Original Studies
The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors

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Abstract

Context

Advance provision of emergency contraception (EC) may increase timely access and improve effectiveness, but the impact on adolescent sexual and contraceptive behaviors is not known.

Objective

To determine whether adolescents given advance EC have higher sexual and contraceptive risk-taking behaviors compared to those obtaining it on an as-needed basis.

Design and setting

Randomized trial conducted at urban, hospital-based adolescent clinic in Pittsburgh, PA, from June 1997 to June 2002.

Participants

301 predominantly minority, low-income, sexually active adolescent women, age 15–20 years, not using long-acting contraception.

Interventions

Advance EC vs instruction on how to get emergency contraception.

Outcome measures

Self-reported unprotected intercourse and use of condoms, EC, and hormonal contraception ascertained by monthly 10-minute telephone interviews for 6 months post-enrollment. Reported timing of EC use after unprotected intercourse.

Results

At both 1- and 6-month followup interviews, there were no differences between advance EC and control groups in reported unprotected intercourse within the past month or at last intercourse. At 6 months, more advance EC participants reported condom use in the past month compared to control group participants (77% vs 62%, P = 0.02), but not at last intercourse (advance EC 83% vs control 78%, P = 0.34). There were no significant differences by group in hormonal contraception use reported by advance EC or control groups in the past month (44% vs 53%, P = 0.19) or at last intercourse (48% vs 58%, P = 0.20). At the first followup, the advance group reported nearly twice as much EC use as the control group (15% vs 8%, P = 0.05) but not at the final followup (8% vs 6%, P = 0.54). Advance EC group participants began their EC significantly sooner (11.4 hours vs 21.8 hours, P = 0.005).

Conclusions

Providing advance EC to adolescents is not associated with more unprotected intercourse or less condom or hormonal contraception use. In the first month after enrollment, adolescents provided with advance EC were nearly twice as likely to use it and began EC sooner, when it is known to be more effective.

Introduction

Despite improvements in the accessibility and range of contraceptive options available to young women, in 1998 American adolescents had over 840,000 pregnancies.1., 2. Eighty-five percent of pregnancies in adolescents were unintended and they resulted in 495,000 births and 270,000 abortions.3 Emergency contraception (EC) reduces the risk of pregnancy after unprotected sex or when a planned contraceptive method fails. EC is effective when taken within 72 to 120 hours after intercourse, but is more effective the sooner it is taken.4., 5., 6. Delaying the first dose of EC by 12 hours increases the odds of pregnancy by almost 50%.5 If used following all contraception failures, EC could prevent 50% of unintended pregnancies and 60–70% of abortions annually.7 Given that EC is safe and significantly more effective the sooner it is used, why not prescribe EC in advance to every female adolescent? Some health care providers have concerns that making EC more available by prescribing it in advance will cause adolescents to have more frequent unprotected intercourse and less frequent use of reliable contraception, which could contribute to higher rates of sexually transmitted diseases (STD) and pregnancies.8., 9., 10.

Several studies have examined the impact of providing advance EC on women's sexual and contraceptive behaviors.11., 12., 13., 14., 15. In the first and largest study of advance provision of emergency contraception published in 1998, Glasier and colleagues enrolled over 1000 Scottish women, ages 16–44, and followed them for a year after enrollment.11 They found that women were more likely to use EC if they had it in advance and were not more likely to abandon reliable contraceptive methods compared to women in the control group. However, consistency of contraceptive use was not assessed. Participants were predominately university-educated adults and were enrolled after having had an abortion or after having received EC thus making results less generalizable to other populations of young women.

In 2000, Lovvern and colleagues reported on adult women, ages 18 to 45 years, from family planning clinics in Ghana who were provided with a single course of advance EC. Participants were recruited from four clinic sites, two where EC was provided in advance and two where EC was provided on demand. They found that women who had EC at home were more likely to use it and were more likely to use EC promptly.12 The study findings were limited by lack of randomization of intervention groups and a relatively short followup at 4 and 8 weeks after enrollment.

