Contraception xx (2014) xxx – xxx
Original research article
Routine counseling about intrauterine contraception for women seeking emergency contraception☆ E. Bimla Schwarz a, b, c,⁎, Melissa Papic a , Sara M. Parisi b , Erin Baldauf a , Rachel Rapkin c , Glenn Updike c a University of Pittsburgh, Department of Medicine University of Pittsburgh, Graduate School of Public Health, Department of Epidemiology c University of Pittsburgh, Department of Obstetrics, Gynecology and Reproductive Sciences Received 19 November 2013; revised 7 February 2014; accepted 13 February 2014 b
Abstract Objective: To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an innercity clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC. Study design: For 8 months before and 21 months after this change in clinic policy, women aged 15–45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n= 328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data. Results: Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, pb0.01; EMR: 32% vs. 68%, pb0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months. Conclusions: Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC. Implications: Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement. © 2014 Elsevier Inc. All rights reserved. Keywords: Intrauterine contraception; Copper IUD; Emergency contraception; Contraceptive counseling; Same day; Title X
1. Introduction Postcoital or emergency contraception (EC) can help women avoid undesired pregnancy after unprotected sex or
☆ Funding: R01PG000859 (PI Schwarz) from Department of Health and Human Services Office of Population Affairs. ⁎ Corresponding author. Women's Health Services Research Unit, Center for Research on Health Care, Associate Professor of Medicine, Epidemiology, Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, Pa 15213. Tel.: +1 412 586 9836; fax: +1 412 692 4838. E-mail address: [email protected] (E.B. Schwarz).
0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2014.02.007
contraceptive failure [1]. Despite initial optimism that EC pills offered a disruptive technology that would provide a quantum leap towards liberating women from undesired pregnancy [2], multiple studies have failed to demonstrate that increasing access to EC pills has reduced population rates of undesired pregnancy [3–5]. This is due in large part to the fact that EC pills are used relatively rarely [6], while unprotected sex remains common. An alternative approach to EC is the placement of a copper intrauterine device (IUD) within 1 week of a contraceptive emergency. Although the option of postcoital IUD use was first discussed over 40 years ago [7], this option is rarely presented to women seeking EC; many of whom
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experience unintended pregnancies after using EC pills [8]. The copper T380A is estimated to be 10 times as effective as EC pills [9] and has been shown to be highly effective at all points of the menstrual cycle [10]. In a previous study, we found that 15% of women seeking EC would be interested in IUD placement if it was offered on the day of their visit [11]. Thus, our inner-city, Title X-funded family planning clinic committed to modifying clinic policy and routinely providing structured counseling about IUDs and offering same-day placement of a copper IUD to all women seeking EC. In this study, we compared knowledge and use of IUDs and implants among women seeking EC, before and after this clinic-wide intervention.
2. Methods During the preintervention period (January 4, 2011 to August 19, 2011), women seeking EC from the study clinic received EC pills from a nurse without structured contraceptive counseling, the offer of IUD placement for EC or any contraceptive counseling from a clinician. During the intervention period (August 22, 2011 to May 30, 2013), women seeking EC were asked to wait to see a nurse practitioner or physician who verbally provided brief structured counseling about IUDs and implants [Appendix 1] and offered same-day placement of a copper IUD for EC or same-day placement of a hormonal IUD or implant with EC pills. The structured counseling was adapted from the scripted introduction to IUDs and implants developed by the St. Louis Contraceptive CHOICE Project [12]. Posters were placed in all clinic rooms identifying IUDs as the most effective form of EC. However, the option of same-day placement of a copper IUD was limited to women who reported no instances of unprotected intercourse during the 8–14 days prior to their clinic visit (due to concerns of risk for luteal phase pregnancy) and women who had no evidence of cervicitis on exam. Likewise, same-day placement of a hormonal IUD or contraceptive implant was limited to women who reported no unprotected intercourse during the 6–14 days prior to their clinic visit and were also willing to take EC pills. During the intervention period, women seeking walk-in pregnancy testing were asked whether they desired pregnancy and whether they had unprotected sex in the last week to assess their need for EC. During both the preintervention and intervention periods of this study, we asked all women seeking EC from the study clinic (including those who initially requested pregnancy testing but were found to be eligible for EC) who stated that they wished to avoid pregnancy for at least 6 months and had a negative pregnancy test at their visit to complete surveys before leaving the study clinic. Women who were already using a highly effective reversible contraceptive (i.e., IUD or implant) at the time of the initial clinic visit or had a tubal ligation were excluded from this study. These surveys assessed women's receipt of contraceptive counseling at
their visit, contraceptive knowledge and plans for contraceptive use. Three months after study enrollment (during both the preintervention and intervention periods of this study), a research assistant contacted each participant to complete a follow-up survey to assess her current contraceptive knowledge, which contraceptives she had used during the last 3 months and whether she had become pregnant. Contraceptive knowledge was assessed with nine items concerning the effectiveness, reversibility and duration of use of intrauterine, subdermal and injectable contraception (Appendix 2). Twelve months after their clinic visit, women who were offered a same-day IUD or implant were again contacted and asked about their contraceptive use. Women received a token gift (worth approximately US$5) for completing a survey immediately after their clinic visit and US$10 following completion of the 3-month and 12-month surveys. We abstracted de-identified data from the study clinic's electronic medical record (EMR) on June 9, 2013 to determine rates of contraceptive initiation, contraceptive removal and pregnancy within 3 months of seeking EC among all women aged 15–45 years who had sought EC from the study clinic (during both the preintervention and the intervention periods). If a woman sought EC more than once during this study, only her first EC visit was included in this analysis. This study was approved by the Institutional Review Board of the University of Pittsburgh. We used descriptive statistics to characterize study participants and chi-square tests to compare the significance of differences between the preintervention and intervention periods in the survey data and EMR data. All analyses were performed using Stata 13.0 (StataCorp, College Station, TX, USA).
