Emergency contraception use increases when pills are provided in advance.

Women who receive an advance supply of emergency contraceptives have four times the likelihood of those who do not of using the method within one year, according to a study of women from an inner-city public hospital. (1) Advance provision of the method did not affect these women's contraceptive consistency or the types of methods they used. At the end of one year, a greater proportion of women provided with emergency contraception than of those in the control group knew of emergency contraception (91% vs. 70%), could correctly name or describe the method (71% vs. 52%) and knew the correct timing of its use (23% vs. 10%).

To determine whether advance provision of emergency contraception is associated with increased use of the method and with changes in contraceptive behavior and knowledge, researchers recruited a sample of 370 postpartum women newly discharged from a San Francisco public inner-city hospital between September 1998 and March 1999. Women were eligible to participate in the study if they had had a live birth, spoke English or Spanish and would be available within the next year for follow-up.

Trained researchers asked participants questions regarding their demographic characteristics, pregnancy history and contraceptive use. In addition, women's knowledge of emergency contraception was determined by their answers to two questions: "If a woman just had sex and thinks she might become pregnant, is there anything she could do in the next few days to prevent pregnancy or not?" and "Have you ever heard of morning-after pills, also called emergency contraceptive pills, or not?"

After women completed the baseline survey, 184 were randomly assigned to the emergency contraceptive group and 186 to the control group. Women in the emergency contraceptive group received one regimen of emergency contraceptive pills (containing levonorgestrel and ethinyl estradiol), a five-minute educational session on how to use the method and an educational brochure; women in the control group received only the standard counseling given to all women prior to discharge. Researchers reinterviewed participants by telephone six months and one year after the baseline survey (78% were available at six months, and 69% at one year). Researchers used bivariate analyses to examine differences between the two groups and within each group over time.

Overall, 72% of participants were Hispanic; the mean age of the sample was 25.6. The majority (73%) were married; 38% of women reported having had a previous unwanted pregnancy, and 17% had had an elective abortion. Two-thirds reported that their most re cent pregnancy was unplanned; 29% of those pregnancies were because of contraceptive failure. There were no significant differences between the demographic characteristics of women in the emergency contraceptive group and those of women in the control group.

At baseline, 3% of women had ever used emergency contraceptives. Thirty-six percent reported knowing about emergency contraception; however, only 19% could name or describe a method, and 7% knew the correct timing for its use.

Over the one-year study period, 17% of women in the emergency contraceptive group used the method (88% of whom were first-time users), compared with 4% in the control group (71% of whom were first-time users); women in the emergency contraceptive group were four times as likely as those in the control group to use the method (relative risk, 4.0) and nearly five times as likely to use it for the first time (4.9). The differential in use was even greater among women who had unprotected sex at least once during the year: Women in the emergency contraceptive group had nearly six times the likelihood of those in the control group of having used emergency contraception (5.8). Three women in the emergency contraceptive group and two in the control group used the method more than once during the study period.

Overall, women were using contraceptives more consistently at one year than at baseline: Some 35-37% of women reported having used contraceptives most or all of the time at the initial interview, compared with 81-83% at the one-year interview. In addition, a greater proportion of women reported using very effective methods (i.e., sterilization, IUD, injectable, implant and the pill) at one year than at baseline (67-70% vs. 56-57%). Furthermore, 28-43% of exclusive condom users reported routine use of condoms at baseline, compared with 87-92% at one year. There were no differences between the emergency contraceptive group and the control group with regard to consistent contraceptive use or types of methods used.

Although women in both groups showed greater general and specific knowledge of emergency contraception at one year than at baseline, women in the emergency contraceptive group showed higher levels of knowledge for most measures. For example, at the one-year survey, a greater proportion of women in the emergency contraceptive group than of those in the control group had heard of emergency contraception (91% vs. 70%), could correctly name or describe the method (71% vs. 52%) and knew the correct timing of its use (23% vs. 10%). Interestingly, knowledge measures of the women in the emergency contraceptive group increased mostly between baseline and six months, whereas knowledge measures of women in the control group increased throughout the year. There were no significant differences between the groups and between interviews in either women's willingness or their reluctance to use emergency contraception.

Although advance provision of emergency contraception was associated with a significant increase in women's use of the method and did not affect their contraceptive behavior, the proportions of women who used the method were small. The researchers comment, "These low rates of use suggest that ready access is not the only issue. A lack of recognition of pregnancy risk has been shown to limit emergency contraception use." In addition, they mention that some women may choose not to use the method because they fear negative effects or believe that it is an abortifacient. The researchers suggest that future studies need to examine what motivates women to or prevents them from using the method appropriately.

REFERENCE

(1.) Jackson RA et al., Advance supply of emergency contraception: effect on use and usual contraception--a randomized trial, Obstetrics & Gynecology, 2003, 102(1):8-16.