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OBJECTIVES: To determine patterns of consultation in general practice and provision of contraception before teenage pregnancy. DESIGN: Case-control study, with retrospective analysis of case notes. SETTING: 14 general practices in Trent region. SUBJECTS: 240 registered patients (cases) with a recorded conception before the age of 20. Three controls per case were matched by age and practice. MAIN OUTCOME MEASURES: Consultations in general practice and provision of contraception in the 12 months before conception and recorded provision of contraception at any time before conception. RESULTS: Overall, 223 cases (93%) had consulted a health professional at least once in the year before conception, 171 (71%) had discussed contraception in this time, and 121 (50%) had been prescribed oral contraception. Cases were more likely to have consulted in the year before conception than controls (odds ratio 2. 70, 95% confidence interval 1.56 to 4.66). Most of the difference was owing to consultation for contraception. Overall, 53 cases (22%) resulted in a termination of pregnancy. Cases whose pregnancy ended in a termination were more likely to have received emergency contraception than either their controls (3.21, 1.32 to 7.79) or cases resulting in other outcomes (3.01, 1.06 to 8.51). CONCLUSIONS: Most teenagers who became pregnant attended general practice in the year before pregnancy, and many had sought contraceptive advice. The reluctance of teenagers to attend general practice for contraception may be less than previously supposed. The association between provision of emergency contraception and pregnancy ending in termination emphasises the need for continuing follow up of teenagers consulting for this form of contraception.

PIP: In western Europe, UK has the highest teenage pregnancy rate among 15-19 year olds. Although general practice is one source of provision of contraception, it has been suggested that teenagers are reluctant to seek advice because of difficulty in gaining access and fears about confidentiality. This case-control study determined patterns of consultation in general practice and provision of contraception before teenage pregnancy. A total of 240 cases with a recorded conception before age 20 and 719 matched controls were identified. Overall, results show that most teenagers who became pregnant attended a general practice in the year before pregnancy, and many had sought contraceptive advice. Cases were more likely to have consulted a doctor in the year before conception than controls (odds ratio, 2.70; 95% confidence interval, 1.56-4.66). An association between provision of emergency contraception and pregnancy ending in termination was found. This finding emphasizes the need for continuing follow-up of teenagers consulting for this form of contraception.

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We performed a multivariate analysis to determine factors associated with knowledge and willingness to use emergency contraception in a consecutive sample of 371 post-partum women from an inner-city public hospital. Women were queried about previous contraceptive use, pregnancy history including abortions and unplanned pregnancies, and demographic characteristics. Outcomes included knowledge of emergency contraception and willingness to use it. Questionnaires were conducted in person, in English or Spanish.Of 371 women, 3% had used emergency contraception, 36% had heard of it, and 7% knew the correct timing for use. Two-thirds of the population indicated a willingness to use emergency contraception in the future. Factors positively associated with knowledge included being a teenager or more than 30 years old, prior use of condoms, and history of an elective abortion. Being multiparous, monolingual Spanish-speaking, or Asian were negatively associated with knowledge. Willingness to use emergency contraception was positively associated with being multiparous and negatively associated with a higher income, moral or religious objections to the use of emergency contraception, a belief that it is unsafe or a perception that it is an abortificient. Knowledge about emergency contraception, especially correct timing, remains low. Multiparous women should receive increased education given their lack of knowledge but willingness to use emergency contraception. In order to increase the acceptability of emergency contraception, educational efforts must include accurate information about its mechanism of use and safety.

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This study evaluated the effect of two approaches to provision of emergency contraceptive pills (ECPs) on ECP use and unprotected intercourse among women relying on spermicides for contraception. The study enrolled 211 women at 4 family planning clinics in Ghana. At two clinics, participants were advised to return to the clinic within 3 days after unprotected intercourse to obtain ECPs. At the other two clinics, participants were given ECPs to take home for use if unprotected intercourse occurred. All participants were asked to maintain daily diaries for 8 weeks to record information on sexual activity, spermicide use, and ECP use. Women at all clinics used ECPs after at least 78% of unprotected coital acts. ECPs were used more promptly by women who had the pills at home. At three of the clinics, at most 1.3% of the coital acts were unprotected; at the fourth, 6.7% were unprotected. Our data did not suggest that the availability of ECPs increased the frequency of unprotected intercourse.

