Knowledge, attitudes, and use of emergency contraception among rural western North Carolina women.

Background: To determine the knowledge, attitudes and self-reported usage of emergency contraception (EC) in rural western North Carolina women.

Methods: Using a cross-sectional survey, with a convenience sample, participants self-administered the survey in waiting rooms of eight medical clinics in three counties in western North Carolina. Participants included 401 English-speaking women of childbearing age (18-44 years old) presenting for routine medical care during a three-month period in 2004.

Results: Of the 70.5% who responded, almost all (97%) were sexually active and most (92%) perceived an unintended pregnancy to be a problem. A majority of the participants (72%) were aware of EC, but only 7.5% of women reported usage in the last year. More than 80% of the surveyed women were uncertain if EC was the same as the abortion pill, RU-486. While only 16% of respondents indicated they had discussed EC with a doctor or another health professional, most women (89%) reported that doctors or other health professionals would be their first choice for accurate information about EC pills.

Conclusions: Among western North Carolina women of childbearing age, EC is rarely used, perhaps because of confusion about its mechanism of action. Furthermore, EC is infrequently discussed with doctors. Since women indicate that health care providers would be their preferred choice for accurate information about EC, improved patient education by physicians about EC would be a first step in increasing knowledge among patients.

Key Words: emergency contraception, Plan B, unintended pregnancy, survey research

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Unintended pregnancy is a major medical, psychosocial and public health problem. Data from the 1995 National Survey of Family Growth show that 49% of pregnancies and 31% of live births are unintended. (1) This translates into 3 million unintended pregnancies each year, of which approximately 1.31 million end in abortion. (2) Despite the increased availability of contraception, the rate of unintended pregnancies has not decreased significantly from 1993 to 1999. (3) Half of these unintended pregnancies result from inconsistent use of birth control or condom breakage. The other half occur in women who did not use any contraception at all. (4) Both of these populations are potential targets for the use of emergency contraception (EC) as a means of preventing unintended pregnancies.

Off label use of high doses of birth control pills for EC or postcoital contraception has been available for years. In 1997, the Food and Drug Administration approved two products (Preven and Plan B) that were specifically marketed for use as EC. Preven has been discontinued and Plan B is the only dedicated emergency contraceptive product currently available in the United States.

If administered within 120 hours of unprotected intercourse or failed contraception, EC pills can prevent 75 to 85% of unintended pregnancies. (5-7) Statistical modeling by Trussell shows that typical use of EC could reduce the unintended pregnancy rate in the United States by half. (6) However, despite its efficacy, use of EC in the US remains low. (8)

Several studies have been conducted to investigate the reasons for this low usage and potential interventions that could increase use among various populations. Data from a 1997 national representative survey of US health professionals suggest that almost all health care providers in the United States consider EC pills to be safe and effective. Yet very few providers discuss EC as a contraceptive option for patients and even fewer write prescriptions for EC. (9) Patients' lack of accurate knowledge and access to EC constitute barriers to use. (10-12)

Most studies regarding women's knowledge, attitudes and use of EC have been conducted in large urban populations or in countries other than the United States. (8-9,13) To date, few studies have surveyed women in the southern United States. This study was undertaken to determine the knowledge, attitudes and use of EC in a population of women in western North Carolina.

Materials and Methods

Surveys were administered to a convenience sample of English-speaking women presenting for medical care at two county health departments, three community-based residency clinics (Family Medicine or Obstetrics and Gynecology) and three private family physician offices across three counties. Institutional review board approval was obtained.

The survey consisted of a 42-item, multiple choice instrument that was adapted from an emergency contraception (EC) survey conducted in California. (14) Questions covered knowledge, attitudes and use of EC, as well as sociodemographics and sexual behavior.

Women between the ages of 18 and 44 were asked to participate in the study by the front office staff during the check-in process. Patients who volunteered to participate were given a packet that included an information sheet about the study, the 42-question survey and a self-addressed, return envelope. The patients anonymously completed the surveys in waiting rooms or examination rooms without assistance from office staff or providers and returned the surveys in sealed envelopes when completed.

Descriptive statistics were calculated and presented with 95% confidence intervals based on an estimated population of 14,028 women of childbearing age who sought medical care at the participating sites. Binary logistic regression was used to calculate odds ratios among self-identified cohorts of participants.

