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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Wilford Hall Medical Center, Lackland Air Force Base, Texas; Women’s Health Care Nurse Practitioner Program, Oregon Health Sciences University, Portland, Oregon; and Wilford Hall Medical Center, San Antonio, Texas.
Address reprint requests to: Alice R. van Royen, MD, Wilford Hall Medical Center, Department of Obstetrics and Gynecology, 2200 Bergquist Drive, Suite 1, Lackland Air Force Base, TX 78236-5300, E-mail: alice.vanroyen{at}gte.net
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Abstract |
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Methods: A survey was distributed to 302 active duty members of the United States Air Force. Descriptive and Pearson 
2 statistical analyses were used to evaluate findings.
Results: There was a general lack of knowledge about reproductive issues and the Yuzpe emergency contraception method. Eighty-five percent of respondents were sexually active, but only 62% used birth control. Only 40% knew when pregnancy was most likely to occur. Sixty-four percent had heard of emergency contraception, but only 15% were aware of the correct time to take it. Fifty-five percent said they would use emergency contraception if needed, with younger or unmarried individuals most willing.
Conclusion: Knowledge deficits must be addressed to keep women deployable. Educational materials and emergency contraception kits should be standard issue items. That might prevent unwanted pregnancies and produce significant savings in reproductive health and emotional costs.
Despite the slight decrease in abortions performed for unwanted pregnancies, the numbers are still staggering: 50 million pregnancies are terminated worldwide each year.1 In the United States, it was estimated that emergency contraception, with an effectiveness of at least 75%2,3 could prevent 600,000 to 1.7 million unintended pregnancies each year.4 The most studied method of emergency contraception is the Yuzpe regimen,5 now commercially available as PREVEN (Gynetics, Inc., Somerville, NJ). This regimen uses 100-µg of ethinyl estradiol and 0.5 mg levonorgestrel on two occasions, separated by 12 hours, within 72 hours of unprotected intercourse. A second formulation, a levonorgestrel-only method, recently became an alternative.6
Previously several surveys measured public knowledge about emergency contraception.7–11 In general, there was poor knowledge about basic reproductive physiology and emergency contraception. Awareness and use of emergency contraception have been cited as reasons for the low rates of abortion and teen pregnancy in The Netherlands.12 Within the United States, awareness is increasing but use of emergency contraception is low,7,8 which might reflect a strong antiabortion sentiment and confusion over the mode of action of the Yuzpe regimen. Recent evidence suggests that this method does not affect implantation13 and should not be considered an abortifacient.
Our study was designed to explore knowledge of reproductive physiology and emergency contraception and opinions about emergency contraception among active duty military members. A MEDLINE search from 1966 to June 2000 using the search terms "emergency contraception," "postcoital contraception," "morning-after pill," and "military" found no prior studies involving a military population. The purpose of our study was to elicit information to direct future educational efforts concerning physiologic and ethical concerns about emergency contraception. We hypothesized that a low level of knowledge concerning basic reproductive physiology and emergency contraception would be found. We also expected to find polarized attitudes about the method with respect to age, education, gender, and frequency of church attendance.
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Materials and Methods |
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We entered data in an Excel worksheet then analyzed it using SPSS (SPSS Inc., Chicago, IL). Differences in responses between demographic subgroups were tested using 2 analysis. We performed stepwise logistic regression analysis using likelihood ratio estimates to evaluate multivariate associations between demographic factors (education, gender, age, church attendance, marital status, and birth control use) and knowledge and attitudes. With 302 subjects, the margin of error for repeated studies of the Lackland Air Force base population from which this sample was drawn would be a response rate of plus or minus 6% of that reported.
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Results |
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gives the demographic characteristics of our population compared with those of the entire United States Air Force. Most of the significant differences might be explained by the function of Lackland as the initial training base for the Air Force. In general, its population is younger and less educated with more women and unmarried individuals. Eighty-five percent of respondents were sexually active, but only 62% of those used contraception.
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Only one quarter of those surveyed were unwilling to use emergency contraception. There was a split of 42% each regarding whether it should be widely available or tightly controlled, with 16% unsure. About a third of respondents had ethical concerns about emergency contraception. Most (56%) believed that it should be available on deployment and 20% were unsure.