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Many biomedical aspects of emergency contraception have been investigated and documented for >30 years now. A large number of social science questions, however, remain to be answered. In this article, we review the rapidly growing but geographically lopsided literature on this topic. Using computer database searches supplemented by reference reviews and professional correspondence with those active in the field, we gathered literature on the social science and service delivery aspects of emergency contraception published in English up through December 1998, as well as a few unpublished papers from the same time and slightly later, representing regions where published material is practically nonexistent. Methodologically acceptable papers are summarized in our tables and text, and form the basis for suggested improvements in existing emergency contraceptive services. The review also offers ideas for designing new emergency contraception services where they do not yet exist. We conclude by proposing an agenda for further social science research in this area.

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In 1996, the Ministry of Health in Ghana included emergency contraception (EC) in its newly issued National Reproductive Health Service Policy and Standards. A short survey was conducted in the summer of 1997 to evaluate health providers' knowledge of EC. Of the 325 providers interviewed, about one-third (34%) had heard of EC. No provider had sufficient knowledge to prescribe EC correctly. A well-coordinated training programme for providers will have to precede successful introduction of EC in Ghana. Moreover, a dedicated product may be critical for the successful introduction of EC in a country like Ghana, where provider knowledge is low.

PIP: In 1996, the Ministry of Health in Ghana included emergency contraception (EC) in its newly issued National Reproductive Health Service Policy and Standards. This paper reports a short survey conducted to evaluate the success of these early efforts to introduce EC into Ghana and evaluate health providers' knowledge of EC. Short structured interviews were conducted with health care providers at a sample of family planning outlets in two regions of Ghana. Findings revealed that health providers' knowledge about EC is low. Out of the 325 people interviewed, only about one-third (34%) had heard of EC. Furthermore, no provider had sufficient knowledge to prescribe EC correctly. Two policy implications can be drawn from this research: 1) well coordinated training of providers will have to precede a successful introduction of EC in Ghana; 2) a dedicated product may be critical for the successful introduction of EC, where providers' knowledge is low.

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PIP: The ¿After the Fact, After the Act¿ campaign in Philadelphia promoted emergency contraception (EC) to women through radio advertisements, and distribution of brochures, fliers, and posters. The program was sponsored by the Reproductive Health Technologies Project (RHTP), a nonprofit organization that helps provide public education and build understanding of safe, effective reproductive health technologies for women. Following the radio advertisement campaign, the hotline call volume increased by 110%, compared with 10 weeks prior to the project, and it remained high for several weeks thereafter. Moreover, RHTP conducted focus groups to examine the effectiveness of its existing EC material. The results led to the development of programs for hard-to-reach populations, including low-income urban African Americans.^ieng

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PIP: This article gives basic information about oral contraceptives based on the findings of Contraceptive Technology Update's 2000 Contraception Survey involving family planning providers and clinicians. Most (66%) of the providers surveyed prefer starting patients on pill packs the Sunday after menstruation (¿Sunday start¿ method). A remaining 34% of participants instruct their patients to begin pills on the first day of menses, known as the ¿same day start¿ method. Still others offer their patients the choice: either a ¿same day start¿, a ¿Sunday start¿, or a start on the day of the first visit. In addition, nearly 60% of providers offer printed materials concerning backup contraception to reinforce counseling especially in cases when women experience diarrhea or vomiting. Women should use backup contraception if they: 1) suspect that pills may be less effective; 2) miss taking any of the hormonal pills; 3) are late in starting new pill packs; 4) have severe vomiting or diarrhea; and 5) take medications such as anticonvulsants, that affect absorption of contraceptive hormones. Finally, counseling women on emergency contraception when discussing contraceptive methods is advised.^ieng

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PIP: This paper presents the findings of the Contraceptive Technology Update 2000 Contraception Survey in the US involving 275 health service providers, which examines the leniency of health care providers in dispensing emergency contraceptive pills (ECPs). According to the survey, three-quarters of the respondents say they prescribe ECPs on-site and provide them at any time. While 41.8% say their facility dispenses standard birth control pills for ECP use, almost 60% say they use products specifically marketed for emergency contraception. In addition, many believe that ECPs should be available over-the-counter (OCT). Advocates for taking emergency contraception OCT are preparing supporting materials for submission to the Food and Drug Administration.^ieng