3. Results During the 8-month preintervention period, the study clinic provided EC on one or more occasions to 82 unique women [including 18 (22%) women who initially requested pregnancy testing], averaging 10.2 women per month. During the 21-month intervention period, 235 unique women received EC [including 102 (43%) who initially requested pregnancy testing], averaging 11.2 women per month. An additional 11 women presented to the clinic seeking EC but ultimately did not receive any form of EC (1 during the preintervention and 10 during the intervention period), providing a total of 328 unique, EC-seeking women for this analysis. Fifty-seven percent (n= 186/328) of eligible women agreed to complete surveys before leaving the study clinic. Women who completed surveys during the intervention period and preintervention periods were very similar. EMR data indicated that women who did and did not agree to complete surveys were of very similar age, race and parity. Most participating women were African American with annual household incomes less than US$20,000. The
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majority of participants had experienced an unwanted pregnancy and previously used EC. Additional sociodemographic characteristics of women completing surveys are shown in Table 1; reproductive characteristics are shown in Table 2. Among those who completed surveys, women were more likely to report having discussed the IUD (77% intervention vs. 8% preintervention, pb0.001) and implant (36% intervention vs. 8% preintervention, p=0.004) with a clinician at the time they sought EC during the intervention period compared to women who sought EC during the preintervention period. Similarly, intervention-period women were more likely to report that all their questions about birth control had been answered (96% intervention vs. 88% preintervention, pb0.001) and more likely to report being very satisfied with the discussion of birth control they had at their visit (76% intervention vs. 63% preintervention,
Table 1 Sociodemographic characteristics of women who completed surveys after seeking EC from the study clinic
Age, mean (standard deviation) Race Black White Bi-racial Other Relationship status Married Not married, but relationship Actively dating, no relationship Single Divorced/Separated Widowed Education level Some high school High school graduate or GED Some college or 2-year degree College degree Employment status Does not work Works full time Works part time Household income bUS$5000 US$5000 to 20,000 US$20,001 to 50,000 More than US$50,000 Do not know Health insurance Public Private
Preintervention (n= 37), % (n)
Intervention (n= 149), % (n)
24.6 (4.9)
23.8 (4.9)
p Value 0.34 0.68
56.8% (21) 21.6% (8) 18.9% (7) 2.3% (1)
67.6% (100) 18.2% (27) 10.1% (15) 4.1% (6)
8.3% (3) 50.0% (18)
3.4% (5) 55.5% (81)
25.0% (9)
14.4% (21)
16.7% (6) 0.0% (0) 0.0% (0)
24.7% (36) 0.0% (0) 2.1% (3)
22.2% (8) 38.9% (14)
16.6% (24) 37.9% (55)
27.8% (10)
37.2% (54)
11.1% (4)
8.3% (12)
52.8% (19) 25.0% (9) 22.2% (8)
54.5% (79) 15.9% (23) 29.7% (43)
23.8% (10) 38.1% (16) 14.3% (6) 7.1% (3) 16.7% (7)
23.8% (34) 33.6% (48) 12.6% (18) 1.4% (2) 28.7% (41)
78.4% (29) 11.1% (4)
84.6% (126) 6.0% (9)
0.26
0.68
0.10
0.20
GED, general educational development.
0.10 0.40
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Table 2 Reproductive characteristics of women who completed surveys after seeking EC⁎
Prior pregnancy Prior unwanted pregnancy Prior use of EC Ever In last year Last 3 months Multiple episodes of unprotected sex in last month Days since unprotected intercourse, med (IQR) Most effective contraceptive used when EC requested None Withdrawal Condoms Pills Patch Ring Depo medroxyprogesterone acetate (DMPA) Plans if pregnant today Abortion Adoption Parent Do not know
Preintervention period (n= 37), n (%)
Intervention period (n=149), n (%)
p Value
27/36 (75%) 20/34 (59%)
107/145 (74%) 81/142 (57%)
0.88 0.85
23/34 (68%) 12/33 (36%) 7/35 (20%) 20/36 (56%)
80/135 (59%) 57/138 (41%) 36/141 (26%) 76/136 (56%)
0.37 0.60 0.50 0.97
1 (1)
2 (2)
0.007 0.76
18/37 (49%) 4/37 (11%) 13/37 (35%) 1/37 (3%) 0/37 (0%) 1/37 (3%) 0/37 (0%)
60/149 (40%) 19/149 (13%) 46/149 (31%) 17/149 (11%) 0/149 (0%) 2/149 (1%) 1/149 (1%)
12/37 (32%) 2/37 (5%) 6/37 (16%) 17/37 (46%)
35/146 (24%) 2/146 (1%) 63/146 (44%) 46/146 (32%)
0.02
IQR, interquartile. ⁎ Denominator not matching the n for each time period indicates missing data due to subjects not answering the survey question.
p=0.03). In addition, a greater percentage of women reported accurate knowledge of the effectiveness, reversibility and duration of use of intrauterine and subdermal contraception after the intervention (Table 3). EMR data indicate that prior to this intervention no women had an IUD or implant placed the day she sought EC. During the intervention period, 11.0% (36/328) of women seeking EC had a same-day IUD placed (33 copper IUDs and 3 levonorgestrel IUDs), while 2 women had a same-day Nexplanon placed after taking levonorgestrel pills; within 5 days of seeking EC, a total of 12% (n= 40) had an IUD or implant placed. As women were more likely to agree to complete surveys if they received a same-day IUD, 21% (n= 31) of women completing surveys reported same-day IUD placement, and a total of 25% (n= 37) reported IUD or implant placement within 5 days of seeking EC. Most women (68%) who opted for same-day IUD placement had heard about IUDs at least twice before they sought EC. Among women who did not get a same-day IUD or implant and were not scheduled
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Table 3 Proportion of participants reporting accurate contraceptive knowledge after visits to the study clinic for EC⁎ When exiting clinic
IUD Effectiveness Duration Reversibility Hormone-free option Implant Effectiveness Duration Reversibility DMPA Effectiveness Duration Reversibility
Three months after visiting clinic
Preintervention (n=37), n (%)
Intervention period (n=149), n (%)
p Value
Preintervention (n=23), n (%)
Intervention period (n=112), n (%)
p Value
9/35 (26%) 21/35 (60%) 19/34 (56%) 18/34 (53%)
70/144 (49%) 117/144 (81%) 92/139 (66%) 103/141 (73%)
0.01 0.007 0.26 0.02
5/23 (22%) 18/23 (78%) 11/23 (48%) 13/23 (57%)
54/112 (48%) 90/112 (80%) 76/112 (68%) 77/112 (69%)
0.02 0.82 0.07 0.26
5/35 (14%) 5/35 (14%) 17/33 (52%)
51/144 (35%) 58/144 (40%) 91/140 (65%)
0.02 0.004 0.15
4/23 (17%) 5/23 (22%) 10/23 (44%)
35/112 (31%) 27/112 (24%) 67/112 (60%)
0.18 0.81 0.15
21/35 (60%) 26/35 (74%) 13/34 (38%)
64/144 (44%) 118/143 (83%) 68/141 (48%)
0.10 0.27 0.29
12/23 (52%) 18/23 (78%) 10/23 (44%)
53/112 (47%) 104/112 (93%) 45/112 (40%)
0.67 0.03 0.77
⁎ Denominator not matching the n for each time period indicates missing data due to subjects not answering the survey question.
