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Improving Access to Emergency Contraception for Female Adolescents
By Jessica L. Barnack
University of Wisconsin, Milwaukee

Emergency contraception (EC), also referred to as the "morning-after-pill", is a high dose of birth control pills, that can be given to women up to 120 hours after unprotected intercourse, to prevent a pregnancy. EC has been found to be highly effective in allaying fears of unwanted pregnancy, but effectiveness is highly dependent on how soon EC is taken after unprotected intercourse (Grimes & Raymond, 2002); therefore, adequate access to EC is crucial in order for women to benefit from the regimen.

On August 24th, 2006, the U.S. Food and Drug Administration (FDA) made the decision to allow women 18 years of age and older to obtain emergency contraception over-the-counter (OTC). The FDA's decision to make EC available to women OTC was an important one, but more needs to be accomplished in terms of increasing availability of EC to females under the age of 18. At present, in the United States female minors (aged 17 and younger) can only obtain EC at a clinic, or with a doctor's prescription. This limits teen's access to EC because it can be difficult for minors to get to a clinic or doctor, especially if they need parental permission, and some States allow pharmacies and hospitals the choice of whether or not to provide EC to women. Although unintended teen pregnancy is decreasing in the U.S., it is still a significant problem that is exacerbated by the limited access of many teenagers to reliable and effective birth control (Guttmacher Institute, 2006). Teenagers often lack the resources necessary to protect themselves from unintended pregnancies; therefore, limiting adolescents' access to EC creates a substantial barrier to reproductive freedom.

People who are in opposition to EC may be morally opposed to it or may believe EC will lead to risky sexual behavior, earlier initiation of sexual activity, and/or increased incidences of sexually transmitted infections (STIs). In addition, some opponents may argue that if given increased access to EC, female teenagers will use it in lieu of other more reliable contraceptive methods (e.g., hormonal contraceptives) (Golden et al., 2001; Sherman, 2005). The purpose of this article is to summarize the research that has examined the effects of EC on female minors' sexual risk behaviors. This research provides no support for the contention that use of EC leads to sexual risk behavior or is associated with lower use of effective contraception.

In a preliminary study conducted by Roye (2001), young women (aged 14 to 20) were given a questionnaire about their sexual behaviors, and a supply of EC. One month and three months later, the young women were asked to fill out questionnaires, which assessed the effects of EC on the young women's sexual behavior. The 38 young women who completed both follow-ups did not report any significant differences in sexual behavior (e.g., condom use, contraceptive use, unprotected intercourse).

Using a larger sample size, Gold, Wolford, Smith, and Parker (2004) also examined how the advanced provision of EC would affect adolescent females' sexual risk behaviors. Participants were 301 women aged 15 to 20, who were either given an advanced supply of EC, or instructions on how to obtain EC at a clinic (control). Sexual risk and contraceptive behaviors were measured at 1 month and 6 months. At both 1 month and 6 months, there were no differences in reports of unprotected intercourse between the adolescents who were given an advanced supply of EC and those who were not. There were also no differences between the groups in terms of condom or oral contraceptive use at 1 month. At 6 months, the group that had been given an advanced supply of EC reported more frequent condom use than the control group. The researchers concluded that the only significant change associated with an advanced supply of EC was increased condom use.

In one study conducted by Raine and her colleagues (2000), 263 young women from a high-risk clinic population (aged 16 to 24) were systematically assigned to either receive an advanced supply of EC and education about it, or only education about EC (control). At follow-up (4 months), the treatment group was no more likely than the control group to have had unprotected intercourse; however, the treatment group reported less effective contraception use (e.g., oral contraceptives) than the control group. It should be noted that the less effective contraception use p value was equal to .05; therefore, it could be argued that the significant difference should be repeatedly found in subsequent research in order to conclude that a supply of EC leads to less effective contraception use. In addition, the sample in this study came from a high-risk clinic population, which limits the extent to which the findings can be generalized to all adolescents. The study conducted by Raine et al. in 2005, corrected these limitations, which resulted in different findings.

Raine and her colleagues (2005) conducted a randomized controlled trial of EC use with 2,117 women aged 15 to 24. About 25% (n = 483) of the sample were minors (age 15 to 17). Participants were either given pharmacy access to EC, advance provision (3 packs) of EC, or clinic access to EC (control). Outcome measures consisted of the number of times participants had used EC, number of pregnancies, contraceptive behavior, STI diagnoses, condom use, and other sexual risk behaviors. No significant differences were found between the three groups in terms of unprotected intercourse, oral contraceptive use, frequency of intercourse, frequency of condom use, consistency of condom use, or number of sexual partners. Harper, Cheong, Rocca, Darney, Philip, and Raine (2005) further analyzed Raine et al.'s (2005) sample, and comparing 964 adolescents (under the age of 20) to the adult women (aged 20 to 24) in the sample. There were no differences in sexual risk behaviors between adolescents and women from other age groups. The findings in this randomized, controlled trial are consistent and challenge the argument that increased EC access results in riskier sexual behavior

In another study, Walker, Torres, Gutierrez, Flemming, and Bertozzi, (2004) surveyed adolescents in Mexico, about their experiences with EC and other sexual risk behaviors. Of the 10,918 adolescents surveyed, 1,695 reported having experiences with EC. For females, experiences with EC meant they had used EC at least once, and for males, this meant they reported that their female partners had used EC in the past. Those adolescents who had experience with EC were more likely to report having used a condom the last time they had sexual intercourse, and greater knowledge about how to use a condom than adolescents who had no experience with EC. Therefore, the finding that EC experiences are associated with condom use appears to be consistent across U.S. and Mexican cultures.

