Challenging Dogma - Spring 2011

Saturday, May 21, 2011

Why Emergency Contraception has Failed to Decrease Unintended Pregnancy Rates – Is There a Better Solution? – Danielle Roncari


Unintended pregnancies, including those that are mistimed, are a significant maternal and child health problem and comprise 49% of all pregnancies in the United States (1). Women with unintended pregnancies are more likely to recognize their pregnancies late, delay the start of prenatal care, and have unhealthy behaviors during their pregnancy (2). Consequences may also extend to the woman’s own health and socioeconomic status and to that of her family. To this end, family planning public health professionals have piloted many interventions to decrease the rate of unintended pregnancy. Programs ranging from comprehensive sexual education, in-depth contraceptive counseling, availability of emergency contraception (EC), increased contraceptive availability and increased use of long-acting reversible contraceptives (LARC) have all been advocated as potential solutions. Success, however, has been mixed. In particular, improved access to EC including over the counter status and advanced provision, has had little effect on decreasing rates of unintended pregnancy. While increasing the use of LARC may be a promising intervention to decrease these rates. Current use of LARC is extremely low and an effective public health intervention to increase use has yet been proposed.

In understanding why EC has met with such little success, it is important to understand how the method works. There are currently two methods of EC available in the United States, levonorgestrel and ulipristal acetate. Each method works most likely by preventing ovulation. As such, these medications are extremely time sensitive. If they are taken too remote from an episode of unprotected intercourse or after ovulation has already occurred, the potential window to prevent a pregnancy is lost. The levonorgestrel method is most effective within 72 hours of unprotected intercourse, but can be used up to 120 hours and ulipristal acetate can be used up to 120 hours (3 and 4).

In attempting to decrease unintended pregnancies, public health and medical professionals have developed many interventions to increase the use of emergency contraception. Among these interventions, have been advanced provision of emergency contraception and a policy change allowing the levonorgestrel method to be available over the counter to people age 17 and over with a picture ID. Both of these interventions have potentially increased access to the medication but have done little to actually decrease unintended pregnancy rates.

In a Cochrane Review of 11 randomized controlled trials of advanced provision of EC, pregnancy rates were unchanged with the intervention (5). While these results are disappointing, it is interesting to note that these studies did not show an increase in STI rates or frequency of unprotected intercourse among participants who had advanced provision of EC.

Emergency Contraception and the Health Belief Model

So why has improved EC access not decreased unintended pregnancy rates? The methods are effective, with efficacy ranging from 60% to 94% depending on when in the cycle it’s taken (3). One reason for its lack of effect is that EC was never designed to be a long-term method of birth control. It was intended to be a “back-up” method, something to be used for those times when a primary method either wasn’t available or had failed. Public health and family planning experts believed that EC could be a solution to a large number of unplanned pregnancies. However, in order for EC to prevent a large percentage of unintended pregnancies, improved access was necessary because of the time sensitive nature of the medication. Past efforts to improve this access have focused on obtaining over the counter status for EC as well as “advanced prescription” - providing patients with prescriptions or actual boxes of the medication at routine annual exams so it’s available “just in case.” The idea behind these interventions was that it was a lack of access that was preventing the widespread use of EC and hampering its ability to decrease unintended pregnancy rates.

Policies and programs to improve EC access can be attributed to adoption of the health belief model. At the core of the health belief model are the following principles: 1. An individual has a perceived susceptibility to a condition 2. An individual has a perceived severity of a condition and its potential consequences 3. There are perceived barriers by the individual to adopting a particular health behavior 4. There are perceived benefits for the individual to adopt a certain health behavior 5. The individual has confidence in his or her ability to take action and 6. The individual is exposed to factors that prompt action (6). Underlying these principles is the assumption that people behave rationally and are able to weigh the costs and benefits of a behavior in order to choose the appropriate course of action. For EC, this would mean that an individual would understand the negative consequences of unprotected intercourse, would understand the benefit of using EC and the minimal cost to using such a medication and would therefore choose to take the medication. The model also assumes that the individual after using EC would recognize that unprotected intercourse can lead to unintended pregnancy and thus after using EC would obtain more reliable contraception or abstain in the future to avoid this consequence.