Results

Surveys were distributed and 422 were completed for an overall response rate of 70.5% (46.2-93.5%). Excluded from analysis were responses from five men, seven women outside the designated age range, four women without an age response, and five women whose survey responses covered little more than demographic characteristics. We analyzed responses from 401 women of childbearing age (18-44 years old).

Sociodemographics and Current Sexual Behavior

One hundred thirty (32%) women were between 18 and 24 years old, 177 (44%) between 25 and 34 years and 94 (23%) between 35 and 44 years (see Table 1). Most women were white (329 [84%]) or African-American (51 [13%]). Slightly more than half the women (213; 53%) were married or living with a partner, and 248 (62%) had children under the age of 18 years old. The median education level was some post secondary education, and the majority were employed (255; 64%). Most women had either private insurance (141; 36%) or Medicaid (174; 45%); 59 (15%) had no financial assistance for medical care.

The majority of women reported being sexually active (382, 97%). Of these, 189 women (47%) reported being not currently pregnant or trying to get pregnant, and neither they nor their partners were sterilized. This subset of women represented potential candidates for emergency contraception. Of these women, 115 (62%) reported always using birth control, while 59 (32%) reported use some to most of the time and 13 (7%) never used birth control.

Knowledge About Emergency Contraception

Most women (250; 63% [+ or -] 5%) answered "yes" when asked the following question: "As far as you know, if a woman has just had unprotected sex or thinks her birth control may have failed, is there anything she can do in the following days to prevent pregnancy?" Women's awareness of options for postcoital pregnancy prevention varied. Two hundred eighty women (72% [+ or -] 4%) knew you could take emergency contraception (EC) or the "morning after pill" to prevent pregnancy, and most women (237; 60% [+ or -] 5%) did know that EC is available in the US. However, 321 (81% [+ or -] 4%) were confused about the difference between RU-486 and EC: 27% thought EC and RU-486 were the same thing, while 54% did not know if there was a difference between the two.

Women reported learning about EC from a variety of sources. Healthcare professionals ranked third behind television news and friends as a source of information (Fig. 1). When directly asked if they had ever discussed EC with a doctor or another health professional, only 64 (16% [+ or -] 4%) indicated they had. When asked where they would seek accurate information about EC, 347 (88% [+ or -] 3%) women reported they would most likely go to a doctor (Fig. 2).

Use of Emergency Contraception

Only 29 women (7.5% [+ or -] 2.5%) indicated they had used EC previously. Eighty-eight women (23% [+ or -] 4%) knew someone who had used it. Overall, 178 (46% [+ or -] 5%) of respondents indicated they were likely to use EC, and 143 (37% [+ or -] 5) of the women were likely to recommend use of EC to others. Women who reported confusion about the difference between EC and RU-486 would be less likely to use EC at some point in the future than women who were not confused (OR = 1.89; 95% CI, 1.107-3.089).

[FIGURE 1 OMITTED]

Potential Candidates for Emergency Contraception

Of the 189 women considered to be potential candidates for EC, 19 (10% [+ or -] 4%) reported previous use of EC and 103 (55% [+ or -] 7%) reported being likely to use EC in the future if needed. Potential candidates anticipated an increased likelihood of EC use if they had a pack at home (109; 58% [+ or -] 7%) or if their doctor or care provider discussed EC with them (93; 50% [+ or -] 7%). Only 34 women (19% [+ or -] 6%) felt the use of EC was morally wrong.

One hundred sixty-seven women (89% [+ or -] 4%) indicated they would seek out accurate information about EC from their doctors, but only 37 (20% [+ or -] 6%) had discussed EC with a doctor or other health care provider to date.

[FIGURE 2 OMITTED]

Discussion

Awareness of emergency contraception (EC) in this population of women was average compared with findings from other studies (ranging from 22.8-84%). (13-18) Although most women were aware of the existence of types of EC, many confused EC with an abortifactant. Until recently, the exact mechanism of EC had not been completely elucidated. (19) EC had been known to prevent pregnancy by preventing ovulation. What had been debated is the effect of EC on implantation if taken after fertilization had already occurred. A recent article by Ortiz et al, studying the effect of EC after fertilization, clarified this confusion by providing evidence that EC does not affect postfertilization events. (20) Education regarding the mechanism of action of EC and defining the difference between EC and RU-486 should be an important focus of patient education to increase the likelihood of use among western North Carolina women.