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PIP: Baltimore-based Planned Parenthood of Maryland and the Baltimore City Health Department have joined forces in "EC to Go," which distributes free emergency contraceptive pills (ECPs) through the seven affiliate sites of Planned Parenthood and the three family planning centers of the city. The distribution program was started in October 1999 and funds were provided by an undisclosed area foundation. Although the program is still in its infancy, it has recorded some 800 prescriptions of ECPs in the last fiscal year, and 600 prescriptions have been logged in just the first 6 months of the current fiscal year. To inform the public about the program, Planned Parenthood developed newspaper advertisements, a 60-second radio spot, and coupon distributions, all of which emphasize the fact that emergency contraception is a higher dose of birth control, which can prevent pregnancy if taken within 72 hours of unprotected sex.^ieng

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PIP: This article provides a guide to eliminating barriers to women who seek emergency contraception (EC) in health facilities. The guide, intended for health care providers, suggests the use of a role-play staff session to see how the staff will respond when they receive a request for EC over the telephone. It is noted that even if health care providers know about EC, the receptionist and the front-end people do not. Educating patients about how to ask for EC over the telephone is also recommended. Education could be done by giving patients a telephone script which can be included in EC pamphlets so that patients will know how to ask for care when they call the clinic. In addition, patients especially adolescents should be given advance counseling on the common side effects of EC and should be assured of the drug's safety. Aside from making EC available round the clock at health centers, a trial protocol to offer telephone EC prescriptions for new services is also being undertaken.^ieng

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PIP: Reproductive health centers are finding successful ways to improve access to emergency contraceptive pills (ECPs) in an effort to reduce the high rate of unplanned pregnancies in the US. In a study by the Pacific Institute for Women's Health and the Family Planning Council, it was noted that there is a specific need for a clear, concise manual for family planning clinicians that would promote awareness of the method and ease the introduction of ECPs into clinical practice. To this effect, the institute and its partners published the manual, "A Clinician's Guide to Providing Emergency Contraceptive Pills". This manual offers tips on policies, organizational and management issues, staff training, and billing and insurance procedures to clinicians. On the other hand, the Planned Parenthood of Los Angeles designed a campaign in which affiliated clinics offered ECPs to most of their patients to take home with them at the time of their clinic visit. Reports from clinic officials indicate that in the campaign's first month of operation, the number of patients who took home ECPs doubled.^ieng

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OBJECTIVE: To evaluate the efficacy in ovulation detection of methods used in natural family planning in comparison with pelvic ultrasonography. DESIGN: Prospective analysis of ovulation detection by natural family planning methods and ultrasonography. SETTING: Natural family planning clinic, Department of Obstetrics and Gynecology, University of Naples "Federico II". PATIENT(S): Forty healthy women who were highly motivated to use natural family planning. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Transvaginal ultrasonographic findings, urinary LH levels, salivary beta-glucuronidase activity, salivary ferning levels and characteristics of cervical mucus, and BBT. RESULT(S): Urinary LH level determination yielded a 100% correlation with the simultaneous ultrasonographic diagnosis of ovulation. Mucus sensations and characteristics yielded a 48.3% correlation when simultaneously evaluated with ovulation. Beta-glucuronidase levels yielded a 27.7% correlation. The salivary ferning test had a 36.8% ovulation-detection rate the day of ovulation, but 58.7% of results were uninterpretable. Body temperature measurements yielded a 30.4% correlation with the simultaneous ultrasonographic diagnosis of ovulation. CONCLUSION(S): Measuring urinary LH levels is an excellent method for determining ovulation. Although variations in mucus characteristics and basal body temperature correlate somewhat with ovulation, the length of the fertile period is overestimated with these methods. The salivary ferning test and measurement of beta-glucuronidase levels are not good methods for home ovulation testing.