We know, however, that EC has not had an effect on unintended pregnancy. It would appear that individuals have not used EC when needed and/or they have not followed up its use with a more long-acting method of contraception. There may be several reasons for this failure, both medical and behavioral. Focusing on behavioral patterns, the health belief model may be a poor choice to determine decision-making surrounding EC and may help explain why improved access interventions have not led to the desired outcomes.

The primary reason that the health belief model has poorly influenced EC use is people are not rational and do not make rational decisions, particularly when it comes to sexual intercourse. Inherent to this model, the individual must understand herself to be at risk of unintended pregnancy. Traditionally, unintended pregnancies are those that are unwanted or mistimed while intended pregnancies refer to those that occur at the “right time” or later than desired (7). These pregnancies, therefore, are caused by a behavior, sexual intercourse that by its very nature is often an unplanned, unintended, or unexpected event. Surveys of college and adolescent students corroborate this view.

College students report a high incidence of unplanned intercourse. In a survey of college students in 1991, 40.9% used either no contraception or withdrawal at first intercourse with 10.1% reporting they did not use contraception because they were not prepared (8). Results among adolescents are similar with 30-38% of adolescents reporting inconsistent contraceptive use (9). Furthermore, we know that 40% of unintended pregnancies are a result of inconsistent or incorrect use of a contraceptive method (10).

These results affirm that intercourse is often unplanned and to expect that people will plan to prevent the outcome of a very behavior that was not intended is unrealistic. And what we know about EC is that it only works if taken immediately after intercourse (or at the very least up to 120 hours after unprotected intercourse). EC is also only effective for a single act of unprotected intercourse; multiple acts will not be prevented by a single course of EC. Some degree of planning is therefore needed even with EC.

A second reason why the health belief model has not been an appropriate model for EC is the individual may have a perceived susceptibility to becoming pregnant that is not in line with scientific principles - the idea that “it won’t happen to me.” We know that EC only works for a single episode of unprotected intercourse. In reality, in a given cycle people may have many such episodes. However, the individual may take EC for one of those episodes and think that they are either protected or not susceptible with subsequent acts. They never follow through after the first episode and obtain more reliable contraception because they do not see the need or the risk in not doing so. In a randomized controlled trial of advanced provision of emergency contraception compared to no advanced provision, adolescent mothers in the intervention group were no more likely to begin another more effective method of birth control at 6 or 12 months (11).

Another reason that the health belief model has failed to be a successful model to predict behavior regarding use of EC is that while unintended pregnancy is something to be avoided by most public health professionals, individuals may not see avoiding this as a beneficial outcome. We know that for some people unintended pregnancy does not mean unwanted and about half of women with an unintended pregnancy choose to continue the pregnancy. Results from the NSFG report that among women who had an unintended pregnancy due to a contraceptive failure, 59% were unhappy or very unhappy about the pregnancy while 25% were happy or very happy (12). Trussell et al suggests that for some women: 1. Planning or intending to become pregnant may be different than wanting to be pregnant: 2. The concept of planning pregnancy may not have the same meaning for all women: and 3. Ambivalence towards pregnancy may lead to contraceptive failure (13).

And while finally, certainly improved access has decreased barriers to EC use, Many individuals may still perceive barriers to using it properly particularly because it has such a short window of action. For example, teenagers under age 17 still need a prescription to obtain EC, an individual may use her one pack of advanced provision and then never keep a second pack available and many pharmacies may refuse on moral objections to stock a medicine despite its over the counter status (14).