Table 2 summarizes only the statistically significant correlations. In general, female gender, higher education, married status, and older age (over 21 years) correlated with better knowledge about emergency contraception. Younger or unmarried individuals were more willing to use it. Older respondents were significantly less likely to approve of emergency contraception during deployment. No demographic factor was significantly associated with ethical concerns.
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. Women and those who attended church frequently were more likely to have heard of emergency contraception. Women were significantly more knowledgeable than men regarding fertile period and that preventive action can be taken after unprotected intercourse. Younger and unmarried respondents were more willing to use emergency contraception.
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compares our results with those of other surveys concerning emergency contraception.7–11 Our results were similar to those of the largest general United States survey. Other recent publications from the international literature support our hypothesis regarding a general lack of knowledge about emergency contraception.14,15
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Discussion |
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As hypothesized, we detected a lack of knowledge about basic reproductive physiology and emergency contraception. We discovered polarized opinions on emergency contraception but not to the degree expected. These findings might reflect the status of Lackland Air Force Base as the starting point for Air Force members who come from all areas of the country.
Our findings have important applications within the military, especially during war. There are few studies about gynecologic care for military women16 during deployment. The Persian Gulf War was the first war in which large numbers of women were put into combat.17–19 Since the Gulf War, 32,694 previously restricted Army jobs have been opened to women. This is also true of other military services.20 It is expected that more military women will be in future engagements.
During the Persian Gulf War, several Army gynecologists reported their experiences with unplanned pregnancies.18,19 Hines19 reported his experience with the First Cavalry Division’s battalion medical units: within a 6-month study period, 24 pregnancies (among 1792 visits) were confirmed, yielding a crude pregnancy rate of 22.7 per 1000. He then extrapolated that number to the 40,000 other deployed women, predicting 900 pregnancies. Markenson and Raez18 found similar results at the Eighth Evacuation Hospital. When one considers the financial costs of returning each of those women to their home units and the cost of replacing them in combat units, the financial burden of unprotected intercourse is evident. It is in combat that emergency contraception could have its greatest effect.
The need for emergency contraception during peacetime is also important. A query of 250 women who presented for pregnancy testing at the Wilford Hall Medical Center gynecology clinic during 6 months of 1998 found an unplanned pregnancy rate of almost 60% among active duty women, most of whom (71%) were unhappy about the pregnancy (unpublished data). These numbers are significant when translated to costs that include pregnancy fees, lost wages, and possible abortion fees. The consequences of an undesired pregnancy include increased adverse pregnancy outcomes.21,22
Emotional costs and consequences of unwanted pregnancies on women or couples are incalculable. Advance provision of emergency contraception to soldiers gives them the ability to choose when childbearing is appropriate, thereby preventing painful decision-making concerning abortion. The problems suffered by unwanted children are then also avoided.
Primary preventive measures seek to prevent an event before it occurs. The finding of a 40% level of knowledge suggests there is much room for improvement in teaching about reproduction. This education should be added to existing lectures on sexually transmitted diseases (STDs) which are standard in basic enlisted and officer training. Unprotected intercourse is a reality during deployments. Reproductive health care during deployments should be maximized by the provision of contraception and condoms for STD prevention. Enough contraception should be provided to cover the entire deployment. Women should be encouraged to remain on their primary methods of contraception, because discontinuation of contraception was a significant problem during the Persian Gulf War.18,19 Troop medical clinics should be supplied with emergency contraception. Providers should be educated about the existence of emergency postcoital contraception and its correct timing. To simplify the process, emergency contraception kits could be issued upon deployment.
In 1994, a congressional mandate resulted in the establishment of the Defense Women’s Health Research Program. An Army offshoot, the Well Women Process Action Team created a goal of ensuring readiness (availability for immediate deployment) that necessitated "not only that the woman not be pregnant at the time of deployment but that she remains so throughout the deployment period."20 Emergency contraception could easily contribute to this readiness goal. The results of this survey demonstrate a need for improving emergency contraception awareness.
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Footnotes |
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Received March 10, 2000. Received in revised form June 21, 2000. Accepted July 26, 2000.
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References |
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2. Creinin MD. A reassessment of efficacy of the Yuzpe regimen of emergency contraception. Hum Reprod 1997;12:496–8.