for contraceptive placement within 5 days of their clinic visit, 23% (n= 25) reported wanting to receive an IUD or implant the day of their clinic visit but not receiving one. The most common reason for not receiving desired sameday IUD or implant placement was concern for luteal phase pregnancy when women had multiple instances of unprotected sex within the 2 weeks prior to their clinic visit (n= 15). Another four women desiring an IUD or implant did not have time to wait for placement, an additional four could not have their contraception inserted due to clinic time constraints (scheduling conflicts, lack of provider, etc.) and two were advised to return on another day after expressing ambivalence about IUD use. Seventy-three percent of survey participants completed follow-up surveys 3 months after seeking EC from the study clinic and being contacted by phone (46%), email (29%), text message/social media (19%) or in-clinic (7%); those who completed 3-month follow-up surveys were similar to those lost to follow-up in terms of race and parity. However, younger participants were more likely to be lost to follow-up [mean age (standard deviation) in years of noncompleters 22.7 (4.8) vs. completers 24.4 (4.9), p=0.04]. Among those who completed 3-month follow-up surveys, significantly more women from the intervention period reported accurate knowledge of the effectiveness of IUDs (Table 3) compared to women in the preintervention period. In addition, there was a drop in the proportion of women reporting use of no contraception 3 months after seeking EC (17% preintervention vs. 4% intervention period, p=0.01), largely due to increased use of IUDs. According to survey data, during the intervention period, 40% of women reported initiation of IUD or implant use within 3 months of seeking EC compared to only 17% during the preintervention period (p=0.04). The EMR data echoed this increase in initiation of IUD or implant use within 3
months of seeking EC (22% intervention vs. 10% preintervention, p=0.01). Importantly, during the intervention period there was no significant change in the proportion of women reporting condom use, either as their most effective contraceptive or in combination with another method (Table 4). Of those who had an IUD placed the day they sought EC and completed 3-month follow up, 88% (23/26) reported ongoing IUD use. Of the 3 women who had discontinued IUD use by 3 month follow-up, one reported IUD expulsion and two requested removal for pain/ bleeding. Of those who have now completed 12-month follow-up surveys, 81% (13/16) reported continued IUD use. Reasons for IUD discontinuation between 3- and 12month follow-up included desire for pregnancy (n= 1). According to the EMR data, only 11.5% (3/26) of women who had a same-day IUD placed had their IUD removed within 3 months of placement. Of the 15 women who had same-day IUD placement 12 or more months before we abstracted EMR data, only 3 (20%) had their IUD removed within 12 months of placement. Pregnancy rates among women who completed 3month follow up surveys were lowest among those who had an IUD or implant placed within 5 days of visiting the study clinic; one woman experienced a copper IUD failure (with her IUD in place) several weeks after IUD placement, producing a pregnancy rate of [3% (1/30), 95% confidence interval (CI): 0%–18%] compared to those who received ulipristal acetate pills [38% (5/13), 95% CI: 18%–65%] or levonorgestrel EC pills [13% (12/ 91), 95% CI: 8%–22%]. EMR data echoed this; pregnancy documented within 3-months of receipt of EC was lowest for women who had an IUD placed within 5 days of seeking EC [3.8% (1/26), 95% CI: 0%–20%], compared to those who received ulipristal acetate [15.4% (2/13), 95% CI: 2%–45%] and those who received
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Table 4 Contraceptive use 3-months after seeking EC from the study clinic Survey data Preintervention (n=23) 17% (4) IUD/Implant placed within 3 months of EC b Most effective method used within 3 months of seeking EC b IUD 17% (4) Implant (0) DMPA (0) Ring 22% (5) Pills 4% (1) Patch (0) Male condoms 39% (9) Withdrawal (0) No contraception within 3 months of seeking EC 17% (4) Condom use in 3 month after seeking EC 61% (14)
EMR data Intervention (n= 112)
p Value
Preintervention (n=83)
Intervention (n= 208 a)
p Value
40% (47)
0.04
10% (8)
22% (46)
0.01
36% (43) 3% (4) 11% (12) 10% (11) 17% (19) (0) 20% (22) 4% (4) 4% (4) 59% (66)
0.08 0.37 0.10 0.11 0.12 — 0.04 0.36 0.01 0.86
10% (8) (0) 4% (3) 10% (8) 10% (8) (0) n/a n/a 68% (56) c
21% (43) 1% (3) 13% (26) 12% (25) 21% (43) 0.5% (1) n/a n/a 32% (67) c
b0.01 0.11 0.02 0.63 0.03 0.52 — — b0.01
IUD: intrauterine contraceptive device. n/a: These methods are not reliably documented in the EMR. a When EMR data was abstracted, it had been less than 3 months since 37 women had sought EC from the study clinic; the women with incomplete data were excluded from these analyses. b Numerator and denominator include women who had a same-day IUD or implant placed even if no follow up survey was completed; during intervention period, n= 119. c No contraception documented in the EMR; barrier or behavioral contraception may have been used.
levonorgestrel EC pills [8.6% (21/244), 95% CI: 5%– 13%]. However, overall pregnancy rates within 3 months of seeking EC dropped only marginally in the EMR data (10.8% preintervention vs. 7.1% intervention, p=0.29) and not at all in the survey data (13.0% preintervention vs. 14.3% intervention, p=0.88).