In summary, EC has failed as a public health intervention to decrease unintended pregnancies. There are many reasons for this failure and in particular, trying to promote the use of EC with the health belief model is particularly flawed because of the following faulty assumptions:

1. Sexual intercourse is a planned event and done rationally.

2. People have only 1 episode of unprotected sex per cycle and if they have greater than 1 episode, they will begin more effective contraception after using EC.

3. People recognize the negative health consequences of unprotected intercourse and because of these health consequences and their perceived susceptibility to pregnancy make the decision to take EC.

4. With over the counter status and advanced provision policies, individuals no longer face barriers to appropriate use.

Alternative Model to Decrease Unintended Pregnancy

Given that we know sexual intercourse to be an inherently irrational, unplanned behavior, an acceptable model to change behavior would not rely on the rationality of individuals. It would also make use of technologies that don’t require planning with each act of intercourse. LARC, in particular the Mirena and Paragard intrauterine contraceptives (IUCs) and the Implanon contraceptive implant, provide highly effective, temporary birth control that is not coitally dependent and is safe for most users. While technology has developed these highly effective, safe methods of birth control, they have not been widely accepted. New policies need to be developed to promote their use. Social network theory can provide a framework for improving utilization of these devices. Such an intervention based on this theory could use new social media such as Facebook and Twitter along with carefully designed advertisements tailored to at-risk populations that air both during network television shows that are popular with young adults and are printed in magazines read by young adults. This is in stark contrast to current media around these devices which typically depict women in their mid 30s with a family, certainly not the demographic most at risk of unintended pregnancy. These concerted media and online efforts would help spread the message through various social networks that these methods are safe and effective. As a result, use of LARC would increase.

Why hasn’t LARC been widely accepted? According to the National Survey of Family Growth, only 4.9% of reproductive aged women were using an IUC and only 0.08% of women were using an implant (15). Yet LARC is an excellent method of birth control in that it’s safe, doesn’t require the user to remember anything, and has very few contraindications.

In part, this low rate of use is secondary to myths surrounding these methods. Many reproductive aged women or their family members still remember an earlier IUC, the Dalkon Shield, which had higher failure rates than some of its predecessors, unacceptably high rates of septic abortion, hospitalization from severe pelvic inflammatory disease, resultant sterility and even death (16). Implanon conjures up images of Norplant, the preceding long-acting contraceptive implant that was introduced in the early 1990s. Norplant was immediately targeted to low-income women through the work of the Norplant Foundation, which provided 2.8 million Norplant devices a year to these women. Many states targeted low-income women and offered them financial incentives to use Norplant. In Kentucky, women were given $500 and an additional $50 a year for each year they continued to use Norplant. Louisiana paid women $100 per year to use the device. At the same time, women were not told about all of the side effects of the drug (17).

In order to combat some of the myths and fears surrounding LARC and gain more widespread acceptance, social networking theory may be an appropriate behavioral model to frame public health interventions. The theory takes advantage of the interconnectedness of individuals on many levels. In 1954, J.A. Barnes first proposed the concept of the “social network, ” which he described as patterns of connection including bounded groups (e.g. families, tribes) and social categories (e.g. race/ethnicity, gender) (18). This theory has been used to explain many behaviors including contraceptive use, alcohol consumption, obesity, and smoking. In a study assessing the prevalence of smoking of a 30+ year period among Framingham Heart Study participants, smoking cessation appeared relevant to one’s social network with smoking behaviors found more commonly among subjects interconnected by both close and distant social relationships. Furthermore, smoking cessation was more common among participants who had a sibling, spouse, friend, or coworker who had also quit smoking (19).

