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Contraception Corner

The Role of Emergency Contraception in Reducing Pregnancy Risk

Elisa S. Wells, MPH; Mitchell D. Creinin, MD; Pablo Rodriguez, MD

Limited access has always been perceived as a major barrier to increased use of emergency contraception (EC). Why then, in a setting where there are no barriers to access, is this method still underutilized

Although EC has clearly been demonstrated to reduce a woman’s risk of pregnancy, a recent analysis found that increased access to EC has not reduced the rate of unintended pregnancy on a population level. This lack of effect may reflect women’s misperception of pregnancy risk and consequent failure to use EC appropriately. Clinicians can play an important role in helping women to understand their risk of pregnancy and use EC more effectively.

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ANALYSIS RESULTS

A systematic review of the data on the effects of increased access to EC on use and pregnancy rates found that such access enhanced use but did not reduce unintended pregnancy rates at the population level.1 However, clinical trials have demonstrated that EC use can reduce pregnancy risk following a single act of unprotected intercourse.2 Estimates of the reduction in a womanês chance of pregnancy after EC use range from 59% to 94% for the levonorgestrel (LNG) regimen, and 56% to 89% for the combination estrogen/progestin regimen.3 Evidence suggests that the LNG regimen is more effective than the combination regimen and that both regimens are more effective the sooner they are used.4

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WOMEN’S PERCEPTION OF RISK

One reason for this “disconnect” between the known efficacy of EC and the lack of visible effect on pregnancy rates at the population level may be that women underestimate their risk of pregnancy and consequently fail to use EC when it is needed. The conclusions of the analysis by Raymond et al1 are supported by four of the studies reviewed therein.5-8 These studies all assessed whether women who became pregnant had used EC during the cycle in which they conceived and found that fewer than 30% of the subjects had done so.

Raymond et al1 noted that qualitative studies have identified a number of reasons why women do not use EC, including:

• Failure to recognize the risk of pregnancy
• Neglect of said risk
• Association between EC and stigma
• Misunderstanding of the method.9-11

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CLINICAL IMPLICATIONS

The failure to prove a population-level effect from EC suggests that physicians must do more to ensure that women know about the availability of EC as well as when and how to use it effectively. These data also make it clear that access alone does not guarantee proper usage. Education, reinforcement of instruction, and the understanding and participation of partners may also be important for correct and effective use.

Clinicians and pharmacists can help women to prevent unintended pregnancies by providing information and guidance in the selection of both primary and back-up contraceptive methods. Patients must know that EC is:'

• A good option to reduce the risk of pregnancy if the primary method fails or there is no primary method
• More effective the sooner after intercourse it is used
• Available for sale without a prescription to patients aged 18 years and older at most pharmacies, and at lower cost through some public health facilities.

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CONCLUSION

Emergency contraception is highly effective, but only when the woman recognizes that she has had unprotected intercourse and that she is at risk and then uses the method. Other integral strategies for increasing EC use and reducing unintended pregnancy rates include advance provision and improved patient education.12

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Elisa S. Wells, MPH, is program consultant, Association of Reproductive Health Professionals, Washington, DC. Mitchell D. Creinin, MD, is professor and director of Gynecologic Specialties, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, PA. Pablo Rodriguez, MD, is associate professor of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI.

References

1. Raymond EG, Trussell J, Polis CB. Population effect of increased access to emergency contraceptive pills: a systematic review. Obstet Gynecol. 2007;109(1):181-188.
2. Croxatto HB, Devoto L, Durand M, et al. Mechanism of action of hormonal preparations used for emergency contraception: a review of the literature. Contraception. 2001;63(3):111-121.
3. Trussell J, Raymond EG. Emergency contraception: a cost-effective approach to preventing unintended pregnancy. Emergency Contraception Web site. http://ec.princeton.edu/questions/ec-review.pdf. Updated April 2007. Accessed July 3, 2007.
4. Piaggio G, von Hertzen H, Grimes DA, Van Look PF. Timing of emergency contraception with levonorgestrel or the Yuzpe regimen. Task Force on Postovulatory Methods of Fertility Regulation. Lancet. 1999;353(9154):721.
5. Raymond EG, Stewart F, Weaver M, Monteith C, Van Der Pol B. Impact of increased access to emergency contraceptive pills: a randomized controlled trial. Obstet Gynecol. 2006;108(5):1098-1106.
6. Hu X, Cheng L, Hua X, Glasier A. Advanced provision of emergency contraception to postnatal women in China makes no difference in abortion rates: a randomized controlled trial. Contraception. 2005;72(2):111-116.
7. Lo SS, Fan SY, Ho PC, Glasier AF. Effect of advanced provision of emergency contraception on womenês contraceptive behaviour: a randomized controlled trial. Hum Reprod. 2004;19(10): 2404-2410.
8. Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med. 1998;339(1):1-4.
9. Moreau C, Bouyer J, Goulard H, Bajos N. The remaining barriers to the use of emergency contraception: perception of pregnancy risk by women undergoing induced abortions. Contraception. 2005;71(3):202-207.
10. Goulard H, Moreau C, Gilbert F, Job-Spira N, Bajos N; Cocon Group. Contraceptive failures and determinants of emergency contraception use. Contraception. 2006;74(3):208-213.
11. Sorensen MB, Pedersen BL, Nyrnberg LE. Differences between users and non-users of emergency contraception after a recognized unprotected intercourse. Contraception. 2000;62(1):1-3.
12. Clark B, Jordan B. Increasing use of emergency contraception. The Female Patient. 2006;31(12):44-45.

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