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Article Excerpt
Emergency contraception is a safe, highly effective method of preventing unintended pregnancy. In 1997, the Food and Drug Administration concluded that the Yuzpe regimen of emergency contraception (two doses of combined estrogen and progestin taken 12 hours apart) is safe and effective in preventing pregnancy within 72 hours of unprotected sex or contraceptive failure; subsequent studies confirmed its effectiveness for up to 120 hours after sex. (1) The dedicated products Preven and Plan B were approved in 1998 and 1999, respectively.
Yet the availability of emergency contraception at pharmacies did not guarantee that women would be able to obtain it within the window of efficacy. Proponents of over-the-counter sales have argued that requiring a prescription limits women's access to emergency contraception, because some women do not know about the method, are reluctant to ask their health care providers for advance supplies or need it when their providers' offices are closed. (2,3) Furthermore, some clinicians typically discuss or provide emergency contraception only after patients request it or report having had unprotected intercourse. (4) The August 2006 approval of over-the-counter sales of Plan B for individuals 18 or older was hailed as an important step toward overcoming some of these barriers. However, for women who are younger than 18 or who cannot afford to buy emergency contraception, significant barriers remain.
One way of addressing disparities in access is to offer emergency contraception in advance of immediate need. Advance provision has been shown to increase the probability that this method will be used. (5,6) Because family planning clinics that are funded by Title X of the Public Health Service Act (the program that established federal funding for family planning) provide reproductive health services to approximately five million low-income women and adolescents annually, (7) these clinics could play a significant role in helping patients prevent unintended pregnancies by providing advance emergency contraception.
Title X-supported clinics and agencies are mandated to provide a broad range of contraceptive methods (including emergency contraception) and services to low-income clients for little or no cost according to their income and ability to pay. The majority of Title X-funded clinics educate clients about emergency contraception and dispense the method on-site or through prescription on an as-needed basis, and nearly half have a policy of providing advance supplies. (8) Although studies have examined patients' and providers' attitudes toward advance provision in general health care settings, (4,9,10) there has been little research on how providers at publicly funded family planning clinics view advance provision.
This study explores staff and patient attitudes and behaviors in the context of a large Title X-supported network of diverse family planning service agencies that has a longstanding policy of providing advance emergency contraception. The Family Planning Council, the Title X grantee for southeastern Pennsylvania, instituted a policy of offering advance provision of this method in 1997, two months after the Food and Drug Administration endorsed the approach. This policy, recommended by the Council's medical committee and approved by all affiliated agencies, stated: "All family planning provider agencies must offer prophylactic emergency contraception to all existing [female] patients (unless medically contraindicated)." According to the policy, patients are to receive information about emergency contraception, including when and how to use it and potential side effects. After signing a form requesting advance provision, women who do not have any medical contraindications receive emergency contraception to take with them; in accordance with Title X guidelines, the emergency contraception is provided free or at reduced cost.
All affiliated agencies agreed to send the Council data from every patient visit, including whether emergency contraception was provided (either in advance or when needed). At monthly meetings of agency representatives, reports on the numbers of eligible women who received advance provision were distributed; in addition, the implementation of the advance provision policy and associated issues were periodically discussed. By 2005, the proportion of eligible women in the Council network who had received advance emergency contraception was still less than 25%, and ranged by clinic from 0% to 46%. Although the Council recognized that many women might not be interested in or might refuse advance emergency contraception, it also recognized a need to understand the views of patients, clinicians and counselors. Thus, this study collected information from patients and staff concerning advance provision--particularly with regard to barriers--with the goal of guiding efforts to improve clinic adherence to the advance provision policy.
METHODS
Study Sites
Like other Title X grantees, the Family Planning Council is the central source within its geographic service area for dispensing Title X funding, overseeing standards of care, purchasing supplies and developing policies to improve services. In 2006, its 29 subcontracted agencies and their 79 clinics provided contraceptive and other reproductive health services to approximately 134,000 female and 10,000 male patients; these clinics were run by teaching and community hospitals, affiliates of the Planned Parenthood Federation of America, public health departments, community health centers and other organizations (e.g., substance use treatment programs). Although affiliated with the Council, these agencies maintain their own operational structure, management responsibilities and policies.
The data used in the present analysis were collected as part of a five-year longitudinal study designed to compare the frequency of emergency contraceptive use by women who have advance access with use by women who have only emergency access, and to identify factors associated with acceptance and use of the method. (11) The longitudinal study was approved by the Council's institutional review board, and this approval was accepted by the affiliated clinics. Patient data were collected at four Title X-funded family planning clinics that were selected because they were willing to participate, had a large client pool and provided advance emergency contraception at levels similar to or above the Council network average. Two of the clinics were community health centers, and two were Planned Parenthood clinics. During the study period (2001-2005), the annual proportion of eligible women provided with advance emergency contraception at the four clinics ranged from 16% to 38%. The present study draws on data collected from 211 patients between June 2001 and July 2002, from 22 staff who were interviewed between November 2004 and February 2005, and from 111 staff who worked at 46 Council-affiliated clinics and who responded to a survey sent in November 2005.
Patients
To be eligible for the study, patients had to be 15-39 years old, sexually active (or expecting to be sexually active within the next 12 months), neither pregnant nor seeking to get pregnant in the next 12 months, and not using sterilization, hormonal implants or an IUD as their primary contraceptive method. Interviewers approached women in the waiting rooms of the four clinics, described the project and invited them to participate. Interested women completed a self-administered screening survey consisting of 10 closed-ended questions. The interviewers then administered the intake survey to all eligible, consenting participants. * The 26 intake questions were closed-ended and collected information...
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