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Access to Emergency Contraception

From the Office of Population Research, Princeton University, Princeton, New Jersey, and the Reproductive Health Technologies Project, Washington, DC.

Address reprint requests to: James Trussell, PhD Office of Population Research Notestein Hall Princeton University Princeton, NJ 08544 E-mail: trussell{at}princeton.edu

	Abstract

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Objective: To evaluate access to emergency contraception among women seeking help from clinicians who registered to be listed on the Emergency Contraception Hotline (1-888-NOT-2-LATE, ie, 1-888-668-2528) and the Emergency Contraception Website (not-2-late.com).

Methods: Two college-educated investigators posing as women who had a condom break the previous night called 200 providers to seek help.

Results: Only 76% of attempts resulted in an appointment or telephone prescription from a hotline provider within 72 hours, 14% were failures, and 11% resulted in referrals to other providers not listed on the hotline or website.

Conclusion: Even under ideal conditions, access to emergency contraception is currently constrained. Although emergency contraception could reduce significantly the incidence of unintended pregnancy and the consequent need for abortion, its potential will not be realized unless women have better access to clinicians who can prescribe emergency contraceptive pills.

Emergency contraception prevents pregnancy after unprotected intercourse.¹ Emergency contraceptive methods available in the United States include regimens of combined estrogen and progestin or progestin-only oral contraceptive pills initiated within 72 hours after unprotected intercourse or insertion of a copper T intrauterine device up to 5 days after unprotected intercourse. Combined emergency contraceptive pills are currently the most commonly used method in the United States.

To increase women’s awareness of and access to emergency contraception, the Reproductive Health Technologies Project and the Office of Population Research at Princeton University operate the Emergency Contraception Hotline (1-888-NOT-2-LATE, ie, 1-888-668-2528), a toll-free, automated, confidential service available 24 hours a day in English and Spanish. It provides information about emergency contraception and the names and telephone numbers of five clinicians in the caller’s geographic area who prescribe emergency contraception. The directory of providers currently contains over 2900 entries from every state, the District of Columbia, Guam, Puerto Rico, and the United States Virgin Islands. An English and Spanish website (not-2-late.com) provides more comprehensive information about emergency contraception, as well as the entire directory.

We conducted a quality assurance study to gauge the ease with which a caller can obtain emergency contraception. Neither the hotline nor the website makes any claims about quality or cost of services offered by the providers. However, ensuring that women can make appointments or get prescriptions within 72 hours clearly contributes to our goal of increasing access to emergency contraception. This research was explicitly exempted from full review by the Princeton University Institutional Review Panel for Human Subjects because it involved a review of existing data collected for quality assurance purposes.

	Materials and Methods

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The quality assurance study consisted of mystery calls in which two investigators posed as women who had a condom break the previous night and did not want to become pregnant. The callers followed a script that reflected minimal knowledge of emergency contraception and that included detailed responses to potential questions by clinical staff. The callers asked for help, but did not specifically use the terms "emergency contraception" or "morning-after pill" unless the clinical staff did not understand what they were asking for. Callers did not ask to speak to additional staff if their first contact could not help them or did not refer them to someone else on staff. Besides tracking information on appointment and telephone prescription availability, callers requested information on appointment procedures and cost. Callers did not deviate from the script except to probe for specific pricing information. The callers, ages 27 and 21, were both white, college-educated women with considerable knowledge about emergency contraception. If asked, they said they were full-time students and not employed. All calls were made in March and April 1999.

At the time of the study, 2833 providers were listed on the hotline, all of whom had consented to periodic verification of their information at the hotline staff’s discretion, including having our staff pose as women who needed emergency contraception. This list was reduced to eliminate pharmacies and providers registered as serving only limited populations (eg, teens, students, or previously established patients). From the remaining 2485 providers, 200 were selected randomly for the quality assurance project. The sample size enabled us to construct two-sided 95% confidence intervals (CIs) for percentages that extended at most ±7 percentage points, which we considered sufficiently precise given our objective. Exact binomial confidence intervals and Fisher exact test for equality of proportions were computed using the statistical software StatXact-3 (Cytel Software Corporation, Cambridge, MA).

The same caller made three attempts to contact each provider, all within 72 hours. Calls were made during standard business hours only, and none were made on weekends or holidays. No appointments were made, and no prescriptions were written or telephoned into pharmacies. If no provider was available, callers did not leave messages or numbers where they could be reached. Instead, they always offered to call back at a more convenient time. Callers never revealed that they were conducting a quality assurance exercise.

	Results

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Providers in the sample were located in 40 states plus the District of Columbia and the United States Virgin Islands. Planned Parenthood affiliates comprised 37% of providers in the sample. Of the 200 providers, 84 (42%) were located in areas classified by ZIP code as urban by the United States Bureau of the Census.

