepristone]) have been shown to be effective in preventing unwanted pregnancy after an episode of unprotected intercourse. Importantly, physicians may wish to reconsider their position on EC in relation to other contraceptive methods; as this study suggests, regular contraception and EC are not in conflict. Sexually active women who do not desire to become pregnant should be counseled about regular methods of birth control, but they can be assured that EC is available if they are concerned their regular method may not have protected them from the possibility of an unwanted pregnancy,” Dr. Litt concludes.