4. Discussion This study demonstrates that routine provision of structured counseling with the offer of same-day placement of an IUD or implant is feasible and increases women's knowledge and use of highly effective reversible contraceptives 3 months after seeking EC. As very few women requested contraceptive removal within 3 months of placement, we feel that the clinic was able to offer convenient access to desired services without raising the specter of coercion. Rather, this population appears to continue to face significant unmet need for highly effective reversible contraception as only 11% of women received same-day IUD or implant placement and among women who did not receive same-day contraceptive placement, 23% reported that they had wanted placement of an IUD or implant the day they sought EC. Cost was generally not a barrier for women served by the study clinic due to the availability of Title X funding and IUDs donated by a private foundation. However, some women had insurance plans which either did not cover their desired form of EC or required prohibitive co-pays [13,14]. More commonly, time constraints that limited women's ability to wait until a clinician was available to place their
desired contraceptive prevented some women from receiving desired same-day placement of an IUD or implant; only four women returned within 5 days of seeking EC to have an IUD inserted. A final factor limiting same-day placement of IUDs was concern for luteal phase pregnancy when women reported unprotected intercourse during the preceding 8–14 days; such women were not offered placement of an IUD on the day she sought EC and were instead asked to schedule a follow-up appointment at least 14 days following her most recent act of unprotected intercourse. Unfortunately, it was relatively common for women who reported unprotected intercourse in the last week to also report unprotected intercourse in the prior week. The number of women who became pregnant within 3 months of seeking EC further highlights this population's unmet need for effective contraception. Previous studies have also reported high rates of unintended pregnancy among women who received only EC pills [8,15], particularly when women are overweight and have repeated acts of unprotected intercourse after use of EC pills [16]. Although this study was not powered to examine changes in rates of pregnancy, we were disappointed to see no change in pregnancy rates given the existing literature on the relative effectiveness of available contraceptives. However, in truth, unless the women destined to experience unintended pregnancies adopted effective contraception, population rates of unintended pregnancy would be expected to remain unchanged, even if all other women initiated use of highly effective reversible contraception. Although 75% of the St. Louis CHOICE Project's 9256 participants opted for highly effective reversible contraceptives, it took a few years to appreciate significant reductions in rates of unintended pregnancy [17].
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Our study participants differ from the St. Louis CHOICE study's participants in a number of important ways. First, women in this study were not required to be willing to try a new method of contraception; they did not complete any phone screening, or even schedule an appointment in an effort to initiate contraception, but rather simply walked into clinic seeking EC, with most expecting to receive EC pills. Finally, we are not aware of any “snowball” referrals by friends or relatives of women who were specifically interested in obtaining free IUDs or implants on the day they came to the study clinic. Thus, although sobering, our findings may offer a realistic sense of how difficult it will be to replicate the CHOICE Project's success in other settings. Nonetheless, the importance of offering same-day contraceptive placement services is highlighted by our finding that some aspects of women's contraceptive knowledge decreased within 3-months of their clinic visit. Of note, although some have worried that providing women at high risk of sexually transmitted infections (STIs) with contraceptive alternatives will decrease women's condom use and increase risk of STI, participants in this study were not less likely to use condoms when offered same-day placement of an IUD or implant. In interpreting this study's findings, certain data limitations must be considered. Although our survey completion rate was higher than expected for this population, we cannot be certain that the changes observed in the surveyed group reflect changes in the overall population served by the study clinic. According to the clinic-wide EMR data, survey completers were, for instance, more likely to opt for same-day IUDs and to report initiation of IUDs in the 3 months after their clinic visit. On the other hand, our EMR data may be incomplete if women took a pregnancy test at home or received contraception and/or had their IUD removed outside this particular health system. However, women served by this clinic typically receive all of their care within this large health system, and our survey and EMR data on IUD discontinuation within 3 months match perfectly. Finally, as our study does not have a temporal control group, it is possible that the changes seen in contraceptive knowledge and use simply reflect secular changes, although we are not aware of any other local efforts to educate this population of women about IUDs or implants either prior to or during this study period. In conclusion, this study demonstrates that routine provision of structured counseling about highly effective reversible contraceptives and the option of same-day placement is feasible and improves contraceptive knowledge and use among women seeking EC without adversely affecting condom use. Women who seek EC must be recognized as at high risk of unintended pregnancy until use of a more effective contraceptive is initiated. Acknowledgments The ECWIP Study team is grateful to Dr. Matthew Reeves, Dr. Caroline Moreau and Dr. Candace McClure for serving on our data safety and monitoring committee.
Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.contraception.2014.02.007. References [1] Cheng L, Che Y, Gulmezoglu AM. Interventions for emergency contraception. Cochrane Database Syst Rev 2012;8 [CD001324: Epub 2012/08/17]. [2] 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(6):932–7 [Epub 1997/06/ 01]. [3] Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007 [CD005497, Epub 2007/04/20]. [4] Rodriguez MI, Curtis KM, Gaffield ML, Jackson E, Kapp N. Advance supply of emergency contraception: a systematic review. Contraception 2013;87(5):590–601. [5] Raymond EG, Trussell J, Polis CB. Population effect of increased access to emergency contraceptive pills: a systematic review. Obstet Gynecol 2007;109(1):181–8 [Epub 2007/01/02]. [6] Daniels K, Jones J, Abma J. Use of emergency contraception among women aged 15–44: United States: 2006–2010. NCHS Data Brief 2013;112:1–8 [Epub 2013/06/08]. [7] Post-coital use of IUD. Asian Pac Popul Programme News 1977;6(4):39 [Epub 1977/01/01]. [8] Falk G, Falk L, Hanson U, Milsom I. Young women requesting emergency contraception are, despite contraceptive counseling, a high risk group for new unintended pregnancies. Contraception 2001;64(1):23–7 [Epub 2001/09/06]. [9] Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 2012;27(7):1994–2000 [Epub 2012/05/10]. [10] Turok DK, Godfrey EM, Wojdyla D, Dermish A, Torres L, Wu SC. Copper T380 intrauterine device for emergency contraception: highly effective at any time in the menstrual cycle. Hum Reprod 2013;28(10):2672–6. [11] Schwarz EB, Kavanaugh M, Douglas E, Dubowitz T, Creinin MD. Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol 2009;113(4):833–9 [Epub 2009/03/24]. [12] Madden T, Mullersman JL, Omvig KJ, Secura GM, Peipert JF. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception 2013;88(2):243–9. [13] Pace LE, Dusetzina SB, Fendrick AM, Keating NL, Dalton VK. The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance. Medical Care 2013;51(11):959–63. [14] Gariepy AM, Simon EJ, Patel DA, Creinin MD, Schwarz EB. The impact of out-of-pocket expense on IUD utilization among women with private insurance. Contraception 2011;84(6):e39–42 [Epub 2011/ 11/15]. [15] Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007–2009. Fertil Steril 2012;98(4):893–7 [Epub 2012/07/17]. [16] Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception 2011;84(4):363–7 [Epub 2011/09/17]. [17] Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstetrics and Gynecology 2012;120(6):1291–7 [Epub 2012/11/22].