The participants who knew about EC most commonly listed television and friends as their source of information, which is consistent with the Kaiser Family Foundation Study. (14,21) Interestingly, when asked where they would go for accurate information about EC, most women indicated their physician or care provider as their preferred source. This suggests that women are receptive to learning about EC from their physicians and providers; thus emphasizing the need for provider education on the importance of discussing EC with their patients.

Our study had several limitations. Because of limited financial resources, the survey was only administered in eight sites in western North Carolina using a convenience sample rather than a regionally representative, random sample. The education level of the sample population is higher than the education level of the population based on the 2000 census data for this region, suggesting that people of lower education levels may have declined to participate. (22) In addition, there is a large and growing Spanish-speaking population in western North Carolina. A second study that specifically targets the Spanish-speaking population has recently received IRB approval and data collection has begun.

Conclusion

We found that reproductive-age women in western North Carolina were aware of emergency contraception (EC), but often confused EC with an abortifactant. This confusion may make some patients less likely to use EC in the future. The women in our region were receptive to learning more about EC and were interested in obtaining that information from their health care providers. Use of EC in western North Carolina could be increased by encouraging health care professionals to provide accurate information about EC to women, thus dispelling the misconception that EC is an abortifactant.

Acknowledgments

We would like to thank the faculty and staff at the 2004 to 2005 UNC-Chapel Hill Faculty Development Fellowship which was partially funded by the US Department of Health and Human Services Grant HRSA# 6-D14-HP00019, and Dr. Suzanne Landis for their assistance with this project. Special thanks to Kelly Christianson for help with manuscript preparation.

References

1. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24-29.

2. Ventura SJ, Abma JC, Mosher WD, et al. Estimated pregnancy rates for the United States, 1990-2000: an update. Natl Vital Stat Rep 2004;52. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_23.pdf. Accessed June 2, 2006.

3. Beck L, Johnson C, Morrow B, et al. PRAMS 1999 Surveillance Report. Atlanta, GA: Center for Disease Control and Prevention. MMWR Morbid Mortal Wkly Rep 2002;51:1-27.

4. Jones RK, Darroch JE, Henshaw SK. Contraceptive use among US women having abortions in 2000-2001. Perspect Sex Reprod Health 2002;34:294-303.

5. Raine TR, Harper CC, Rocca CH, et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA 2005;293:54-62.

6. Trussell J, Stewart F, Guest F, et al. Emergency contraceptive pills: a simple proposal to reduce unintended pregnancies. Fam Plann Perspect 1992;24:269-273.

7. Rodrigues I, Grou F, Joly J. Effectiveness of emergency contraceptive pills between 72 and 120 hours after unprotected sexual intercourse. Am J Obstet Gyneco 2001;184:531-537.

8. Trussell J, Stewart F, Guest F, et al. Emergency contraception: a review of the programmatic and social science literature. Contraception 2000;61:145-186.

9. Delbanco SF, Stewart FH, Koenig JD, et al. Are we making progress with emergency contraception? Recent findings on American adults and health professionals. J Am Med Womens Assoc 1998;53:242-246.

10. Anonymous. Improving access to emergency contraceptive pills. Popul Briefs 1999;5:3.

11. Glasier A. Emergency contraception. Br Med Bull 2000;56:729-738.

12. Pham A. Emergency contraception (post-coital Contraception). J Okla State Med Assoc 2002;95:371-374.

13. Jackson R, Schwarz EB, Feedman L, et al. Knowledge and willingness to use emergency contraception among low-income post-partum women. Contraception 2000;61:351-357.

14. Salganicoff A, Wentworth B, Ranji U. Emergency Contraception in California; Findings from a 2003 Kaiser Family Foundation Survey. Available at: http://www.kff.org/womenshealth/whp021804pkg.cfm. Accessed June 2, 2006.

15. Smit J, McFadyen L, et al. Emergency contraception in South Africa: knowledge, attitudes and use among public sector primary health care clients. Contraception 2001;64:333-337.

