Advertisement

Emergency Contraception

  • Association of Women's Health, Obstetric and Neonatal Nurses

      Position

      The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) supports the provision of comprehensive education on contraception, including use, indications, side effects, and ways to obtain emergency contraception (EC), to women. Nurses are uniquely positioned to correct misconceptions about EC and can advocate for initiatives that remove barriers to access.

      Background

      In 2011, approximately 45% of pregnancies in the United States were unintended (
      • Finer L.B.
      • Zolna M.R.
      Declines in unintended pregnancy in the United States, 2008–2011.
      ). While this represents a substantial decline from recent years, there remains opportunity for further improvement, especially in younger and disadvantaged populations. Teens ages 15–19 had the highest percentage of pregnancies that were unintended (75%), followed by women ages 20–24 (59%). Rates of unintended pregnancy among and women living below the federal poverty level were two to three times greater than the national average (
      • Finer L.B.
      • Zolna M.R.
      Declines in unintended pregnancy in the United States, 2008–2011.
      ). Government expenditures related to all unintended pregnancies in the United States totaled $21 billion in 2010, and in the same year, the total gross potential savings from averting all unintended pregnancies would have been more than $15 billion (
      Guttmacher Institute
      Unintended pregnancies cost federal and state governments $21 billion in 2010.
      ).
      The physical, social, and emotional implications of unintended pregnancy can be serious and long-term for the woman and her fetus. For example, compared to planned births, births from unintended pregnancies were associated with more adverse maternal, infant, and child health outcomes such as delayed prenatal care, premature birth, and negative mental and physical health effects for children (). In addition, women who experienced unintended pregnancies had higher incidences of mental health problems (
      • Abajobir A.A.
      • Maravilla J.C.
      • Alati R.
      • Najman J.M.
      A systematic review and meta-analysis of the association between unintended pregnancy and perinatal depression.
      ) and experienced higher rates of physical violence in their relationships (
      • Pallitto C.C.
      • García-Moreno C.
      • Jansen H.A.
      • Heise L.
      • Ellsberg M.
      • Watts C.
      Intimate partner violence, abortion, and unintended pregnancy: Results from the WHO multi-country study on women's health and domestic violence.
      ).
      From social and economic perspectives, a woman who can delay the birth of her first child and plan the spacing of any subsequent children is more likely to have completed her education and to have kept or gotten a job; therefore, she better able to care for herself and her family (
      • Sonfield A.
      • Hasstedt K.
      • Kavanaugh M.L.
      • Anderson R.
      The social and economic benefits of women's ability to determine whether and when to have children.
      ). When pregnancies are properly spaced, infant and maternal mortality can be reduced, and the well-being of women and their families can be increased (
      • World Health Organization
      Family planning/contraception fact sheet #351.
      ). Contraceptive drugs and devices allow women to space or prevent pregnancies, and EC is a vital tool in the mission to continue to lower rates of unintended pregnancy.