Original research article
Routine counseling about intrauterine contraception for women seeking emergency contraception☆ E. Bimla Schwarz a, b, c,⁎, Melissa Papic a , Sara M. Parisi b , Erin Baldauf a , Rachel Rapkin c , Glenn Updike c a University of Pittsburgh, Department of Medicine University of Pittsburgh, Graduate School of Public Health, Department of Epidemiology c University of Pittsburgh, Department of Obstetrics, Gynecology and Reproductive Sciences Received 19 November 2013; revised 7 February 2014; accepted 13 February 2014 b
Abstract Objective: To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an innercity clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC. Study design: For 8 months before and 21 months after this change in clinic policy, women aged 15–45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n= 328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data. Results: Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, pb0.01; EMR: 32% vs. 68%, pb0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months. Conclusions: Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC. Implications: Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement. © 2014 Elsevier Inc. All rights reserved. Keywords: Intrauterine contraception; Copper IUD; Emergency contraception; Contraceptive counseling; Same day; Title X
1. Introduction Postcoital or emergency contraception (EC) can help women avoid undesired pregnancy after unprotected sex or
☆ Funding: R01PG000859 (PI Schwarz) from Department of Health and Human Services Office of Population Affairs. ⁎ Corresponding author. Women's Health Services Research Unit, Center for Research on Health Care, Associate Professor of Medicine, Epidemiology, Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, Pa 15213. Tel.: +1 412 586 9836; fax: +1 412 692 4838. E-mail address: [email protected] (E.B. Schwarz).
0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2014.02.007
contraceptive failure [1]. Despite initial optimism that EC pills offered a disruptive technology that would provide a quantum leap towards liberating women from undesired pregnancy [2], multiple studies have failed to demonstrate that increasing access to EC pills has reduced population rates of undesired pregnancy [3–5]. This is due in large part to the fact that EC pills are used relatively rarely [6], while unprotected sex remains common. An alternative approach to EC is the placement of a copper intrauterine device (IUD) within 1 week of a contraceptive emergency. Although the option of postcoital IUD use was first discussed over 40 years ago [7], this option is rarely presented to women seeking EC; many of whom
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experience unintended pregnancies after using EC pills [8]. The copper T380A is estimated to be 10 times as effective as EC pills [9] and has been shown to be highly effective at all points of the menstrual cycle [10]. In a previous study, we found that 15% of women seeking EC would be interested in IUD placement if it was offered on the day of their visit [11]. Thus, our inner-city, Title X-funded family planning clinic committed to modifying clinic policy and routinely providing structured counseling about IUDs and offering same-day placement of a copper IUD to all women seeking EC. In this study, we compared knowledge and use of IUDs and implants among women seeking EC, before and after this clinic-wide intervention.
2. Methods During the preintervention period (January 4, 2011 to August 19, 2011), women seeking EC from the study clinic received EC pills from a nurse without structured contraceptive counseling, the offer of IUD placement for EC or any contraceptive counseling from a clinician. During the intervention period (August 22, 2011 to May 30, 2013), women seeking EC were asked to wait to see a nurse practitioner or physician who verbally provided brief structured counseling about IUDs and implants [Appendix 1] and offered same-day placement of a copper IUD for EC or same-day placement of a hormonal IUD or implant with EC pills. The structured counseling was adapted from the scripted introduction to IUDs and implants developed by the St. Louis Contraceptive CHOICE Project [12]. Posters were placed in all clinic rooms identifying IUDs as the most effective form of EC. However, the option of same-day placement of a copper IUD was limited to women who reported no instances of unprotected intercourse during the 8–14 days prior to their clinic visit (due to concerns of risk for luteal phase pregnancy) and women who had no evidence of cervicitis on exam. Likewise, same-day placement of a hormonal IUD or contraceptive implant was limited to women who reported no unprotected intercourse during the 6–14 days prior to their clinic visit and were also willing to take EC pills. During the intervention period, women seeking walk-in pregnancy testing were asked whether they desired pregnancy and whether they had unprotected sex in the last week to assess their need for EC. During both the preintervention and intervention periods of this study, we asked all women seeking EC from the study clinic (including those who initially requested pregnancy testing but were found to be eligible for EC) who stated that they wished to avoid pregnancy for at least 6 months and had a negative pregnancy test at their visit to complete surveys before leaving the study clinic. Women who were already using a highly effective reversible contraceptive (i.e., IUD or implant) at the time of the initial clinic visit or had a tubal ligation were excluded from this study. These surveys assessed women's receipt of contraceptive counseling at
their visit, contraceptive knowledge and plans for contraceptive use. Three months after study enrollment (during both the preintervention and intervention periods of this study), a research assistant contacted each participant to complete a follow-up survey to assess her current contraceptive knowledge, which contraceptives she had used during the last 3 months and whether she had become pregnant. Contraceptive knowledge was assessed with nine items concerning the effectiveness, reversibility and duration of use of intrauterine, subdermal and injectable contraception (Appendix 2). Twelve months after their clinic visit, women who were offered a same-day IUD or implant were again contacted and asked about their contraceptive use. Women received a token gift (worth approximately US$5) for completing a survey immediately after their clinic visit and US$10 following completion of the 3-month and 12-month surveys. We abstracted de-identified data from the study clinic's electronic medical record (EMR) on June 9, 2013 to determine rates of contraceptive initiation, contraceptive removal and pregnancy within 3 months of seeking EC among all women aged 15–45 years who had sought EC from the study clinic (during both the preintervention and the intervention periods). If a woman sought EC more than once during this study, only her first EC visit was included in this analysis. This study was approved by the Institutional Review Board of the University of Pittsburgh. We used descriptive statistics to characterize study participants and chi-square tests to compare the significance of differences between the preintervention and intervention periods in the survey data and EMR data. All analyses were performed using Stata 13.0 (StataCorp, College Station, TX, USA).
