Executive Summary
A recently published commentary calls for changes in patient counseling for emergency contraception (EC). Why? Typical counseling does not take into account the relative effectiveness of available methods or patient characteristics, it asserts.
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• Women in the United States now have several options when it comes to emergency contraception, including the insertion of a Copper-T380A intrauterine device, the ulipristal acetate emergency contraceptive pill, and the levonorgestrel emergency contraceptive pill.
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• the Effectiveness Of Ec Pills Differs By Characteristics Outside Women’s Immediate Control, Such As Body Mass Index And The Timing Of Ovulation, States The New Commentary. By Presenting Ec Options In A Tiered Approach, Women Can Clearly Grasp The Most Effective Options Available To Them.
A recently published commentary calls for changes in patient counseling for emergency contraception (EC).1 Why? Typical counseling does not take into account the relative effectiveness of available methods or patient characteristics, it asserts.
Women in the United States now have several options when it comes to emergency contraception, including the insertion of a Copper-T380A intrauterine device (IUD), the ulipristal acetate emergency contraceptive pill (ella, Afaxys, Charleston, SC), and the levonorgestrel emergency contraceptive pill.
Levonorgestrel pill options include:
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Plan B One-Step (Teva Women’s Health, North Wales, PA);
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Take Action (Teva);
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Next Choice One Dose (Actavis, Parsippany, PA);
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My Way (Gavis Pharmaceuticals, Somerset, NJ);
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Levonorgestrel 0.75 mg tablets (Perrigo, Allegan, MI);
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AfterPill (Syzygy Healthcare Solutions, Westport, CT).
The ulipristal pill is by prescription only. Levonorgestrel pills are approved for unrestricted sales on store shelves.
The effectiveness of EC pills differs by characteristics outside women’s immediate control, such as body mass index (BMI) and the timing of ovulation, states the new commentary. Research indicates that women are at a statistically significant increased risk of pregnancy after taking EC pills when they:
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have a BMI equal to or above 30 kg/m2 compared to a BMI below 25 kg/m2;
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have unprotected sex the day before estimated ovulation compared to women outside their fertile window; or
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have additional acts of unprotected intercourse after taking EC compared to women who did not.2
Family planning clinicians are familiar with presenting contraception using the tiered effectiveness chart developed by the World Health Organization. (Download a free copy of the chart at http://1.usa.gov/1oOY2Bw.) The commentary asks, why not take that same approach when it comes to counseling on emergency contraception?
Planned Parenthood Federation of America is using a tiered approach to EC in its counseling. Known as “EC4U,” the program began a few years ago with the development of a toolkit to help Federation affiliate clinicians and staff members talk with women about their EC options, says Deborah Nucatola, MD, senior director of medical services. Part of the toolkit contained a “Wait A Minute” chart, developed to educate women on the complete range of EC options, ranked by their typical rates of effectiveness.
“We tried to in a simple way explain that there are three methods — levonorgestrel pills, ulipristal acetate pills, and the copper IUD — and the different factors, such as time since unprotected intercourse and the possibility of BMI or weight that might influence the effectiveness of their EC,” explains Nucatola.
Thanks to a grant from the William and Flora Hewlett Foundation of Menlo Park, CA, the Federation was able to launch a second-phase initiative to help affiliates increase the use of copper IUD as emergency contraception, says Nucatola. Nine demonstration projects were funded from that grant. For the nine pilot sites combined, the clinics inserted 101 copper IUDs for EC, where in an equal six-month period, only 20 devices had been inserted, says Nucatola. The pilot projects used an array of approaches to increase IUD for EC usage. Publication of data is pending.
The Federation has received additional funding from the Hewlett Foundation to take the project even further, says Nucatola. The funding will allow the Federation to refine the original toolkit, incorporate some of the lessons learned from the second-phase pilot projects, and implement a “train-the-trainer” project in fall 2015 in which at least one staff member at each affiliate will be deemed the local “champion.”
“You really need somebody on the ground who really wants this project to succeed and be the champion and the resource,” says Nucatola. “We’re going to train that champion for every one of our affiliates, and then we will see what type of effect that has on the Federation as a whole.”
Researchers at the Bixby Center for Global Reproductive Health at the University of California San Francisco are looking at the impact of the tiered approach with respect to patient knowledge and health outcomes. Researchers are in process with a study to test the approach in student health centers around the greater San Francisco area, says Kirsten Thompson, MPH, project director. Thompson served as a co-author of the current commentary on tiered counseling.
The research team is using an EC effectiveness chart similar to the one shown on the Bedsider.org web site, says Thompson. (The English version of the EC chart is at http://bit.ly/1xae3Bh. The Spanish version is at http://bit.ly/14J2YPy.)
Research indicates that while young women in particular might have heard of emergency contraception, they are unfamiliar with the IUD for emergency contraception, says Thompson.3 There is not great knowledge about ulipristal acetate prescription EC, and many people still don’t know that levonorgestrel EC pills are available over the counter, she notes.
“We tried to create a tool that would give a little bit of all that information for people,” explains Thompson. “Where can you get it? What are the different options? How soon after unprotected sex do you need to use them? The tool shows all that.”
REFERENCES
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Thompson K, Belden P. Counseling for emergency contraception: Time for a tiered approach. Contraception 2014; 90(6):559-561.
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Glasier A, Cameron ST, Blithe 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):363-367.
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Wright RL, Frost CJ, Turok DK. A qualitative exploration of emergency contraception users’ willingness to select the copper IUD. Contraception 2012; 85(1):32-35.