In 2000, Raine and colleague examined the effects of providing advance EC on the ongoing contraception use of predominantly minority, high-risk young women in San Francisco, ages 16–2413 recruited from publicly funded family planning clinics. They provided participants with a single course of EC and re-assessed them at a single followup interview 4 months later. They found that, compared to participants in the control group, young women with advance EC were significantly more likely to use EC but not more likely to report unprotected intercourse. However, the advance EC group was more likely to report using less effective and less consistent contraception at followup. This study had a higher percentage of adolescent women than any other (mean age of subjects of 19 years).

In 2001, Ellertson and colleagues published a study of adult women in Pune, India, who used condoms for contraception.14 In this study participants were provided with three courses of EC at enrollment. Participants who had EC in advance were more likely to use it compared to the control group but did not use EC more than once. Generalizability to U.S. adolescent women was limited because only adult women in India who used condoms for contraception were enrolled, none of the participants in the study had ever heard of EC before enrolling in the study, and few (6%) reported unprotected intercourse during the study.

In 2003, Jackson and colleagues evaluated the impact of advance provision of EC vs. usual care on the use of EC and usual contraceptive practices among 370 predominantly adult post-partum women from an inner-city public hospital.15 They found women provided EC in advance were four times more likely to use it over the course of the 1-year followup compared to women in the control group. However, the women in the advance provision group were no more likely to change to a less effective method of contraception or to report using contraception less consistently. Generalizability to U.S. adolescents was limited because few participants (18%) were adolescents and most were Latina (72%). In addition, staff who conducted the baseline survey were not blinded to treatment group.

Prior studies of advance provision of EC have not focused specifically on adolescent women. Researchers have either excluded women under the age of 1812., 14. or had low percentages of participants (18–25%) who were under the age of 20.11., 15. The largest study with adolescents assessed predominantly late adolescents with a mean age of 19 years.13 To assess whether adolescent women who were provided with advance emergency contraception (AEC) would have riskier sexual behaviors, we conducted a randomized prospective study of young women, ages 15 to 20 years, who either received EC in advance or who had to obtain EC at the time it was needed. We wanted to test the hypotheses that AEC group participants would use EC more frequently than the control group and that they would begin a course of EC sooner after unprotected intercourse. We also wanted to test whether AEC group participants would increase their frequency of unprotected intercourse and decrease their use of ongoing, reliable contraception, such as condoms or oral contraceptive pills.

Section snippets

Study design

This randomized prospective study compared the sexual and contraceptive behaviors of adolescent women provided with EC education and advance EC (AEC group) with the behaviors of adolescent women who were provided with EC education only (control group). Using the medical indications for emergency contraceptive use, unprotected intercourse was defined as vaginal-penile intercourse where nothing was used to prevent pregnancy or where a method failed. The outcome measures of this study were

Participants

We screened 779 young women and enrolled 301 with a mean age of 17.1 ±1.7 years. See Fig. 1 for a flow diagram of recruitment and retention. At the 1-month followup, 240 participants (80%) of the enrollment sample were interviewed. At the 6-month followup, 192 participants (64%) of the enrollment sample were interviewed. There were no significant differences in retention by group at the 1-month followup but at the 6-month followup a significantly higher proportion of control group participants

Discussion

The results of this study suggest that providing advance EC promotes earlier use of EC without negatively impacting the ongoing use of condoms or hormonal contraception. Although there have been several studies that have assessed the impact of providing advance EC on women's sexual and contraceptive behaviors,11., 12., 13., 14., 15. this is the first study that focuses solely on young adolescent women between the ages of 15 and 20 years of age. Similar to Glasier and colleagues, our study

Conclusions

In this setting, advance provision of EC was not associated with more frequent unprotected intercourse reported in the past month or at last intercourse at either the 1- or the 6-month followup interviews when compared to the control group participants. Indeed, contrary to many health care providers' and the public's views, at the final interview the AEC group participants reported significantly higher condom use. At the 1-month followup, the AEC group participants reported using EC nearly

Acknowledgements

We would like to thank the Laurel Foundation for providing financial support for participant reimbursement, for purchasing and re-packaging medications used in this project, and for support of statistical analysis. We would also like to acknowledge the Women's Capitol Corporation for generously donating the medication (Plan B) that was used in the latter half of the study. We would like to thank the Research Advisory Committee of Children's Hospital of Pittsburgh for providing summer research

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