16. Van Royen AR, Calvin CK, Lightner CR. Knowledge and Attitudes About Emergency Contraception in a Military Population. Obstet Gynecol 2000;96:921-925.

17. Foster D, Harper C, Bley J, et al. Knowledge of emergency contraception among women aged 18-44 in California. Am J Obstet Gynecol 2004;191:150-156.

18. Sorhaindo A, Becker D, Fletcher H, et al. Emergency contraception among university students in Kingston, Jamaica: A survey of knowledge, attitudes and practices. Contraception 2002;66:261-268.

19. Croxatto HB, Ortiz ME, Mechanisms of action of emergency contraception. Steroids 2003;68:1095-1098.

20. Post-coital administration of levonorgestrel does not interfere with post-fertilization events in the new-world monkey Cebus apella. Hum Reprod 2004;19:1352-1356.

21. Delbanco SF, Mauldon J, Smith MD. Little knowledge and limited practice: emergency contraceptive pills, the public and the obstetrician-gynecologist. Obstet Gynecol 1997;89:1006-1011.

22. Buncombe County Educational Attainment, 2000 Census Data. Available at: http://www.censusscope.org/us/s37/c21/print_chart_education.html. Accessed June 2, 2006.

Never fear shadows. They simply mean there's a light shining somewhere
nearby.
--Ruth E. Renkel

E. Blake Fagan, MD, H. Eleni Boussios, MPH, Ruchi Moore, MD, and Shelley L. Galvin, MA

From the Division of Family Medicine and the Department of Obstetrics and Gynecology Mountain Area Health Education Center, Asheville, NC, and the Department of Maternal and Child Health, University of North Carolina Chapel Hill School of Public Health, Chapel Hill, NC.

Reprint requests to Shelley L. Galvin, MAHEC Department of Obstetrics and Gynecology, 93 Victoria Road, Asheville, NC 28801. Email: [e-mail]

This project was funded in part by a grant from the Bureau of Health Professional, HRSA Grant #5-D55-HP00019, US Department of Health and Human Services, Washington, DC, and in part by a grant from the UNC/AHEC Reproductive Health Research Network, UNC Chapel Hill, School of Public Health, Department of Maternal and Child Health.

Accepted April 6, 2006.

RELATED ARTICLE: Key Points

* Over 80% of surveyed women incorrectly believed or expressed confusion about emergency contraception being the same as the abortion pill.

* Very few women (7.5%) in western North Carolina report use of emergency contraception (EC); however, 46% report being likely to use EC in the future.

* Women without accurate knowledge about EC have more objection to potential use of EC than women with accurate information (OR = 1.89; 95% CI, 1.107-3.089).

* Most women (89%) desire to obtain accurate information about EC from their care provider but only 16% reported any discussion of EC by their care provider with them.

Table Sociodemographic characteristics of respondents

N = 401                                                  N (%)

Age
  18-24                                                  130 (32.4%)
  25-34                                                  177 (44.1%)
  35-44                                                   94 (23.4%)

Race
  White/White Latino                                     329 (83.5%)
  African American/Black Latino                           51 (12.9%)
  Other                                                   13 (3.3%)
  Do not know                                              1 (0.3%)

Marital status
  Married/living with partner                            213 (53.3%)
  Widowed/divorced/separated                              73 (18.2%)
  Never married                                          109 (27.3%)
  Do not know                                              5 (1.3%)

Children under 18 at home
  Yes                                                    248 (62.0%)
  No                                                     151 (37.8%)
  Do not know                                              1 (0.3%)

Last grade completed
  Less than high school                                   63 (15.9%)
  High school graduate or GED                            105 (26.4%)
  Business, technical or vocational school/some college  145 (36.5%)
  College graduate                                        61 (15.4%)
  Postgraduate/professional training                      22 (5.5%)
  Do not know                                              1 (0.3%)

Employment/student status
  Employed full or part time                             220 (63%)
  Student                                                 28 (7.0%)
  Student & employed                                      35 (8.8%)
  Unemployed/not in school                               111 (27.8%)
  Retired                                                  2 (0.5%)
  Do not know                                              4 (1.0%)

Main source of health insurance coverage
  No health insurance                                     59 (15.4%)
  Private insurance                                      141 (36.8%)
  Government program                                     172 (44.9%)
  Do not know                                             11 (2.9%)