3. Results During the 8-month preintervention period, the study clinic provided EC on one or more occasions to 82 unique women [including 18 (22%) women who initially requested pregnancy testing], averaging 10.2 women per month. During the 21-month intervention period, 235 unique women received EC [including 102 (43%) who initially requested pregnancy testing], averaging 11.2 women per month. An additional 11 women presented to the clinic seeking EC but ultimately did not receive any form of EC (1 during the preintervention and 10 during the intervention period), providing a total of 328 unique, EC-seeking women for this analysis. Fifty-seven percent (n= 186/328) of eligible women agreed to complete surveys before leaving the study clinic. Women who completed surveys during the intervention period and preintervention periods were very similar. EMR data indicated that women who did and did not agree to complete surveys were of very similar age, race and parity. Most participating women were African American with annual household incomes less than US$20,000. The
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majority of participants had experienced an unwanted pregnancy and previously used EC. Additional sociodemographic characteristics of women completing surveys are shown in Table 1; reproductive characteristics are shown in Table 2. Among those who completed surveys, women were more likely to report having discussed the IUD (77% intervention vs. 8% preintervention, pb0.001) and implant (36% intervention vs. 8% preintervention, p=0.004) with a clinician at the time they sought EC during the intervention period compared to women who sought EC during the preintervention period. Similarly, intervention-period women were more likely to report that all their questions about birth control had been answered (96% intervention vs. 88% preintervention, pb0.001) and more likely to report being very satisfied with the discussion of birth control they had at their visit (76% intervention vs. 63% preintervention,
Table 1 Sociodemographic characteristics of women who completed surveys after seeking EC from the study clinic
Age, mean (standard deviation) Race Black White Bi-racial Other Relationship status Married Not married, but relationship Actively dating, no relationship Single Divorced/Separated Widowed Education level Some high school High school graduate or GED Some college or 2-year degree College degree Employment status Does not work Works full time Works part time Household income bUS$5000 US$5000 to 20,000 US$20,001 to 50,000 More than US$50,000 Do not know Health insurance Public Private
Preintervention (n= 37), % (n)
Intervention (n= 149), % (n)
24.6 (4.9)
23.8 (4.9)
p Value 0.34 0.68
56.8% (21) 21.6% (8) 18.9% (7) 2.3% (1)
67.6% (100) 18.2% (27) 10.1% (15) 4.1% (6)
8.3% (3) 50.0% (18)
3.4% (5) 55.5% (81)
25.0% (9)
14.4% (21)
16.7% (6) 0.0% (0) 0.0% (0)
24.7% (36) 0.0% (0) 2.1% (3)
22.2% (8) 38.9% (14)
16.6% (24) 37.9% (55)
27.8% (10)
37.2% (54)
11.1% (4)
8.3% (12)
52.8% (19) 25.0% (9) 22.2% (8)
54.5% (79) 15.9% (23) 29.7% (43)
23.8% (10) 38.1% (16) 14.3% (6) 7.1% (3) 16.7% (7)
23.8% (34) 33.6% (48) 12.6% (18) 1.4% (2) 28.7% (41)
78.4% (29) 11.1% (4)
84.6% (126) 6.0% (9)
0.26
0.68
0.10
0.20
GED, general educational development.
0.10 0.40
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Table 2 Reproductive characteristics of women who completed surveys after seeking EC⁎
Prior pregnancy Prior unwanted pregnancy Prior use of EC Ever In last year Last 3 months Multiple episodes of unprotected sex in last month Days since unprotected intercourse, med (IQR) Most effective contraceptive used when EC requested None Withdrawal Condoms Pills Patch Ring Depo medroxyprogesterone acetate (DMPA) Plans if pregnant today Abortion Adoption Parent Do not know
Preintervention period (n= 37), n (%)
Intervention period (n=149), n (%)
p Value
27/36 (75%) 20/34 (59%)
107/145 (74%) 81/142 (57%)
0.88 0.85
23/34 (68%) 12/33 (36%) 7/35 (20%) 20/36 (56%)
80/135 (59%) 57/138 (41%) 36/141 (26%) 76/136 (56%)
0.37 0.60 0.50 0.97
1 (1)
2 (2)
0.007 0.76
18/37 (49%) 4/37 (11%) 13/37 (35%) 1/37 (3%) 0/37 (0%) 1/37 (3%) 0/37 (0%)
60/149 (40%) 19/149 (13%) 46/149 (31%) 17/149 (11%) 0/149 (0%) 2/149 (1%) 1/149 (1%)
12/37 (32%) 2/37 (5%) 6/37 (16%) 17/37 (46%)
35/146 (24%) 2/146 (1%) 63/146 (44%) 46/146 (32%)
0.02
IQR, interquartile. ⁎ Denominator not matching the n for each time period indicates missing data due to subjects not answering the survey question.
p=0.03). In addition, a greater percentage of women reported accurate knowledge of the effectiveness, reversibility and duration of use of intrauterine and subdermal contraception after the intervention (Table 3). EMR data indicate that prior to this intervention no women had an IUD or implant placed the day she sought EC. During the intervention period, 11.0% (36/328) of women seeking EC had a same-day IUD placed (33 copper IUDs and 3 levonorgestrel IUDs), while 2 women had a same-day Nexplanon placed after taking levonorgestrel pills; within 5 days of seeking EC, a total of 12% (n= 40) had an IUD or implant placed. As women were more likely to agree to complete surveys if they received a same-day IUD, 21% (n= 31) of women completing surveys reported same-day IUD placement, and a total of 25% (n= 37) reported IUD or implant placement within 5 days of seeking EC. Most women (68%) who opted for same-day IUD placement had heard about IUDs at least twice before they sought EC. Among women who did not get a same-day IUD or implant and were not scheduled
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Table 3 Proportion of participants reporting accurate contraceptive knowledge after visits to the study clinic for EC⁎ When exiting clinic
IUD Effectiveness Duration Reversibility Hormone-free option Implant Effectiveness Duration Reversibility DMPA Effectiveness Duration Reversibility
Three months after visiting clinic
Preintervention (n=37), n (%)
Intervention period (n=149), n (%)
p Value
Preintervention (n=23), n (%)
Intervention period (n=112), n (%)
p Value
9/35 (26%) 21/35 (60%) 19/34 (56%) 18/34 (53%)
70/144 (49%) 117/144 (81%) 92/139 (66%) 103/141 (73%)
0.01 0.007 0.26 0.02
5/23 (22%) 18/23 (78%) 11/23 (48%) 13/23 (57%)
54/112 (48%) 90/112 (80%) 76/112 (68%) 77/112 (69%)
0.02 0.82 0.07 0.26
5/35 (14%) 5/35 (14%) 17/33 (52%)
51/144 (35%) 58/144 (40%) 91/140 (65%)
0.02 0.004 0.15
4/23 (17%) 5/23 (22%) 10/23 (44%)
35/112 (31%) 27/112 (24%) 67/112 (60%)
0.18 0.81 0.15
21/35 (60%) 26/35 (74%) 13/34 (38%)
64/144 (44%) 118/143 (83%) 68/141 (48%)
0.10 0.27 0.29
12/23 (52%) 18/23 (78%) 10/23 (44%)
53/112 (47%) 104/112 (93%) 45/112 (40%)
0.67 0.03 0.77
⁎ Denominator not matching the n for each time period indicates missing data due to subjects not answering the survey question.