      Emergency Contraception

      Emergency contraception is used to prevent pregnancy after unprotected sexual intercourse, contraception failure (e.g., broken condom, missed pill), or when a woman has sexual intercourse against her will (coercion, assault, exploitation; ). Emergency contraception is often incorrectly referred to as the morning after pill. While most effective within 24 hours of unprotected intercourse, it is effective to prevent pregnancy for as many as 120 hours after unprotected intercourse ().
      Three forms of EC are currently available in the United States: levonorgestrel, ulipristal acetate, and copper intrauterine devices (IUDs). Levonorgestrel is available as a single-dose regimen (1.5 mg levonorgestrel taken once) and as a two-dose regimen (two tablets of 0.75 mg levonorgestrel taken 12 hours apart). The levonorgestrel single-dose method was made available over-the-counter without age restrictions in 2013; however, ongoing barriers to access include availability at all pharmacy locations, cost, and awareness (). Ulipristal acetate (30 mg taken once) requires a prescription but was more effective to prevent pregnancy at all time points within 120 hours (
      • Glasier A.
      The rationale for use of ulipristal acetate as first line in emergency contraception: Biological and clinical evidence.
      ). Finally, the copper IUD may be inserted for up to 120 hours after unprotected intercourse by trained health care providers and can provide up to 10 years of contraception after insertion.
      Recent evidence indicated that a woman's weight may affect the effectiveness of levonorgestrel and ulipristal acetate. These options may be less effective in women who were overweight (body mass index ([BMI] of 25–29.9 kg/m2) and obese (BMI > 30 kg/m2;
      • Fok W.K.
      • Blumenthal P.D.
      Update on emergency contraception.
      ,
      • Glasier A.
      • Cameron S.T.
      • Blithe D.
      • Scherrer B.
      • Mathe H.
      • Levy D.
      • Ulmann A.
      Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel.
      ,
      • Kapp N.
      • Abitbol J.L.
      • Mathé H.
      • Scherrer B.
      • Guillard H.
      • Gainer E.
      • Ulmann A.
      Effect of body weight and BMI on the efficacy of levonorgestrel emergency contraception.
      ). However, the evidence remains inconclusive, and current recommendations indicate that these emergency contraceptives should continue to be used in women of all weights because the benefits outweigh the risks (

      European Medicines Agency. (2014). Levonorgestrel and ulipristal remain suitable emergency contraceptives for all women regardless of bodyweight. Retrieved from http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2014/07/news_detail_002145.jsp&mid=WC0b01ac058004d5c1

      ). The copper IUD is not affected by a woman's weight and is considered to be the most effective form of EC (
      • Fok W.K.
      • Blumenthal P.D.
      Update on emergency contraception.
      ,
      • Turok D.K.
      • Jacobson J.C.
      • Dermish A.I.
      • Simonsen S.E.
      • Gurtcheff S.
      • McFadden M.
      • Murphy P.A.
      Emergency contraception with a copper IUD or oral levonorgestrel: An observational study of 1-year pregnancy rates.
      ).
      Emergency contraception should be recommended based on access, the women's personal preference, timing since unprotected intercourse, weight and BMI, and plans for routine birth control (
      • Stone R.
      • Rafie S.
      • El-Ibiary S.Y.
      • Vernon V.
      • Lodise N.M.
      Emergency contraception algorithm and guide for clinicians.
      ). Medical professionals consider a woman to be pregnant when a fertilized egg is implanted in the wall of the uterus (
      • American College of Obstetricians and Gynecologists
      Statement on contraceptive methods..
      ). Current methods of EC inhibit ovulation or prevent fertilization (
      • Gemzell-Danielsson K.
      • Berger C.
      • Lalitkumar P.G.L.
      Emergency contraception—Mechanisms of action.
      ). Therefore, ECs do not terminate a pregnancy and should not be confused with mifepristone (RU-486), the abortion pill.