3. Trussell J, Rodriquez G, Ellertson CE. New estimates of the effectiveness of the Yuzpe regimen of emergency contraception. Contraception 1998;57:363–9.[Medline]
4. Trussell J, Stewart F, Guest F, Hatcher RA. Emergency contraceptive pills: A simple proposal to reduce unintended pregnancies. Fam Plann Perspect 1992;24:269–73.[Medline]
5. Yuzpe AA, Lancee WJ. Ethinyl estradiol and dl-norgestrel as a postcoital contraceptive. Fertil Steril 1977;28:932–6.[Medline]
6. Task Force on Postovulatory Methods of Fertility Regulation. Randomized controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 1998;352:428–33.[Medline]
7. Harper CC, Ellertson CE. The emergency contraceptive pill: A survey of knowledge and attitudes among students at Princeton University. Am J Obstet Gynecol 1995;173:1438–45.[Medline]
8. Delbanco SF, Mauldon J, Smith MD. Little knowledge and limited practice: Emergency contraceptive pills, the public, and the obstetrician-gynecologist. Obstet Gynecol 1997;89:1006–11.[Abstract]
9. Graham A, Green L, Glasier AF. Teenagers’ knowledge of emergency contraception: Questionnaire survey in southeast Scotland. BMJ 1996;312:1567–9.
10. Smith BH, Gurney EM, Aboulela L, Templeton A. Emergency contraception: A survey of women’s knowledge and attitudes. Br J Obstet Gynaecol 1996;103:1109–16.[Medline]
11. Langer A, Harper C, Garcia-Barrios C, Schiavon R, Heimburger A, Elul B, et al. Emergency contraception in Mexico City: What do health care providers and potential users know and think about it? Contraception 1999;60:233–41.[Medline]
12. Van Look PF, von Hertzen H. Emergency contraception. Br Med Bull 1993;49:158–70.
13. Trussell J, Raymond EG. Statistical evidence about the mechanism of action of the Yuzpe regimen of emergency contraception. Obstet Gynecol 1999;93:872–6.
14. McDonald G. Women’s knowledge and attitudes about emergency contraception: A survey in a Melbourne women’s health clinic. Aust N Z J Obstet Gynaecol 1999;39:460–4.[Medline]
15. Muia E, Ellerston C, Lukhando M, Elel B, Clark S, Olenja J. Emergency contraception in Nairobi, Kenya: Knowledge, attitudes and practices among policymakers, family planning providers and clients, and university students. Contraception 1999;60:223–32.[Medline]
16. Lyon DS. Medical care of women deployed during Desert Storm. South Med J 1996;89:172–6.[Medline]
17. Hines JF. A comparison of clinical diagnoses among male and female soldiers deployed during the Persian Gulf War. Milit Med 1993;158:99–101.
18. Markenson G, Raez E. Female health care during Operation Desert Storm: The Eighth Evacuation Hospital experience. Milit Med 1992;157:610–3.
19. Hines JF. Ambulatory health care needs of women deployed with a heavy armor division during the Persian Gulf War. Milit Med 1992;157:219–21.
20. Davis LJ, Woods AB. Military women’s research. Milit Med 1999;164:6–10.
21. Sable MR, Spencer JL. Pregnancy wantedness and adverse pregnancy outcomes: Differences by race and Medicaid status. Fam Plann Perspect 1997;29:76–81.[Medline]
22. Brown SS, Eisengerg L. The best of intentions: Unintended pregnancy and the well-being of children and families. Washington, DC: National Academy Press, 1995.
This article has been cited by other articles:
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  E. Espey, T. Ogburn, D. Howard, C. Qualls, and J. Ogburn Emergency Contraception: Pharmacy Access in Albuquerque, New Mexico Obstet. Gynecol., November 1, 2003; 102(5): 918 - 921. [Abstract] [Full Text] [PDF]
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R. A. Jackson, E. B. Schwarz, L. Freedman, and P. Darney Advance Supply of Emergency Contraception: Effect on Use and Usual Contraception--A Randomized Trial Obstet. Gynecol., July 1, 2003; 102(1): 8 - 16. [Abstract] [Full Text] [PDF]
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