Mini-Review
Advance Provision of Emergency Contraception among Adolescent and Young Adult Women: A Systematic Review of Literature

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Abstract

Objective

The purpose of this review is to summarize the findings of randomized controlled trials assessing the advance provision of emergency contraception (EC) to women 24 years of age or younger.

Design

We conducted a comprehensive search of the PubMed database from 1950 to November 11, 2009. This review includes seven studies that randomly assigned women aged 24 and younger to advance provision of EC or a control group.

Results

All studies reviewed found that women assigned to advance provision were more likely to use EC, though not all reached statistical significance. Furthermore, studies assessing time to EC use (N = 4) found that those with advance provision used EC sooner following intercourse. Most studies found that women assigned to advance provision of EC did not engage in more sexual risk taking behaviors (assessed by reported number of sexual partners, number of episodes of unprotected intercourse, and acquisition of sexually transmitted infections) or switch to less reliable contraceptive methods. Despite increased use and decreased time to use, women who were provided EC in advance did not report significantly lower pregnancy rates.

Conclusions

The existing literature suggests that among women 24 years of age or younger, advance provision has a positive impact on use and time to use of EC. Most findings indicate that increased use of EC does not have significant negative effects for ongoing contraceptive use or sexual risk taking behaviors. Despite increased use, advanced provision of EC has not been associated with a significant corresponding decrease in pregnancy.

Introduction

The birth rate for women 15 to 17 and 18 to 19 years of age decreased 45% and 26%, respectively between 1991 and 2005.1 Unfortunately, this trend has reversed with a 3% increase between 2005 and 2006 for adolescents 15 to 19 years of age. This trend was also observed among 20 to 24-year-olds with a 1% increase between 2004 and 2005, and a 4% increase between 2005 and 2006. Not surprisingly, a large portion of these births were unintended, corresponding to a higher number of abortions.2, 3 Since 1973, the number of abortions per live births has been highest for those <15 years of age.3 Women 15 to 19 years of age have had the second highest ratio since the early 1980s, although the ratio for women ≥40 years of age did exceed that of this age group briefly in the early 1990s. The ratio for women 20 to 34 years of age is generally lower than the ratio for those ≥40 years of age, but has been higher than that of women 35 to 39 years of age since the late 1990s. Furthermore, women 20 to 24 years of age account for 33% of all legal abortions. The risk of unintended pregnancy among young women is demonstrated by the fact that 26% of women 15 to 19 years of age did not use any contraceptive method the first time they had sex.4 Further, among women 24 years and younger who were obtaining abortions, less than half reported contraceptive use in the month prior to conception.5

While combination oral contraceptive pills and condoms are the most common methods used among women ≤24 years of age,6 intrauterine devices, implantable contraceptive methods, hormonal injectables, the patch, and the contraceptive ring are other contraceptive options young women may consider to prevent unplanned pregnancy. Emergency contraception (EC) may still be warranted for individuals who choose hormonal methods in the event that an injection is not received in a timely manner or if the patch or ring is not applied/inserted on time. EC pills undoubtedly have the most potential for women who choose to use time-sensitive hormonal birth control methods and those who choose to use less reliable, coitally timed methods including barrier methods, spermicides, withdrawal, fertility awareness, or no method at all.

Plan B™, the most commonly used EC pill available in the United States, consists of two tablets, each containing 0.75mg of levonorgestrel; it is estimated to prevent 85% of pregnancies when started within 72 hours of unprotected sexual intercourse. As time passes following unprotected intercourse, the effectiveness of this method diminishes.7 While the FDA has approved over-the-counter access to Plan B™ for women ages 17 years of age and older, state regulations vary. Some states have passed regulations to further restrict EC availability, while others provide less restricted access compared to the federal regulations.8 Access restrictions impacting adolescent and young adult women may hinder EC effectiveness considering the importance of timely use after unprotected intercourse. One alternative for adolescent women is to provide EC prior to unprotected intercourse, which may overcome some potential access barriers.

We systematically review studies designed to determine the effect of advance provision of EC prior to unprotected intercourse on its rate of and time to use following unprotected intercourse. Changes in sexual risk taking behaviors will be reviewed to determine whether or not advance provision is associated with more frequent reporting of these behaviors. Pregnancy rates will also be assessed given that the ultimate goal of EC use is pregnancy prevention.

Section snippets

Methods

This review includes original, peer-reviewed journal articles that evaluated the impact of advance provision on the use of EC among women ≤24 years of age. Advance provision refers to providing EC before, rather than after, unprotected intercourse. Randomized trials assessing the use of EC among women assigned to advance provision versus a control group were included in this review. Publications were excluded if they did not address the specific intervention mentioned, did not provide

Results

Studies assessing the advance provision of EC among adolescent and young adult women are characterized in Table 1 with findings and limitations addressed in Table 2. Several studies have been conducted comparing educational information about EC plus advance provision of EC to information alone.9, 10, 11 The primary aim of a randomized clinical trial conducted by Gold and colleagues was to assess whether providing EC in advance corresponded with an increase in risk-taking behavior among 301

Discussion

The findings of these studies suggest that advance provision increases use of EC and improves promptness of EC use following unprotected intercourse. Most studies found no negative effects in ongoing contraceptive use or risky sexual behaviors. However, Belzer and colleagues found that women in the advance provision group were more likely to report having unprotected sex at the 12-month follow-up.10 Although EC use appeared to increase with advance provision, a corresponding decrease in

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