for contraceptive placement within 5 days of their clinic visit, 23% (n= 25) reported wanting to receive an IUD or implant the day of their clinic visit but not receiving one. The most common reason for not receiving desired sameday IUD or implant placement was concern for luteal phase pregnancy when women had multiple instances of unprotected sex within the 2 weeks prior to their clinic visit (n= 15). Another four women desiring an IUD or implant did not have time to wait for placement, an additional four could not have their contraception inserted due to clinic time constraints (scheduling conflicts, lack of provider, etc.) and two were advised to return on another day after expressing ambivalence about IUD use. Seventy-three percent of survey participants completed follow-up surveys 3 months after seeking EC from the study clinic and being contacted by phone (46%), email (29%), text message/social media (19%) or in-clinic (7%); those who completed 3-month follow-up surveys were similar to those lost to follow-up in terms of race and parity. However, younger participants were more likely to be lost to follow-up [mean age (standard deviation) in years of noncompleters 22.7 (4.8) vs. completers 24.4 (4.9), p=0.04]. Among those who completed 3-month follow-up surveys, significantly more women from the intervention period reported accurate knowledge of the effectiveness of IUDs (Table 3) compared to women in the preintervention period. In addition, there was a drop in the proportion of women reporting use of no contraception 3 months after seeking EC (17% preintervention vs. 4% intervention period, p=0.01), largely due to increased use of IUDs. According to survey data, during the intervention period, 40% of women reported initiation of IUD or implant use within 3 months of seeking EC compared to only 17% during the preintervention period (p=0.04). The EMR data echoed this increase in initiation of IUD or implant use within 3
months of seeking EC (22% intervention vs. 10% preintervention, p=0.01). Importantly, during the intervention period there was no significant change in the proportion of women reporting condom use, either as their most effective contraceptive or in combination with another method (Table 4). Of those who had an IUD placed the day they sought EC and completed 3-month follow up, 88% (23/26) reported ongoing IUD use. Of the 3 women who had discontinued IUD use by 3 month follow-up, one reported IUD expulsion and two requested removal for pain/ bleeding. Of those who have now completed 12-month follow-up surveys, 81% (13/16) reported continued IUD use. Reasons for IUD discontinuation between 3- and 12month follow-up included desire for pregnancy (n= 1). According to the EMR data, only 11.5% (3/26) of women who had a same-day IUD placed had their IUD removed within 3 months of placement. Of the 15 women who had same-day IUD placement 12 or more months before we abstracted EMR data, only 3 (20%) had their IUD removed within 12 months of placement. Pregnancy rates among women who completed 3month follow up surveys were lowest among those who had an IUD or implant placed within 5 days of visiting the study clinic; one woman experienced a copper IUD failure (with her IUD in place) several weeks after IUD placement, producing a pregnancy rate of [3% (1/30), 95% confidence interval (CI): 0%–18%] compared to those who received ulipristal acetate pills [38% (5/13), 95% CI: 18%–65%] or levonorgestrel EC pills [13% (12/ 91), 95% CI: 8%–22%]. EMR data echoed this; pregnancy documented within 3-months of receipt of EC was lowest for women who had an IUD placed within 5 days of seeking EC [3.8% (1/26), 95% CI: 0%–20%], compared to those who received ulipristal acetate [15.4% (2/13), 95% CI: 2%–45%] and those who received
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Table 4 Contraceptive use 3-months after seeking EC from the study clinic Survey data Preintervention (n=23) 17% (4) IUD/Implant placed within 3 months of EC b Most effective method used within 3 months of seeking EC b IUD 17% (4) Implant (0) DMPA (0) Ring 22% (5) Pills 4% (1) Patch (0) Male condoms 39% (9) Withdrawal (0) No contraception within 3 months of seeking EC 17% (4) Condom use in 3 month after seeking EC 61% (14)
EMR data Intervention (n= 112)
p Value
Preintervention (n=83)
Intervention (n= 208 a)
p Value
40% (47)
0.04
10% (8)
22% (46)
0.01
36% (43) 3% (4) 11% (12) 10% (11) 17% (19) (0) 20% (22) 4% (4) 4% (4) 59% (66)
0.08 0.37 0.10 0.11 0.12 — 0.04 0.36 0.01 0.86
10% (8) (0) 4% (3) 10% (8) 10% (8) (0) n/a n/a 68% (56) c
21% (43) 1% (3) 13% (26) 12% (25) 21% (43) 0.5% (1) n/a n/a 32% (67) c
b0.01 0.11 0.02 0.63 0.03 0.52 — — b0.01
IUD: intrauterine contraceptive device. n/a: These methods are not reliably documented in the EMR. a When EMR data was abstracted, it had been less than 3 months since 37 women had sought EC from the study clinic; the women with incomplete data were excluded from these analyses. b Numerator and denominator include women who had a same-day IUD or implant placed even if no follow up survey was completed; during intervention period, n= 119. c No contraception documented in the EMR; barrier or behavioral contraception may have been used.
levonorgestrel EC pills [8.6% (21/244), 95% CI: 5%– 13%]. However, overall pregnancy rates within 3 months of seeking EC dropped only marginally in the EMR data (10.8% preintervention vs. 7.1% intervention, p=0.29) and not at all in the survey data (13.0% preintervention vs. 14.3% intervention, p=0.88).