PIP: This methodological study aims to evaluate the efficacy of methods used for determining ovulation in a natural family planning in comparison with pelvic ultrasonography. Prospective analysis of ovulation detection methods was conducted with 40 women. Ovulation-detection methods employed in the study include transvaginal ultrasonography, daily morning urinary luteinizing hormone (LH) determinations, determination of salivary beta-glucuronidase activity, salivary ferning test, determination of cervical mucus levels and characteristics, and measurement of rectal or oral basal body temperature. Results revealed a 100% correlation between urinary LH level and ovulation diagnosis obtained from ultrasonographic examination. Other ovulation-detection methods contain the following correlation results: mucus sensations and characteristics, 48.3%; alpha-glucuronidase, 27.7%; and salivary ferning test, 36.8%. These findings draw the researchers to conclude that self-determination of LH levels could be an excellent method in ovulation determination.

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PIP: More than 100 general medical practices in Lothian, Scotland, have agreed to take part in the 2-year research project designed to see if improving the availability of emergency contraception will reduce unplanned pregnancies and lower the abortion rate. At the end of 2 years, the change in the abortion and unplanned pregnancy rate of women attending the 100 general practices will be compared with any change in rates among other practices in the region. Both the BMA and the Royal College of Obstetricians and Gynaecologists have supported moves to make emergency contraception available over the counter in pharmacies. However, this has been strongly resisted in Great Britain by anti-abortion groups and the Catholic Church. Expectations are bright that the project will reduce the number of abortion cases in Lothian by about 15%.^ieng

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The aim of the study was to assess the knowledge of emergency contraception amongst new female patients attending an inner-city department of genitourinary medicine. Information was also sought about use of regular contraception and demography. Three hundred and ninety nine questionnaires were suitable for analysis. Half of the sample answered that the latest a woman could take emergency contraception after unprotected sex was three days. None of the sample knew that emergency contraception could be obtained up to five days. Twenty nine per cent of the sample reported sex without contraception during the menstrual cycle preceding attendance. Women who had ever used regular contraception in the past were statistically less likely to have reported unprotected sex in the menstrual cycle preceding attendance (p=0.0000068). Professional women were statistically less likely to have reported unprotected sex in the menstrual cycle preceding the clinic visit. Fourteen per cent of the sample had genital warts at this first clinic visit, 10 per cent had Chlamydia trachomatis, seven per cent had herpes simplex infection, six per cent had gonococcal infection and five per cent had trichomonal infection. Women who reported unprotected sex during the preceding menstrual cycle were not statistically more likely to have a sexually transmitted infection at this first clinic visit. A large number of women attending departments of genitourinary medicine are at risk of both pregnancy and also sexually transmitted infection. Staff working in all areas of sexual health need to have a good knowledge of both contraception and sexually transmitted infections in order to educate the clients on both aspects of unprotected sex.

PIP: 399 questionnaires were analyzed to evaluate the knowledge of emergency contraception among female patients in a genitourinary medicine (GUM) department. The use of regular contraception and demography was also examined. 50% of the sample stated that the latest a woman could take emergency contraception after unprotected sex was 3 days, while none of them knew that emergency contraception could be taken up to 5 days afterwards. 29% admitted having engaged in unprotected sex during the menstrual cycle preceding their clinic visit. On the other hand, women who had ever used regular contraception in the past showed low incidence of unprotected sex in the menstrual cycle prior to attendance at the clinic. Among the sample, 14% had genital warts, 10% had Chlamydia trachomatis, 7% had herpes simplex infection, 6% had gonococcal infection, and 5% had trichomonal infection. This study has revealed that several women attending GUM departments are at risk of both pregnancy and sexually transmitted infection. Therefore, there is a need to provide intensive education regarding contraception and sexually transmitted infections among the female patients attending GUM departments.

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A cross-sectional descriptive study on knowledge, attitudes, and practice about emergency contraception (EC) was conducted among nurses and nursing students using a self-administered questionnaire. One-hundred-sixty-seven qualified nurses and 63 nursing students completed the questionnaire. Over 95% listed at least one regular contraceptive method but only 2.6% spontaneously listed EC as a contraceptive method, whereas 48% of the respondents had heard of EC. Significantly more nursing students than qualified nurses were familiar with EC. Knowledge about the types of EC, applications, and side effects was poor and 49% of the respondents considered EC as an abortifacient. Of those familiar with EC, 77% approved its use for rape victims and 21% for adolescents and schoolgirls. Only 3.5% of all respondents had personally used EC in the past, 23% of those familiar with EC intend to use it in the future, whereas 53% intend to provide or promote it. The view that EC was abortifacient negatively influenced the decision to use or provide EC in the future. The present findings suggest that the level of knowledge of EC is poor and more information is needed. These findings indicate the potential to popularize emergency contraception in Kenya among nurses and nursing students.

