Increased access to emergency contraception: why it may fail.

BACKGROUND: To explore why increased access to emergency contraception (EC) failed to reduce pregnancies in a recent randomized controlled trial. METHODS: We used multivariable logistic regression to identify risk factors for unintended pregnancy using data from a trial involving sexually active women (n = 1490, aged 14-24 years) randomly assigned to either increased access or standard access to EC. We used predictive modeling to generate estimated pregnancy risk scores for each participant. We then examined EC use among women at low or high baseline risk of pregnancy. RESULTS: Gravidity, recent history of unprotected sex (within 14 days of enrollment to study) and lower aversion to pregnancy predicted unintended pregnancy. Women in the increased access group were more likely than women in the standard access group to use EC repeatedly. This difference was significantly stronger (P = 0.03) among low risk women than high risk women [Relative risk (RR) 10.0, 95% confidence interval (CI) 6.5-15.4 and RR 5.5, 95% CI 3.8-7.9, respectively]. CONCLUSIONS: Increased access to EC had a greater impact on women who were at lower baseline risk of pregnancy. This may explain in part why increased access to EC has had no measurable benefit in clinical trials.

Attitude and behavior effects in a randomized trial of increased access to emergency contraception.

OBJECTIVE: To explore the effects of providing unrestricted access to emergency contraception in advance of need on various psychosocial outcomes and pregnancy. METHODS: In the trial, women were randomly assigned to either increased access to emergency contraception (two free packs at enrollment with unlimited free resupply) or standard access. Participants were evaluated for 1 year for pregnancy and other outcomes. Psychosocial data were collected at enrollment and at 6 and 12 months. We applied exploratory factor analysis for data reduction. We compared the resulting psychosocial factors (including factors related to "aversion to pregnancy" and to the perceived "relative benefit" and "accessibility" of emergency contraception), two items directly assessing substitution, and pregnancy between randomization groups over time. RESULTS: On average, women in the increased access group had significantly stronger perceptions of both the "relative benefit" and "accessibility" of emergency contraception (P<.001 for each). Women in the increased access group were significantly more likely to report that they had ever used emergency contraception because they did not want to use either condoms or another contraceptive method (P<.001). Regarding pregnancy, we noted a significant interaction between randomization group and "aversion to pregnancy" (P=.010): among the least "averse" women, increased access had a protective effect (hazard ratio 0.64, 95% confidence interval 0.39-1.04); among the most "averse" women, increased access had a deleterious effect (hazard ratio 1.73, 95% confidence interval 1.01-2.98). CONCLUSION: As a result of having unrestricted access, some women substituted emergency contraception for their usual contraceptive methods. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00060463 LEVEL OF EVIDENCE: I.

The effect of consolidation of abortion services on patient outcomes.

BACKGROUND: In 2001, a service dedicated to family planning was created within a large public hospital to improve patient care services. This retrospective chart review demonstrates the benefit of focusing these services in a specialty clinic. STUDY DESIGN: A power analysis was performed and determined that a minimum of 136 charts were needed in each arm of the study to determine if, following an elective abortion, there was a significant increase in attendance at the scheduled postoperative visit. Secondary variables included analysis of contraceptive choice, incidence of continuation of injectable contraception and incidence of repeat pregnancy. RESULTS: After counseling services were initiated, there was a 27% increase in the number of patients returning for the postoperative clinic appointment within 8 weeks [32% (61/191) in 1998 vs. 59% (80/136) in 2001; p<.0001]. There was also a significant decrease in patients without a plan for contraception, 29% in 1998 vs. 11% in 2001, and a decrease in repeat pregnancies from 9% in 1998 to 1.5% in 2001. There was no difference in patient adherence with injectable contraception. CONCLUSION: Consolidation of abortion services improves subsequent use of contraception and reduces incidence of repeat pregnancy.

Prenatal antibiotic treatment does not decrease group B streptococcus colonization at delivery.

OBJECTIVE: To evaluate whether an outpatient antibiotic regimen decreased group B streptococcal (GBS) colonization to preclude the use of intrapartum antibiotics. METHODS: A double-blind randomized controlled trial evaluating prenatal oral amoxicillin versus placebo with the primary outcome of GBS colonization at the time of labor. RESULTS: Of those patients receiving both amoxicillin and a repeat culture at the time of labor, 6 of the 14 (43%) tested positive for GBS colonization. Given persistent GBS colonization of 67% (10/15) in the placebo group, treatment with amoxicillin did not significantly impact colonization at the time of delivery (P=0.20). CONCLUSION: A regimen of outpatient amoxicillin was associated with persistent GBS colonization in 43% of women at the time of labor. Oral prenatal antibiotic prophylaxis against GBS does not sufficiently reduce colonization to preclude intrapartum intravenous antibiotics.

Rupture of the preterm uterus in the nonlaboring woman: a report of 3 cases.

BACKGROUND: Uterine rupture in a laboring patient is a well-known pregnancy complication. There is a paucity of information regarding uterine rupture at a preterm gestational age in a nonlaboring patient. CASE: Three women experienced spontaneous uterine rupture at a preterm gestational age prior to the onset of labor. All women presented with a primary complaint of abdominal pain that was nonfocal and had been noted over hours to days. In no case was a common risk factor for uterine rupture present. On initial evaluation, no woman appeared hemodynamically unstable, and all fetuses had a reassuring status. In all cases, rapid deterioration of maternal and/or fetal status resulted in emergency delivery. CONCLUSION: Uterine rupture at a preterm gestational age in a nonlaboring woman may present with nonspecific findings and be associated with rapid maternal and fetal decompensation. Awareness of this complication is necessary if maternal and fetal outcomes are to be optimized.