4. Discussion This study demonstrates that routine provision of structured counseling with the offer of same-day placement of an IUD or implant is feasible and increases women's knowledge and use of highly effective reversible contraceptives 3 months after seeking EC. As very few women requested contraceptive removal within 3 months of placement, we feel that the clinic was able to offer convenient access to desired services without raising the specter of coercion. Rather, this population appears to continue to face significant unmet need for highly effective reversible contraception as only 11% of women received same-day IUD or implant placement and among women who did not receive same-day contraceptive placement, 23% reported that they had wanted placement of an IUD or implant the day they sought EC. Cost was generally not a barrier for women served by the study clinic due to the availability of Title X funding and IUDs donated by a private foundation. However, some women had insurance plans which either did not cover their desired form of EC or required prohibitive co-pays [13,14]. More commonly, time constraints that limited women's ability to wait until a clinician was available to place their
desired contraceptive prevented some women from receiving desired same-day placement of an IUD or implant; only four women returned within 5 days of seeking EC to have an IUD inserted. A final factor limiting same-day placement of IUDs was concern for luteal phase pregnancy when women reported unprotected intercourse during the preceding 8–14 days; such women were not offered placement of an IUD on the day she sought EC and were instead asked to schedule a follow-up appointment at least 14 days following her most recent act of unprotected intercourse. Unfortunately, it was relatively common for women who reported unprotected intercourse in the last week to also report unprotected intercourse in the prior week. The number of women who became pregnant within 3 months of seeking EC further highlights this population's unmet need for effective contraception. Previous studies have also reported high rates of unintended pregnancy among women who received only EC pills [8,15], particularly when women are overweight and have repeated acts of unprotected intercourse after use of EC pills [16]. Although this study was not powered to examine changes in rates of pregnancy, we were disappointed to see no change in pregnancy rates given the existing literature on the relative effectiveness of available contraceptives. However, in truth, unless the women destined to experience unintended pregnancies adopted effective contraception, population rates of unintended pregnancy would be expected to remain unchanged, even if all other women initiated use of highly effective reversible contraception. Although 75% of the St. Louis CHOICE Project's 9256 participants opted for highly effective reversible contraceptives, it took a few years to appreciate significant reductions in rates of unintended pregnancy [17].
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Our study participants differ from the St. Louis CHOICE study's participants in a number of important ways. First, women in this study were not required to be willing to try a new method of contraception; they did not complete any phone screening, or even schedule an appointment in an effort to initiate contraception, but rather simply walked into clinic seeking EC, with most expecting to receive EC pills. Finally, we are not aware of any “snowball” referrals by friends or relatives of women who were specifically interested in obtaining free IUDs or implants on the day they came to the study clinic. Thus, although sobering, our findings may offer a realistic sense of how difficult it will be to replicate the CHOICE Project's success in other settings. Nonetheless, the importance of offering same-day contraceptive placement services is highlighted by our finding that some aspects of women's contraceptive knowledge decreased within 3-months of their clinic visit. Of note, although some have worried that providing women at high risk of sexually transmitted infections (STIs) with contraceptive alternatives will decrease women's condom use and increase risk of STI, participants in this study were not less likely to use condoms when offered same-day placement of an IUD or implant. In interpreting this study's findings, certain data limitations must be considered. Although our survey completion rate was higher than expected for this population, we cannot be certain that the changes observed in the surveyed group reflect changes in the overall population served by the study clinic. According to the clinic-wide EMR data, survey completers were, for instance, more likely to opt for same-day IUDs and to report initiation of IUDs in the 3 months after their clinic visit. On the other hand, our EMR data may be incomplete if women took a pregnancy test at home or received contraception and/or had their IUD removed outside this particular health system. However, women served by this clinic typically receive all of their care within this large health system, and our survey and EMR data on IUD discontinuation within 3 months match perfectly. Finally, as our study does not have a temporal control group, it is possible that the changes seen in contraceptive knowledge and use simply reflect secular changes, although we are not aware of any other local efforts to educate this population of women about IUDs or implants either prior to or during this study period. In conclusion, this study demonstrates that routine provision of structured counseling about highly effective reversible contraceptives and the option of same-day placement is feasible and improves contraceptive knowledge and use among women seeking EC without adversely affecting condom use. Women who seek EC must be recognized as at high risk of unintended pregnancy until use of a more effective contraceptive is initiated. Acknowledgments The ECWIP Study team is grateful to Dr. Matthew Reeves, Dr. Caroline Moreau and Dr. Candace McClure for serving on our data safety and monitoring committee.
Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.contraception.2014.02.007. References [1] Cheng L, Che Y, Gulmezoglu AM. Interventions for emergency contraception. Cochrane Database Syst Rev 2012;8 [CD001324: Epub 2012/08/17]. [2] 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(6):932–7 [Epub 1997/06/ 01]. [3] Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA. Advance provision of emergency contraception for pregnancy prevention (full review). Cochrane Database Syst Rev 2007 [CD005497, Epub 2007/04/20]. [4] Rodriguez MI, Curtis KM, Gaffield ML, Jackson E, Kapp N. Advance supply of emergency contraception: a systematic review. Contraception 2013;87(5):590–601. [5] Raymond EG, Trussell J, Polis CB. Population effect of increased access to emergency contraceptive pills: a systematic review. Obstet Gynecol 2007;109(1):181–8 [Epub 2007/01/02]. [6] Daniels K, Jones J, Abma J. Use of emergency contraception among women aged 15–44: United States: 2006–2010. NCHS Data Brief 2013;112:1–8 [Epub 2013/06/08]. [7] Post-coital use of IUD. Asian Pac Popul Programme News 1977;6(4):39 [Epub 1977/01/01]. [8] Falk G, Falk L, Hanson U, Milsom I. Young women requesting emergency contraception are, despite contraceptive counseling, a high risk group for new unintended pregnancies. Contraception 2001;64(1):23–7 [Epub 2001/09/06]. [9] Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod 2012;27(7):1994–2000 [Epub 2012/05/10]. [10] Turok DK, Godfrey EM, Wojdyla D, Dermish A, Torres L, Wu SC. Copper T380 intrauterine device for emergency contraception: highly effective at any time in the menstrual cycle. Hum Reprod 2013;28(10):2672–6. [11] Schwarz EB, Kavanaugh M, Douglas E, Dubowitz T, Creinin MD. Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol 2009;113(4):833–9 [Epub 2009/03/24]. [12] Madden T, Mullersman JL, Omvig KJ, Secura GM, Peipert JF. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception 2013;88(2):243–9. [13] Pace LE, Dusetzina SB, Fendrick AM, Keating NL, Dalton VK. The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance. Medical Care 2013;51(11):959–63. [14] Gariepy AM, Simon EJ, Patel DA, Creinin MD, Schwarz EB. The impact of out-of-pocket expense on IUD utilization among women with private insurance. Contraception 2011;84(6):e39–42 [Epub 2011/ 11/15]. [15] Finer LB, Jerman J, Kavanaugh ML. Changes in use of long-acting contraceptive methods in the United States, 2007–2009. Fertil Steril 2012;98(4):893–7 [Epub 2012/07/17]. [16] Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception 2011;84(4):363–7 [Epub 2011/09/17]. [17] Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstetrics and Gynecology 2012;120(6):1291–7 [Epub 2012/11/22].
