Emergency contraception: from accessibility to counseling

1. Introduction 

Direct access to emergency contraception (EC) through pharmacies has been shown to increase EC use [1], [2], [3] but may also have negative effects, such as the possibility of risk displacement, which in this case refers to a potential rise in the incidence of undiagnosed sexually transmitted infections since women who get EC directly from a pharmacy might not visit a doctor [4]. In an effort to help structure this important public health debate, we report the results of a survey that was designed to study the social determinants of contraception failures. This survey was undertaken in France in November 1999 at a time when EC was still almost exclusively available only with a medical prescription.

2. Participants, methods and results 

A representative national random sample of 1,782 households with at least one woman aged 18–44 was first selected from the telephone directory. If there was more than one eligible woman in a given household, the participant was chosen at random (by date of next birthday and, in the case of twins, by first name in alphabetical order). Interviews were conducted by telephone since this method has been shown to improve the reliability of answers when conducting surveys on sensitive topics such as sexuality and sexual risk-taking [5], [6]. Refusal rate among eligible women was 8%. All of the 1,639 consenting women were administered a short telephone questionnaire aimed at identifying those who had had an unwanted pregnancy or an abortion during the previous 5 years. Women who met these criteria (n = 113), along with a randomly selected sample of the remaining participants (n = 284), were administered an additional telephone questionnaire (n = 397 overall). This complex sampling procedure was designed in order to capture a sufficient number of women who had recently faced a contraceptive failure and were, thus, likely to have used EC. The unequal selection probabilities resulting from such a sample design were taken into account in the analysis with STATA software. Chi-square tests were performed to compare characteristics of EC users and nonusers.

Among the 397 women who answered the additional questionnaire, 383 were sexually active, 9% of whom had used EC. EC users, as compared to nonusers, had more lifetime sexual partners (12 vs. 4, p < 0.001), but they did not report having had more sexual intercourse in the last month (Table 1). They reported more often ever having had a sexually transmitted infection (29% vs. 6%, p < 0.001) or an unwanted pregnancy (39% vs. 22%, p < 0.06), regardless of the outcome of the pregnancy. Although they reported current use of a contraceptive method in the same proportion as nonusers, they reported less frequent use of oral contraception and more frequent use of condoms and barriers methods (Table 1). On the whole, EC users reported having visited a physician for gynecological reasons in the last 12 months less frequently than nonusers (1.4 vs. 2.6 visits, p < 0.001). Furthermore, EC users who were currently using oral contraception or an intrauterine device (IUD) had visited a medical doctor less often than non-EC users who were using oral contraception or an IUD (1.6 vs. 2.3 visits, p < 0.001).

Table 1. Characteristics of EC users and nonusers among sexually active women 18–44 years old in France (n = 383)

		EC users n = 34	Nonusers n = 349	p-value
	Age			0.07
	18–19	;>35%	16%
	20–24	9%	18%
	25–34	29%	43%
	35–44	27%	23%
	Education			0.05
	No qualification	0%	10%
	Less than high school graduation	22%	41%
	High school graduation	31%	20%
	Higher education qualification	47%	29%
	Marital status			<0.05
	Single	70%	37%
	Married	26%	56%
	Divorced, widow	4%	6%
	Number of sexual partners lifetime	12	4	<0.05
	Sexual intercourse in the last 4 weeks	87%	85%	NS
	Ever had an unintended pregnancy	39%	22%	0.06
	Ever had an abortion	38%	14%	<0.01
	Ever had a sexually transmitted disease	29%	6%	<0.001
	Currently using a contraceptive methoda	81%	74%	NS
	Contraceptive method
	Oral contraception	32%	63%	<0.05
	Condoms	26%	9%
	IUD	19%	18%
	Barriers methods	17%	7%
	Sterilization	6%	3%
	Visit to a medical doctor for gynecological reasons in the last 12 monthsa (mean)	1.4	2.6	<0.001

a Among women not pregnant and not intending to get pregnant.

3. Comments 

Due to their high-risk sexual profile and to their high prevalence of a history of sexually transmitted infection, it is particularly important that EC users, who are less likely to consult a doctor than other women, do not an miss opportunity for medical counseling, which could include the occasion provided by EC delivery.

At the same time, easy access to EC remains an important public health issue in France, where the prevalence of EC use was low at the time the study was conducted. Because the accessibility of EC is of great importance to encouraging its use, this issue must be addressed by optimizing the conditions of pharmacy access to EC rather than on restricting its availability through prescription status. Pharmacists could be informed specifically about the risk profile of women requesting EC. However, the question of counseling (i.e., conversation with women when dispersing EC and urging use of local reproductive health services) remains open since its efficacy is under debate [7], [8]. Counseling effectiveness could be established through a randomized controlled trial. Furthermore, a pharmacy environment may not be appropriate to ensure the confidentiality of counseling. At the least, informational material given to EC users could alert women of the importance of checking for sexually transmitted infections, considering the health issues related to sexually transmitted diseases.