Today these connections have expanded to include online media such as Facebook, Twitter and MySpace, which have proven to be powerful tools to promulgate ideas and promote behaviors and products. Healthcare is just starting to use this media as well. As an example, one primary care practice in Brooklyn, called Hello Health, uses social media to take the place of many traditional health care roles. Patients can IM a question to the doctor, get an online “visit” for a problem and even read the physicians’ biographies on Facebook (20). In addition, peer-peer education is already occurring on many of these social networking sites. One study on the number of breast cancer groups on Facebook found 620 such groups with activities related to fundraising, awareness, service promotion, and patient/caregiver support. The support groups were the most popular sites on Facebook with the greatest number of posts (21). There remains tremendous opportunity to capitalize on the success of these media outlets to promote health behaviors.

Contraceptive use is particularly prone to influence by one’s social network. Often misconceptions, misperceptions as well as personal stories, dissatisfaction or satisfaction with a particular method are shared among people in the same social network (22). In some social networks, individuals may consider the advice regarding contraceptive effectiveness, side effects, safety and instructions for use to be more reliable coming from those in their network than from health care professionals. In a qualitative study of Latina females on their concerns about contraceptive side effects, women in the focus groups tended to value anecdotal information from peers over that of providers (23). In another qualitative study among a group of postpartum African American and Latina young women, the authors similarly found that the social network played a large role in family planning decision-making. Women often reported that while providers gave accurate information, the stories and experiences of women in their social circle had a more direct impact on their contraceptive choice (22). However, this information from their social network was also used in a positive way to encourage women to choose a more reliable method.

Given the influence that one’s social network has on contraceptive use and knowledge, this network could be exploited by public health professionals to increase use of LARC. If LARC were more commonly used, many of the reasons that improved EC access failed to decrease unintended pregnancy rates could be avoided. First, sexual intercourse is unplanned and often done irrationally. LARC, however, because it is long-acting does not require an individual to plan for each act of intercourse. It’s already in place even during unexpected sexual encounters. Second, EC only works with a single episode of unprotected intercourse. LARC is good for multiple acts without requiring any additional effort on the part of the user. Third, many people perhaps do not use EC because they do not believe in their own susceptibility to pregnancy or do not believe in the negative health consequences of unintended pregnancy. Likely, women’s belief in their susceptibility to pregnancy and their feelings regarding how a pregnancy may positively or negatively affect their lives may change several times during their reproductive life. With LARC, an individual needs to only recognize at one point in time that she is at risk of an unintended pregnancy and that this is not a desired outcome and subsequently visit a provider for a device. After this initial insertion, she needs to then consciously make a decision that an unintended pregnancy would not be a negative consequence and visit a health care professional for removal. In fact, in a study looking at interest in intrauterine contraception among seekers of emergency contraception or pregnancy testing, presumably a population that at the time of their clinic visit recognized the importance of avoiding pregnancy, 85% reported an interest in same-day insertion of an IUC (24). The challenge thus is to capture this group of patients at their most vulnerable time. And finally as compared to EC, while LARC may have a high upfront cost, once the device is inserted or implanted, there are no additional barriers. An individual does not need to visit a pharmacy, see a health care provider or pay any additional cost for effective contraception. In a research setting that eliminated many of these barriers to use of more effective methods, including provider misinformation and cost, 67% of subjects chose a LARC device (25).

LARC has many inherent advantages as a contraceptive method to decrease unintended pregnancy rates. It is safe, highly effective, doesn’t require repeated effort once in place and has no additional barriers to use once it is inserted. This is in contrast to EC, which is user-dependent and less effective. LARC, however, is infrequently used in the United States. The challenge to public health professionals is to develop innovative ways to increase utilization of these methods. Given the inherent unpredictability of sexual intercourse, constantly changing attitudes and emotions surrounding pregnancy, and a lack of understanding of the negative health consequences of unintended pregnancy, an intervention for increasing utilization based on the health belief model would be ineffectual. Furthermore, given that beliefs about fertility, childbearing and contraception are often tied to one’s cultural and social beliefs, social network theory may provide a more appropriate framework for an intervention to improve LARC uptake among at risk populations which would and thus decrease unintended pregnancy rates.


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