      Role of the Nurse

      AWHONN supports the protection of an individual nurse's right to choose to participate in any reproductive health care service or research activity (
      Association of Women's Health, Obstetric and Neonatal Nurses
      AWHONN position statement: Rights and responsibilities of nurses related to reproductive health care.
      ). Nurses have a professional responsibility to provide nonjudgmental nursing care to all patients directly or through appropriate and timely referrals. This responsibility includes ensuring that appropriate family planning education and services that cover the full range of family planning options are provided (
      Association of Women's Health, Obstetric and Neonatal Nurses
      AWHONN position statement: Rights and responsibilities of nurses related to reproductive health care.
      ).
      Nurses at all levels who provide reproductive health care should ensure that women of childbearing age receive comprehensive contraceptive education, including information on use, indications, side effects, and ways to obtain EC. Nurses can work to correct misconceptions about EC and increase awareness of their value, how they work to prevent pregnancy, and how to access different types (
      • Munro M.L.
      • Dulin A.C.
      • Kuzma E.
      History, policy and nursing practice implications of the Plan B® emergency contraceptive.
      ). Special attention should be given to teenagers and women who may not know to ask for ECs, including those seeking pregnancy testing or testing for sexually transmitted infections. Nurses should ensure appropriate follow-up for women who receive EC in clinical settings, including a plan to discuss results of tests for sexually transmitted infections if indicated. Nurses should be aware of the possibility of sexual coercion, exploitation, or assault when women, especially adolescents (
      • Hopkins C.
      Supplying emergency contraception to adolescents: The nurse's role.
      ) or those in vulnerable populations, seek EC after unprotected intercourse. In these cases, sensitive history taking, appropriate referrals for counseling, and safeguards for safety are priorities. If a woman reports sexual assault or rape, nurses should engage a sexual assault nurse examiner if one is available and follow institutional protocols. Such protocols may include social workers, rape crisis counselors, and others who provide comprehensive care, including psychological counseling, emotional support, and referrals to ensure safety (
      • Linden J.A.
      Care of the adult patient after sexual assault.
      ).
      Nurses can promote appropriate access to EC by advocating their availability in their health care systems, local health clinics, and hospital emergency departments. Nurses can learn about their state's current laws and advocate for laws that promote appropriate access to EC, especially for those in their states most likely to experience unintended pregnancy (, ).
      The rising rates of maternal mortality and severe morbidity in the United States and wide racial disparities in these rates (
      • Creanga A.A.
      • Berg C.J.
      • Syverson C.
      • Seed K.
      • Bruce F.C.
      • Callaghan W.M.
      Pregnancy-related mortality in the United States, 2006–2010.
      ) increase the urgency for nurses to counsel women about how to plan for and space pregnancies appropriately and facilitate their access to ECs and other contraceptive methods. Such education has the potential to reduce the risk of pregnancy and birth complications (
      • Ruhl C.
      Contraception is health promotion.
      ).

      Policy Considerations

      Policy considerations for EC revolve around access. Over-the-counter access for women of all ages has improved since 2014 when the Food and Drug Administration removed the point-of-sale age requirements and generic versions have become available. However, access is still limited because of cost, lack of adequate counseling by health care providers, and limited availably in pharmacies. Currently, nurse practitioners cannot independently prescribe ECs in all 50 states. Only 18 states and the District of Columbia require hospital emergency rooms to provide EC services to sexual assault victims. Six states allow pharmacists to refuse to dispense EC, and three states allow pharmacies to refuse to dispense EC. Only 10 states allow pharmacists to prescribe progestin-based EC without a physician's prescription ().
      While access has improved, insurance coverage, counseling on EC as a standard of care, prescriptive privileges that expand access to all forms of EC, and required dispensing of EC prescriptions at pharmacies should continue to be a focus of policy efforts to reduce the incidence of unplanned pregnancies (, ).

      References

        • Abajobir A.A.
        • Maravilla J.C.
        • Alati R.
        • Najman J.M.
        A systematic review and meta-analysis of the association between unintended pregnancy and perinatal depression.
        Journal of Affective Disorders. 2016; 192: 56-63
        • American College of Obstetricians and Gynecologists
        Statement on contraceptive methods..
        Author, Washington, DC1998
        • American College of Obstetricians and Gynecologists
        ACOG committee opinion number 707: Access to emergency contraception.
        (Retrieved from)
        • Association of Women's Health, Obstetric and Neonatal Nurses
        AWHONN position statement: Emergency contraception.
        Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2012; 41: 711-713
        • Association of Women's Health, Obstetric and Neonatal Nurses
        AWHONN position statement: Rights and responsibilities of nurses related to reproductive health care.
        Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2017; 46: 119
        • Creanga A.A.
        • Berg C.J.
        • Syverson C.
        • Seed K.
        • Bruce F.C.
        • Callaghan W.M.
        Pregnancy-related mortality in the United States, 2006–2010.
        Obstetrics & Gynecology. 2015; 125: 5-12
      1. European Medicines Agency. (2014). Levonorgestrel and ulipristal remain suitable emergency contraceptives for all women regardless of bodyweight. Retrieved from http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2014/07/news_detail_002145.jsp&mid=WC0b01ac058004d5c1