PIP: A descriptive research study on knowledge, attitudes and practices with regard to emergency contraception (EC) was conducted using a questionnaire among 167 nurses and 63 nursing students in Nairobi, Kenya. Results revealed that 95% recorded at least one regular contraceptive method. About 48% of the respondents had heard about EC, but only 2.6% had used it. More nursing students than qualified nurses were aware of EC. There was poor knowledge about the types, applications and side effects of EC. Some 49% of the subjects regarded EC as an abortifacient. About 77% of those knowledgeable about EC approved its use for rape victims and 21% for adolescents and schoolgirls. Only about 3.5% had personally used it. Some 23% of those aware of EC intended to use it in the future. About 53% planned to provide or promote it. The perception that EC is abortifacient affected the decision whether to use or provide it. The data imply that there is potential for effective promotion of EC among nurses and nursing students in Kenya.

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PIP: This is a report of a survey on the use of emergency contraception among teenagers in Finland. The school health promotion study provided data on adolescent health behaviors. Each of the 52,700 respondents from comprehensive schools and upper secondary schools answered a structured questionnaire. Findings showed that adolescent girls were widely aware of emergency contraception. Only a small proportion of teenagers had actually used emergency contraception. The proportion of girls who had used emergency contraception increased in proportion with age, but among multiple users, there was no evidence that multiple use increased systematically with age. The survey results suggest that accessibility of contraception and intensive sex education has not increased the level of adolescent sexual activity.^ieng

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PIP: A double-blind, randomized controlled trial conducted at 21 centers in 14 countries compared the effectiveness and side effects of the traditional Yuzpe method of emergency contraception (200 mcg of ethinyl estradiol and 1 mg of levonorgestrel divided into 2 equal doses) and levonorgestrel alone (2 doses of 0.75 mg each). 1955 women (979 in the Yuzpe group and 976 in the levonorgestrel group) completed the study. 42 women had subsequent pregnancies, although at least 4 women were pregnant at the time of treatment. The pregnancy rate was 1.1% (95% confidence interval [CI], 0.6-2.0) for the levonorgestrel group and 3.2% (95% CI, 2.2-3.5) for the Yuzpe regimen. The relative risk of pregnancy was 0.36 (95% CI, 0.18-0.70). Levonorgestrel prevented 85% of expected pregnancies while the Yuzpe method prevented only 57%. Efficacy increased when the regimen was initiated within 24 hours and decreased as the time after unprotected intercourse approached 72 hours. Women in the levonorgestrel group reported less nausea, vomiting, dizziness, and fatigue than their counterparts in the Yuzpe group. Overall, 57% of women started bleeding within 3 days of their expected menses and the mean duration of menses of 4.7 days in both groups. Results of this study support use of levonorgestrel alone as an alternative for emergency contraception.^ieng

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In this two centre study, the efficacy of 200 mg mifepristone orally followed 48 h later by 0.4 mg misoprostol orally for menstrual regulation was investigated. The dose of mifepristone was taken the day before the expected day of menstruation. Each volunteer was planned to participate for up to 6 months. A plasma beta human chorionic gonadotrophin (HCG) was measured on the day of mifepristone intake. The study was disrupted prematurely due to low efficacy. In 125 treatment cycles the overall pregnancy rate was 17.6% (22 pregnancies) and the rate of continuing pregnancies (failure) was 4.0%. Eight women discontinued the study due to bleeding irregularities which were seen in 15 cycles (12%). These effects on bleeding pattern made the timing of treatment day difficult. Late luteal phase treatment with a combination of mifepristone and misoprostol is not adequately effective for menstrual regulation.