Calls were placed to 200 providers in our sample. Results were categorized as successes (caller was offered an appointment or telephone prescription within 72 hours), failures (no appointment or prescription offered), or referrals (no appointment or prescription offered, but caller received an unsolicited suggestion to call another provider). The referrals were further classified as general referrals, such as "call your regular doctor" or "try Planned Parenthood," or specific referrals, in which the caller was given a name and telephone number. Nine of the specific referral sites were listed on the hotline and were followed up and treated as part of the original study, with up to three additional calls. Referrals that resulted in successes or failures were categorized as such and excluded from the referral group in the analyses.

Approximately three fourths (76%, 95% CI 69%, 82%) of attempts resulted in appointments or telephone prescriptions within 72 hours; 14% (95% CI 9%, 19%) were failures; and 11% (95% CI 7%, 16%) resulted in referrals to other providers that could not be followed up because we did not have prior consent to verify services at nonhotline sites. We do not know whether those nonhotline attempts would have been successful. Among successes, 74% of callers were offered appointments for the same day, 16% for the next day, and 2% for the day after that. Telephone prescriptions were offered by 8% of successes. Calls to Planned Parenthood affiliates were more likely to result in successes than other calls (86% versus 70%, P = .005, Fisher exact test). However, only one Planned Parenthood provider offered to telephone in a prescription.

The main reasons for a call being classified as a failure were the inability to make telephone contact, refusal to see women who were not established clients, and unavailability of appointments (Table 1). Of attempts that resulted in referrals, two thirds were general, and one third were specific. The main reasons that those providers gave referrals were unavailability of appointments, refusal to see women who were not established clients, and unavailability of emergency contraception at that site. Information was also collected on appointment protocols. Callers were able to obtain that information from 95% of sites that offered appointments (the information was not gathered from providers who gave telephone prescriptions because there was no clinic visit involved). Of providers that offered appointments, almost one third (31%) required pregnancy tests and over one fourth (27%) required pelvic examinations. Planned Parenthood clinics had similar protocols, with 32% requiring negative pregnancy test results, and 22%, pelvic examinations.

The other quarter of providers used sliding scale systems to determine prices for emergency contraception services. Most sites (69%) with sliding scale systems provided estimated costs for student clients, which were substantially lower than at sites with fixed prices. Costs ranged from free to $54, with mean and median costs of $22 and $18, respectively; 29% provided services at no cost, and 67% charged $25 or less.

	Discussion

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This quality assurance study evaluated access to emergency contraception under the most favorable conditions. Clinicians in our sample were self-selected, having registered to be listed on the hotline’s directory as providers of emergency contraception. All calls were made during business hours; none were made on weekends or holidays, when many clinics and private medical offices are closed. A woman who has unprotected intercourse on a Friday night would undoubtedly face greater obstacles finding an available provider within the 72-hour time frame. The callers were not typical of the range of women who normally seek emergency contraception; they were white, native English speakers, and highly educated. A script was written to simulate minimal knowledge of emergency contraception, but the callers were highly knowledgeable about the topic, and knew how to ask the right questions and get the right answers to facilitate provision of emergency contraception. Most callers would be less likely to have such successful outcomes.

Most of the hotline’s clinicians did an excellent job of providing women with access to emergency contraception. To improve the quality of service, we will contact all providers for whom calls resulted in failures or referrals to assess their eligibility. We also will send the results of the study to all providers in the database and repeat quality assurance surveys periodically.

Our results showed a woman’s best-case scenario for obtaining emergency contraception, so the fact that one fourth of the calls did not lead to a prescription from a provider on the hotline within the necessary time frame is worrisome. Our results suggest that providers could do more to ensure that women can obtain emergency contraception when they need it. The efficacy of emergency contraceptive pills declines significantly with time since unprotected intercourse,² so treatment should be initiated as soon as possible. That imperative presents a great challenge for women, who must find providers who will prescribe the pills and do so immediately. Although most providers in our sample could see women the same day they called, one fifth asked them to wait an additional 24–48 hours.

We offer several recommendations to ensure that women get emergency contraception expediently. All obstetrics-gynecology, family practice, adolescent health, and internal medicine clinicians should routinely discuss emergency contraception with clients so they know to ask for it should the need arise. For many women, arranging a visit with a clinician for a prescription might delay treatment beyond the 72–hour time frame. The need for an office visit would be obviated if clinicians provided women with a supply of or a prescription for emergency contraceptive pills in case of future need. With supplies at home or in their handbags, women could take the pills within minutes after unprotected intercourse, thus maximizing their efficacy. Some clinicians are resistant to that approach because they fear that increased access to emergency contraception would cause some women to stop using ongoing methods of contraception. However, a study found that women who were given pills in advance were more likely than women merely counseled about emergency contraception to use them once—but not repeatedly—and did not abandon other more reliable ongoing methods of contraception.³

