15-19 gold

Emergency Contraception:
A National Survey of Adolescent Health Experts
By Melanie A. Gold, Aviva Schein and Susan M. Coupey
In a survey of 167 physicians with expertise in adolescent health, 84% said they prescribe con- traception to adolescents, but only 80% of these prescribe emergency contraception, general- ly a few times a year at most. Some 12% of respondents said they believe that providing emer- focus-group discussions with PrincetonUniversity students, who have convenient gency contraception to adolescents would encourage contraceptive risk-taking, 25% said they think it would discourage correct use of other methods and 29% said they think repeated use of the method could pose health risks. Physicians who were more likely than their colleagues to prescribe emergency contraception included obstetrician-gynecologists (92%), those who grad- the method within this group, but a lackof specific knowledge about appropriate uated from medical school after 1970 (77%) and those who describe their practice as being in an “academic” setting (76%). Physicians may restrict use of the method by limiting treatment to adolescents who seek it within 48 hours after unprotected intercourse (29%), by requiring a preg- and called for routine education about themethod. Similarly, in a survey of college nancy test (64%) or an office visit (68%), or by using the timing of menses as a criterion for pro- students attending a women’s health clin- viding the method (46%). While 41% of physicians who provide emergency contraception coun- sel adolescents about the method during family planning visits, only 28% do so during visits for routine health care; 16% counsel women who are not yet sexually active about the method. (Family Planning Perspectives, 29:15–19 & 24, 1997)
bined pill is packaged and marketedspecifically for postcoital use, knowledge tives effectively during a relationship and using failed (e.g., a condom broke or a di- method or she was sexually assaulted.
ed to adolescents because of their patterns it.14 By contrast, 81% of adolescents seek- of sexual behavior and contraceptive use.
ing abortions in Devon had heard of emer- Adolescents often do not plan their first contraception used in the United States is the “Yuzpe” method, an oral regimen of 200 ception is partly attributable to health care mcg of ethinyl estradiol and 1.0 mg of dl- first intercourse,2 and the mean interval between the initiation of sexual activity within 72 hours of unprotected intercourse and a clinic visit for contraception varies tioners surveyed said they had received re- method reduces the risk of pregnancy after od available for patients, and many lacked gency contraception: a copper IUD insert- ate prescribing practices.16 However, in a ed within 5–7 days of unprotected inter- Melanie A. Gold is assistant professor of pediatrics, Di- *Different brands of oral contraceptives contain differ- vision of General Academic Pediatrics/Adolescent Med- ent amounts of hormones; consequently, the number of icine, Children’s Hospital of Pittsburgh; Aviva Schein is tablets a woman must take for a complete dose varies a medical student, Albert Einstein College of Medicine, Knowledge and Use
according to the brand of pill prescribed. Women using New York; and Susan M. Coupey is professor of pedi- Ovral (the preparation Yuzpe used in his original trials In the past few years, interest in women’s atrics, Division of Adolescent Medicine, Department of of the method) take a total of four tablets; those using Pediatrics, Albert Einstein College of Medicine/Monte- Lo-Ovral, Levlen, Nordette or the yellow Trilevlen or traception in particular, has surged. Yet, Volume 29, Number 1, January/February 1997 Adolescent Health Experts and Emergency Contraception Purpose of the Study
Table 1. Percentage distribution of physicians
surveyed about attitudes toward and practices
regarding emergency contraception services
for adolescents, by selected characteristics,
the patient, the health care system and the 1994 (N=167)
barriers related to patient attitudes or be- Finally, we thought that if physicians’ liefs. In addition, system-related barriers personal beliefs influence their practice, cer- Region
Northeast
(e.g., third-party payers’ denial of reim- tain demographic variables (e.g., gender, bursement for care, health facility policies religious affiliation or location) might be as- that restrict use for religious reasons and legal limits on advertising and promotion tion counseling and prescribing practices.