PIP: A 2-center study was undertaken to examine the efficacy, safety and acceptability of a once-a-month administration of a combination of 200 mg mifepristone and 0.4 mg misoprostol for menstrual regulation in the late luteal phase. About 24 women from Shanghai and 8 from Stockholm were administered 200 mg mifepristone taken orally before or on the day of menstruation, followed by 0.4 mg misoprostol taken orally after 48 hours. Urine samples were collected during 3 days before to 4 days after ovulation for an analysis of luteinizing hormone. In addition, a plasma beta human chorionic gonadotrophin was measured immediately before intake of mifepristone. Volunteers were to participate for 6 months, but the study was disrupted prematurely due to low efficacy. In 125 treatment cycles, the total pregnancy rate was 17.6% (22 pregnancies) and the failure pregnancy rate was 4.0%. Discontinuation of the study among 8 women was due to bleeding disturbances seen in 15 cycles (12%). In conclusion, late luteal phase treatment with a combination of mifepristone and misoprostol was not effective enough to be used for menstrual regulation.

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The aim of this survey was to examine the number of abortion applicants not using contraception at the time of conception, to shed light on the reasons for this, and to acquire information about the knowledge of postcoital anticonception in this patient group. The registered data is collected from precoded medical records at the University Hospital of Trondheim comprising 2,074 women applying for abortion in the period 1.1. 1995-15.7. 1997. The 291 applying for abortion 15.1-15.7. 1997, and who had not used contraception were given a questionnaire. 160 (55%) answered the questionnaire. During the period of 2.5 years 57.4% had not used contraception at the time of conception. The tendency of non-use has increased significantly during the last 2.5 years. Concern about sideeffects was the most common reason for not using contraceptives (36%). One third trusted the rhythm method and coitus interruptus. The postcoital pill was known by 93%; of the 61 women who had considered using it, 67% thought of it too late. To prevent unwanted pregnancies, it is important to focus on the positive health effects of oral contraception. Information efforts should especially be aimed at young and single women, who represent the majority of the non-users. The cost is no great impediment to the use of contraception. Availability of emergency contraception should be improved.

PIP: Precoded medical records of 2074 women seeking abortion at the University Hospital of Trondheim, Norway, during the period of January 1, 1995, to July 15, 1997, were analyzed to find out which women had not used contraceptives. In 1995 a total of 413 (51.8%) out of 798 women did not use contraception; in 1996 a total of 487 (59.4%) out of 820 women did not use contraception; and in 1997 a total of 291 (63.8%) out of 456 women did not use contraception. This was a significantly increasing trend (p 0.001). During the period of January 15 to July 7, 1997, a total of 447 provided information about contraceptive use: 156 (34%) used contraceptives and 291 (64%) did not. 50 of 63 adolescents (79%) did not use contraception. In the 25-34 age group there were significantly more contraceptive users than in the 15-24 age group (p = 0.003) and in the 35 age group (p = 0.026). 160 women (55%) out of 291 women who did not use contraception during the first half of 1997 answered a questionnaire. 51 women (32%) thought that they could not get pregnant because of various causes of infertility (childbirth, safe period, or abdominal infections). 55 women (34%) relied on coitus interruptus or safe periods. Here there was a significantly increasing trend with advancing age (p 0.01). Condom use was undesired in 41 cases (26%), and 25 women (16%) reported unavailability of contraception. 148 women (93%) had heard about postcoital contraceptives and 61 women (38%) figured that they would use them.

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PIP: The Yuzpe method of using combined oral contraceptives for emergency contraception has been available for 25 years; prevents 75% of pregnancies that would have occurred if no treatment were used; has an excellent safety record; and is contraindicated only in patients with a history of thromboembolism, migraine at presentation, or a history of migraine with aura. However, this method has side effects of nausea and vomiting, and the World Health Organization recently reported that use of levonorgestrel alone is effective and associated with fewer side effects. No additional research has been conducted on the timing or dosage of the estrogen-progestogen method, but some dose-effectiveness studies have been performed on mifepristone. Mifepristone, however, is not widely available. The levonorgestrel studies found a negative correlation between the interval from unprotected intercourse to treatment and effectiveness but concluded that levonorgestrel was more effective than the combined method (this study found a lower effectiveness for the combined method than previously reported). Given that each method is effective, consideration of whether the new one should be adopted must take into account the fact that the levonorgestrel is currently not licensed for this use, is not prepared in convenient dosages, and is more expensive and less available. Introduction of new methods of emergency contraception should augment choices rather than replace other methods.^ieng

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