Women are likely to need emergency contraception outside regular office hours, particularly during weekends and holidays, so clinicians should identify alternative service delivery mechanisms, eg, collaborations between clinics and emergency departments, to ensure access at all times.^4,5 Information about back-up services should be left on clinics’ after-hours voice mail recordings or with their answering services. Provision of emergency contraception by pharmacists is another approach with great potential to expand women’s access. Pharmacies are often conveniently located and open on evenings, weekends, and holidays when clinicians generally are not available. In Washington state, pharmacists can prescribe emergency contraceptive pills directly to women, who do not first have to see a clinician, through voluntary collaborative drug therapy agreements. These agreements allow health care professionals with independent prescribing authority to delegate to pharmacists the authority to prescribe according to a specific and mutually agreed upon protocol. Thirteen months after the initiative was launched, 130 pharmacies were prescribing emergency contraceptive pills directly to women, and 9333 prescriptions had been written and filled by pharmacists working under collaborative agreements. Twenty-five states currently have some form of collaborative drug therapy legislation and 20 other states are pursuing such legislation. The degree of prescriptive authority allowed to pharmacists varies by state, and not all state legislation would support the Washington state model.

Providers should consider prescribing over the telephone, thereby eliminating the need for appointments. Planned Parenthood Federation of America has established a "Dial EC" protocol that allows new and established patients to receive prescriptions for emergency contraceptive pills and instructions for their use over the telephone, with no clinic visit required. However, we found that only one Planned Parenthood provider in our study offered the mystery caller a telephone prescription. Wider availability of that protocol would make emergency contraception more easily accessible for many women, especially those who live in rural areas or do not have clinicians.

Providers should eliminate physical examinations and unnecessary pregnancy tests. Although no emergency contraception protocol from a major medical organization mandates routine pregnancy testing or pelvic examinations, our study found that many providers required them. A pelvic examination is unnecessary for safe provision of emergency contraceptive pills and significantly increases the total cost. A routine pregnancy test is also unnecessary.⁶ Emergency contraceptive pills will not work if a woman is already pregnant, and there is no evidence of teratogenicity among women who were already pregnant when treated or became pregnant despite treatment.^7,8

Half of all pregnancies in the United States each year are unintended, and over half of those pregnancies (54%) end in abortion.⁹ Although emergency contraception can cost-effectively reduce the incidence of unintended pregnancy and the need for abortion significantly,¹⁰ clinicians do not routinely inform women of that option.¹¹

	Footnotes

 
The Emergency Contraception Hotline and the work to support it have been made possible by grants from private foundations including Fred H. Bixby Foundation (Los Angeles, CA), California Wellness Foundation (Woodland Hills, CA), Educational Foundation of America (Westport, CT), General Service Foundation (Aspen, CO), Richard and Rhoda Goldman Fund (San Francisco, CA), Leland Fikes Foundation (Dallas, TX), Henry J. Kaiser Family Foundation (Menlo Park, CA), Mandel Family Foundation (Los Angeles, CA), The John Merck Fund (Boston, MA), David and Lucile Packard Foundation (Los Altos, CA), Open Society Institute (New York, NY), Rockefeller Foundation (New York, NY), and Turner Foundation (Atlanta, GA). No corporate or government funding has been received.

PII S0029-7844(99)00518-9

Received May 27, 1999. Received in revised form July 28, 1999. Accepted August 5, 1999.

	References

Top Abstract Materials and Methods Results Discussion References

 
1. Consensus statement on emergency contraception. Contraception 1995;52:211–3.[Medline]

2. Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;332:428–33.

3. Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med 1998;339:1–4.[Abstract/Free Full Text]

4. Gbolade BA, Kirkman RJ, Elstein M. Emergency contraception, weekends and bank holidays: Improving access through cooperation between hospital and community based services. Br J Fam Plann 1996;22:120–2.

5. Priddy A, Reed B. A survey of a hospital based out-of-hours emergency contraception service. Br J Fam Plann 1996;21:139–41.

6. Grimes DA, Raymond EG. Bundling a pregnancy test with the Yuzpe regimen. Obstet Gynecol 1999;94:471–3.[Abstract/Free Full Text]

7. Glasier A. Emergency postcoital contraception. N Engl J Med 1997;337:1058–64.[Free Full Text]

8. Food and Drug Administration. Prescription drug products; certain combined oral contraceptives for use as postcoital emergency contraception. Federal Register 1997;62:8610–2.

9. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24–9.[Medline]

10. Trussell J, Koenig J, Ellertson C, Stewart F. Preventing unintended pregnancy: The cost-effectiveness of three methods of emergency contraception. Am J Public Health 1997;87:932–7.[Abstract/Free Full Text]

11. DelBanco SF, Stewart FH, Koenig JD, Parker ML, Hoff T, McIntosh M. Are we making progress with Emergency Contraception? Recent findings on American adults and health professionals. J Am Med Womens Assoc 1998;53:242–6.

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