As mentioned previously, opponents to EC often argue that increasing the availability of EC to female minors would lead them to use the regimen in lieu of more reliable contraceptive measures. In Switzerland, Ottesen, Narring, Renteria, and Michaud (2002) conducted a study that examined EC knowledge, attitudes, and sexual risk behaviors of 4,283 adolescents (aged 16 to 20). Of the 211 female adolescents who had used EC, there were no significant differences between one-time EC users and multiple-time EC users in their sexual risk behaviors (e.g., contraceptive use, condom use). These findings suggest that if adolescents use EC more than once, they are not necessarily using it in lieu of regular contraceptives or condoms. One possible explanation of this finding is that adolescents may be more diligent about using EC when an initial attempt to prevent pregnancy fails because they have a greater fear of pregnancy.

The availability of EC is important for teenagers' reproductive freedom, yet EC is still not available to teenagers in the way it is available to women aged 18 and older. In yet a further analysis of Raine et al.'s (2005) study, Rocca, Schwarz, Stewart, Darney, Raine, and Harper (2007) found that of the 14% of women who reported that on at least one occasion they did not use EC when they thought they should, the most common reason for not taking EC was that obtaining it would be too troublesome or inconvenient. This finding suggests that under some circumstances, women are in need of EC, but do not take it due to issues of accessibility. It is possible that unintended pregnancies result from such circumstances.

Raine and her colleagues have argued that there are several complex barriers to EC use, including a woman's perceived pregnancy risk, motivation to prevent pregnancy, knowledge about EC and how to obtain it, and having the resources needed to obtain it; therefore, providing adolescents with access to EC is only one part of the solution. The empirical evidence summarized above, is an attempt to dispel the myths that surround EC, which has yet to fulfill its potential in helping to prevent unintended pregnancies. In addition to educating adolescents about EC and increasing acceptability of the regimen, providing adolescents with adequate access to EC can help reduce unintended pregnancies without increasing risky sexual behavior, which has far-reaching positive effects for all members of society.

References

Grimes, D. A., & Raymond, E. G. (2002). Emergency contraception. Annals of Internal Medicine, 137, 180-189.

Gold, M. A., Wolford, J. E., Smith, K. A., & Parker, A. M. (2004). The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors. Journal of Pediatric and Adolescent Gynecology, 17, 87-96.

Golden, N. H., Seigel, W. M., Fisher, M., Schneiger, M., Quijano, E., Suss, A., Bergeson, R., Seitz, M., & Saunders, D. (2001). Emergency contraception: Pediatricians' knowledge, attitudes, and opinions. Pediatrics, 107, 287-292.

Guttmacher Institute. (2006). U.S. teenage pregnancy statistics: National and State trends and trends by race and ethnicity. Retrieved on September 30, 2007 from: http://www.guttmacher.org/pubs/2006/09/12/USTPstats.pdf.

Harper, C. C., Cheong, M., Rocca, C. H., Darney, P. D., & Raine, T. R. (2005). The effect of increased access to emergency contraception among young adolescents. Obstetrics & Gynecololgy, 106, 483-491

Ottesen, S., Narring, F., Renteria, S., & Michaud, P. (2002). Emergency contraception among teenagers in Switzerland: A cross-sectional survey on the sexuality of 16- to 20-year olds. Journal of Adolescent Health, 31, 101-110.

Advance provision in a young, high-risk clinic population. Obstetrics & Gynecology, 96(1), 1-7.

Raine, T. R., Harper, C. C., Rocca, C. H., Fischer, R., Padian, N., Klausner, J. D., & Darney, P. D. (2005). Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs. Journal of the American Medical Association, 293, 54-62.

Rocca, C. H., Schwarz, E. B., Stewart, F. H., Darney, P. D., Raine, T. R., & Harper, C. C. (2007). Beyond access: Acceptability, use and nonuse of emergency contraception among young women. American Journal of Obstetrics & Gynecology, 196, 29.e1-29.e6.

Roye, C. F. (2001). Routine provision of emergency contraception of teens and subsequent condom use: A preliminary study. Journal of Adolescent Health, 28, 165-166.

Sherman, C. A. (2005). Emergency contraception: The politics of post-coital contraception. Journal of Social Issues, 61, 139-157.

Walker, D. M., Torres, P., Gutierrez, J. P., Flemming, K., & Bertozzi, M. (2004). Emergency contraception use is correlated with increased condom use among adolescents: Results from Mexico. Journal of Adolescent Health, 329-334.

 
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