In France, over-the-counter emergency contraception increases access, not risk.

The use of emergency contraception increased in France between 1999 and 2004, following the May 1999 introduction of a dedicated product that was almost immediately available in pharmacies with no prescription requirement. (1) According to a study of two cross-sectional surveys of women, increases in the use of emergency contraception had little apparent effect on indirect indicators of women's risky sexual behavior: The researchers found no increase in the proportion of women who had ever had intercourse, no decrease in the age at first sex and no increase in the proportion of young women at risk for unintended pregnancy. The use of modern contraceptives increased in the first five years of emergency contraception's over-the-counter status, and among women at risk for unintended pregnancy, levels of contraceptive use and use of effective methods did not diminish.

The data came from two household-based health surveys of 12-75-year-olds, conducted in 1999 and 2004. Analyses were restricted to the 4,166 women in 1999 and 7,490 in 2004 who were between the ages of 15 and 44 and had responded to questions on sexual activity, STDs, contraceptive use and abortion. Relevant questions were the same in both surveys. The researchers used a variety of logistic regression techniques to examine differences between survey years in women's emergency contraception use, sexual experience, contraceptive use and experience of abortion.

In late 1999 (six months after the introduction of the dedicated over-the-counter emergency contraceptive pill), 10% of sexually experienced women reported that they had ever used emergency contraception. By 2004, the proportion had risen to nearly 17%, and increases were significant for all age-groups but the oldest (40-44). Women aged 15-24 experienced an increase in emergency contraception use of 17 percentage points, while use among women aged 25 and older increased only five percentage points between 1999 and 2004.

In 2004, most women (60%) who had ever used emergency contraception had last obtained the drug from a pharmacy with no prescription. Further reflecting women's preference for obtaining emergency contraception directly from a pharmacy, 85% of women who had used the method in the last year had gotten it without a prescription. Older women had sought a prescription more commonly than their younger counterparts had (48% of 40-44-year-olds, compared with 12% of women younger than 40).

Despite the increase in emergency contraception use, the availability of the drug apparently encouraged little change in women's sexual activity or risk for unintended pregnancy. The proportion of women who had ever had sex did not change, with the exception of a small but significant decline among women aged 35 and older. Age at first intercourse did not change in any age-group.

The proportion of women younger than 25 who were at risk for unintended pregnancy (sexually active in the 12 months prior to the survey, currently with a partner, able to conceive and not trying to become pregnant) did not change between 1999 and 2004. The proportion of women aged 25 or older who were at risk exhibited a slight upswing, which was attributable to an increase from 72% in 1999 to 80% among those aged 40-44. Among those at risk for unintended pregnancy, the proportion who used contraceptives, either consistently or sporadically, remained stable among women younger than 25 years (94% in 1999 and 96% in 2004), and decreased slightly but significantly among older women (from 95% to 93%). However, the researchers point out, the increase in risk and decrease in contraceptive use cannot be attributed to use of emergency contraception, because only a small proportion of women older than 25 (9-21%, depending on specific age-group) reported having used emergency contraception in 2004.

Among women using any contraceptive, the proportion using the most effective methods increased from 84% in 1999 to 87% in 2004, while the proportion using other methods decreased from 16% to 14%. These changes were mainly attributable to a substantial shift among 18-19-year-olds from condom use to pill use: In 1999, 22% of 18 19-year-olds used condoms and 77% used the pill; in 2004, 12% of 18-19-year-olds used condoms, while 88% were pill users. Among the youngest women in the sample (15-17-year-olds), contraceptive use did not change between 1999 and 2004.

Overall, 17% of women in 1999 and 16% of women in 2004 reported having had an abortion. The proportion decreased from 20% to 17% among women aged 25 and older, but was 7% in both years among those younger than 25.

According to the researchers, France's "introduction of a dedicated product that was almost immediately available in pharmacies with no prescription requirement" had no negative influence on women's sexual behaviors. The researchers imply that instead of substantiating "concerns about the negative impact of easier access to [emergency contraceptive pills] on sexual risk-taking and regular contraceptive use," the policy did little more than allow women greater access to a needed drug.

REFERENCE

(1.) Moreau C, Bajos N and Trussell J, The impact of pharmacy access to emergency contraceptive pills in France, Contraception, 2006, 73(6):602 608.