Methodology
the first step toward understanding emer- A 71-item structured interview was devel- Religion
gency contraception utilization is under- oped for this study and pretested on eight adolescent health experts. Questions were formulated to gather data on physicians’ tics, as well as their general experience pro- Year of medical school graduation
viding contraception to adolescents. A sec- physician aspect of the equation. In order based on those from earlier studies21 that Medical specialty
explored physicians’ attitudes and coun- ception, they must know of its availabili- seling and prescribing practices related to ty and where to obtain it. Therefore, they % of patients who are females aged 10–25
od before they are exposed to the risk of Ever prescribe contraception to adolescents
Practice setting
Academic
In this article, we report on a survey of zations represent 1,950 U. S. physicians, the physicians who have a specific interest or expertise in adolescent health. The survey lescent health. (Currently, 231 physicians Have teaching responsibilities
Yes
questioned these “adolescent health ex- perts” about their attitudes toward emer- certified in adolescent medicine; these in- gency contraception and their prescribing and counseling practices. In view of find- Note: Total includes respondents who do not practice clinical med- providers,20 we anticipated that few physi- that the variability among physicians was cians who offer care for adolescents would sufficient to reveal significant differences, national survey of British health authori- prescribe and offer counseling about emer- ties, or boards (which are regional equiv- clinicians and academic adolescent health alents of public health departments in the experts. We began by selecting every third eral characteristics of physicians’ education might be associated with their prescribing 3–5 times a week, and 57% reported doing so 1–10 times a week; only 19% said they trained in obstetrics and gynecology, who would have the most in-depth fertility-re- lated training, might be more likely to pre- stetrician-gynecologists and 39% of fami- scribe this method than physicians trained ber from the AAP Section list, again elim- in other disciplines, who serve adolescents first became available in the 1960s, physi- be calling to schedule a telephone inter- sexually assaulted.18 In contrast to British view about “a topic related to adolescent reproductive health.” The letter explained prescribing it for indications other than infrequently—about 2–6 times a year, de- for which the pill is approved by the Food that the data would be examined solely in have an impact on policy and teaching re- We were able to contact 304 physicians’ no significant differences in attitudes to- offices by telephone; the remainder could not be located on the basis of the infor- Attitudes Toward the Method
Eight questions were used to assess physi- Prescribing and Counseling Practices
for an interview after five attempts. Thus, traception for adolescents (Table 2). These of contraception for adolescents, 80% pre- concerns noted in the literature regarding er, of these 112 physicians, 81% prescribe this method only a few times a year or less be interviewed did not differ significant- The majority of respondents did not think (Table 3, page 18). All of the respondents ly by gender, specialty or location. Inter- provision of emergency contraceptive pills risk-taking (83%) or would discourage ado- routinely offer an antiemetic—not shown); extent of physicians’ attitudes and pre- dents’ most frequently cited reasons for scribing and counseling practices. To as- traception would pose health risks (such as preferring a particular regimen were their sess the relationship between physicians’ an increase in sexually transmitted disease nience and its cost (79%, 38% and 13%, re- istics and their attitudes and practices re- rates if availability of the method led to lax formed chi-square analyses for categorical about the health risks. Whereas 55% of re- age for Social Sciences. The study proto- gency contraception to an adolescent even col was approved by the institutional re- scribing the method up to 72 hours after a nancy in the event that the method failed, said they would not restrict the number of cutoff of 24 hours. Only 14% limit the num- Physicians’ Characteristics
times they would prescribe emergency con- Participating physicians were distributed Table 2. Percentage distribution of physicians, by responses to sur-
vey questions regarding attitudes toward emergency contraception
of the country (Table 1). Consistent with the distribution of the membership of the Do you think that providing emergencycontraceptive pills would encourage from medical school after 1970 (76%).
compliance with other contraceptive methods? tricians, 23% were obstetrician-gynecolo- contraceptive pills would pose health risks? At times, emergency contraceptive pills fail practitioners. Overall, 73% reported that to prevent pregnancy. If you knew in advance at least half of their patients are women that a patient would elect to continue herpregnancy if she encountered such a failure, aged 10–25, and 84% said they prescribe would you prescribe emergency contraception? of participants described their practice as you would dispense emergency contraceptive situated in an academic setting (i.e., a uni- versity or teaching hospital), 82% report- ed teaching responsibilities, which reflects the additional teaching contribution made have on hand PRIOR to an episode ofunprotected sexual intercourse? place in private practice or other nonaca- Do you think emergency contraceptive pills should be available over the counter, do not provide clinical care, they were in- If it was approved by the Food and Drug Admin-istration, would you prescribe mifepristone, cluded in the analysis of attitudes toward Note: Percentages may not add to 100% because of rounding.
ministrators and researchers, they may still Volume 29, Number 1, January/February 1997 Adolescent Health Experts and Emergency Contraception traception to adolescents (Table 4). Where- Table 3. Percentage of physicians who pre-
scribe emergency contraception to adoles-
cents, by prescribing and counseling practices
od, only 59% of those trained in pediatrics use.23) One-quarter of the physicians in the Prescribing
graduated earlier (77% vs. 35%) and high- haps because of these beliefs, close to half Prescribe only in emergency dept. setting of all physicians surveyed would restrict working in other settings (76% vs. 52%).
the number of times they prescribed emer- Demographic characteristics, on the other cians’ likelihood of prescribing emergency more than three-quarters oppose over-the- tion but do not prescribe emergency meth- offering this method are a lack of requests highly trained expert physicians reflects the paucity of data on this method in the U. S.
Use timing of menses to determine prescribing Counseling
scribing practices related to emergency con- Counsel at visits for routine health care traception have been conducted outside the Counsel sexually inexperienced adolescents cycle, and physician inexperience with the United States and reported in the Canadi- cians limit adolescents’ access to this ception was significantly correlated with method in a variety of ways: by restrict- contraception. Physicians who do not pre- within 24 or 48 hours after unprotected in- nancy test, 32% will prescribe this meth- tercourse, rather than using the standard ical visit (instead of prescribing over the menses as a further criterion before pre- health risks (49% vs. 30%). They also are more likely to favor restricting the num- for routine health care as an opportunity whether to prescribe this method for ado- to counsel about the method’s availabili- dispensed to any one patient (58% vs.
lescents is particularly problematic, since Table 4. Percentage of physicians surveyed
who prescribe emergency contraception to
adolescents, by statistically significant char-
ually active about its availability. In ad- acteristics (N=167)
Discussion
Contrary to our initial hypotheses, the ma- Medical specialty
ported that they have printed patient in- jority of U. S. adolescent health experts prescribe emergency contraceptive pills.
their offices, 18% provide this information Year of medical school graduation
only when patients request it, instead of making it available in waiting areas or ex- cians’ reasons for such infrequent pre- scription may be related to their attitudes Practice setting
Likelihood of Prescribing
Various educational characteristics are sig- **Difference is significant at p<.01. ***Difference is significant at p<.001.
nificantly associated with the likelihood Note: The number of internists and family practitioners was too smallfor analysis.
pills would pose health risks, while near- References
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