        • Finer L.B.
        • Zolna M.R.
        Declines in unintended pregnancy in the United States, 2008–2011.
        New England Journal of Medicine. 2016; 374 (Retrieved from): 843-852
        • Fok W.K.
        • Blumenthal P.D.
        Update on emergency contraception.
        Current Opinions in Obstetrics and Gynecology. 2016; 28: 522-529
        • Gemzell-Danielsson K.
        • Berger C.
        • Lalitkumar P.G.L.
        Emergency contraception—Mechanisms of action.
        Contraception. 2013; 87: 300-308
        • Glasier A.
        The rationale for use of ulipristal acetate as first line in emergency contraception: Biological and clinical evidence.
        Gynecological Endocrinology. 2014; 30: 688-690
        • Glasier A.
        • Cameron S.T.
        • Blithe D.
        • Scherrer B.
        • Mathe H.
        • Levy D.
        • Ulmann A.
        Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel.
        Contraception. 2011; 84: 363-367https://doi.org/10.1016/j.contraception.2011.02.009
        • Guttmacher Institute
        Unintended pregnancies cost federal and state governments $21 billion in 2010.
        (Retrieved from)
        • Guttmacher Institute
        Unintended pregnancy in the United States.
        (Retrieved from)
        • Guttmacher Institute
        Emergency contraception.
        • Hopkins C.
        Supplying emergency contraception to adolescents: The nurse's role.
        Nursing Standard. 2014; 29: 37-43
        • Kaiser Family Foundation
        Emergency contraception.
        (Retrieved from)
        • Kapp N.
        • Abitbol J.L.
        • Mathé H.
        • Scherrer B.
        • Guillard H.
        • Gainer E.
        • Ulmann A.
        Effect of body weight and BMI on the efficacy of levonorgestrel emergency contraception.
        Contraception. 2015; 91: 97-104
        • Linden J.A.
        Care of the adult patient after sexual assault.
        New England Journal of Medicine. 2011; 365: 834-841
        • Munro M.L.
        • Dulin A.C.
        • Kuzma E.
        History, policy and nursing practice implications of the Plan B® emergency contraceptive.
        Nursing for Women's Health. 2015; 19: 142-153
        • Pallitto C.C.
        • García-Moreno C.
        • Jansen H.A.
        • Heise L.
        • Ellsberg M.
        • Watts C.
        Intimate partner violence, abortion, and unintended pregnancy: Results from the WHO multi-country study on women's health and domestic violence.
        International Journal of Gynecology & Obstetrics. 2013; 120: 3-9
        • Ruhl C.
        Contraception is health promotion.
        Nursing for Women's Health. 2012; 16: 73-77https://doi.org/10.1111/j.1751-486X.2012.01703.x
        • Sonfield A.
        • Hasstedt K.
        • Kavanaugh M.L.
        • Anderson R.
        The social and economic benefits of women's ability to determine whether and when to have children.
        (Retrieved from)
        • Stone R.
        • Rafie S.
        • El-Ibiary S.Y.
        • Vernon V.
        • Lodise N.M.
        Emergency contraception algorithm and guide for clinicians.
        Nursing for Women's Health. 2017; 21: 297-305
        • Turok D.K.
        • Jacobson J.C.
        • Dermish A.I.
        • Simonsen S.E.
        • Gurtcheff S.
        • McFadden M.
        • Murphy P.A.
        Emergency contraception with a copper IUD or oral levonorgestrel: An observational study of 1-year pregnancy rates.
        Contraception. 2014; 89: 222-228
        • World Health Organization
        Family planning/contraception fact sheet #351.
        (Retrieved from)

      Linked Article

      • Emergency Contraception
        Journal of Obstetric, Gynecologic & Neonatal NursingVol. 41Issue 5
        • Preview
          The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) supports over‐the‐counter access to emergency contraceptives (ECs) without age restriction.
        • Full-Text
        • PDF