Practice and determinants of emergency contraceptive utilization among women seeking termination of pregnancy in Northwest Ethiopia-A mixed quantitative and qualitative study.

BACKGROUND: Emergency contraceptives are used within 72 hours after unprotected sexual intercourse to prevent unwanted pregnancy. Although emergency contraceptives are widely available in Ethiopia, termination of pregnancy remains a public health problem indicating low uptake of emergency contraceptives after unprotected sexual intercourse. This study aimed to assess utilization and determinants of emergency contraceptives among women seeking termination of pregnancy in Northwest Ethiopia. METHODS: An institutional-based cross-sectional study was carried out, supplemented by phenomenologically approached in-depth interviews. Systematic random sampling was used to select study participants. A structured questionnaire and an in-depth interview guide were used to collect data. Data were entered by EPI-info and analyzed through SPSS version 23 to conduct logistic regressions. Thematic analysis was used to conduct qualitative interpretation. RESULTS: Almost one-fifth (78; 19.2%) of the study participants used emergency contraceptives to prevent their index pregnancy. Women who had secondary education (aOR 3.28; 95% CI 1.59, 6.79) and women who had no living children (aOR 4.52; 95% CI 1.40, 14.57) had a positive significant association with emergency contraceptive utilization. On the other hand, women who did not discuss contraceptives with their sexual partner (aOR 0.49; 95% CI 0.27-0.91) and women without a history of abortion (aOR 0.45; 95% CI 0.24-0.97) had a negative significant association with emergency contraceptive utilization. CONCLUSION AND RECOMMENDATION: There is relatively low utilization of emergency contraception among pregnancy terminating women. Reproductive health programs should encourage women discussion with their partners about emergency contraceptives to decrease occurrence of unwanted pregnancy and termination of pregnancy.

Women in larger bodies' experiences with contraception: a scoping review.

BACKGROUND: As the prevalence of obesity increases and the age of onset decreases, more women of reproductive age will be living in larger bodies. Research on weight-related efficacy and safety has informed clinical guidelines for routine and emergency contraceptive use by women with a higher body mass index; however, patient perspectives are needed to understand women in larger bodies' experiences with contraception and contraceptive care. This scoping review summarizes the literature on women in larger bodies' experiences with contraception with the goal of gaining a better understanding of the nature of these experiences and identifying gaps in the existing research. METHODS: Following Arksey and O'Malley's framework, a scoping review of the literature was conducted. Four databases (PubMed, PsycINFO, SCOPUS, and CINAHL) were searched for peer-reviewed, empirical articles published in English between 2010 and 2020, with a focus on North America, Europe, Australia, and New Zealand. Data were summarized by identifying key themes in the reviewed literature. RESULTS: Twenty-nine articles meeting the eligibility criteria were reviewed. The literature was predominantly quantitative (n = 27), with only one qualitative study and one systematic review, respectively. Five themes were identified, including (1) use of contraception among women in larger bodies; (2) knowledge, attitudes towards and beliefs about contraception; (3) contraceptive (dis)satisfaction among women in larger bodies; (4) contraceptive counseling; and (5) barriers to contraception. The findings revealed that women in larger bodies may have unmet contraceptive care needs. Despite many articles addressing the need to improve contraceptive counseling for women in larger bodies (n = 26), few explored how women felt about their care (n = 2). Finally, only two articles focused on emergency contraception, indicating a need for further research. CONCLUSION: This scoping review emphasizes the pressing need for qualitative research to explore women in larger bodies' experiences with routine and emergency contraception, as well as receiving contraceptive counseling and care. Future research exploring the lived experiences of women in larger bodies is necessary to better characterize their contraceptive needs and identify avenues to improve patient care.

As obesity becomes more prevalent, more women of reproductive age will be living in larger bodies. This review highlights what is known about women in larger bodies' experiences with contraception and suggests where future research is needed. We searched four databases for papers published in English from 2010 to 2020. Our review included 29 articles. Nearly all of the studies were quantitative, with one qualitative study and one review. Most articles talked about contraceptive use, but few of them included emergency contraception. Some papers highlighted women's knowledge and opinions about contraception, whereas others talked about their contraceptive (dis)satisfaction. Many articles discussed contraceptive counseling. Finally, some papers considered potential barriers to contraception. Our findings suggest that women in larger bodies have unmet contraceptive needs. Notably, this review aimed to focus on patient experiences but women's voices were rarely represented. Future qualitative research on women's lived experiences will provide a better understanding of women in larger bodies' contraceptive needs and suggest how care can be improved.

Emergency Contraception Administration, Toxicology Kit Use, and Postassault Reporting: A Comparison of Sexual Assault Nurse Examiner (SANE) and Non-SANE Medical Providers.

ABSTRACT: Sexual assault nurse examiners (SANEs) are specially trained to meet the postassault medical forensic needs of sexual assault patients. However, there remains a dearth of literature comparing directly postassault service provision and action in cases treated by SANEs as compared to non-SANE medical providers. In this study, we compare rates of emergency contraception administration, toxicology kit use, reports to police at the time of examination, and mandatory child abuse reports among n = 3,969 sexual assault cases treated by SANEs and non-SANE medical providers. Compared to cases treated by non-SANE medical providers, cases treated by SANEs were significantly more likely to have emergency contraception administered, less likely to have a toxicology kit collected, less likely to have a police report filed at the time of examination, and more likely to have a mandatory child abuse report filed. Observed patterns suggest that non-SANE medical providers may find it difficult to balance the needs of the criminal justice system with those of their patients, whereas SANEs provide a tailored, comprehensive first response. We discuss the importance of consistent, accurate documentation and clearly defined protocols in the medical forensic response to sexual assault patients.

Alleged rape: an analysis of management of cases seen at specialist hospital Gombe, Nigeria.

The aim of this study was to determine how patients who presented following sexual assault were managed at a secondary health facility in Gombe, Nigeria. The case notes of patient who presented at the Accident and Emergency Unit of State Specialist Hospital Gombe after serious sexual assault from August 1 2016 to July 30 2018 were retrieved and the data were entered into SPSS Version 20 (SPSS Inc., Chicago, IL) and summarised as proportions. Of the 15,613 patients who presented, 277 were alleged rapes which constituted 1.77% of presentations. Two hundred and one of the patients were females with a total of 2341 admissions at the gynaecological ward representing 8.6%. One hundred and seventy one (67%) of the patients did not receive any form of care, 127 (54.0%) were not given antibiotics prophylaxis against STIs, 117 (42%) did not receive post-exposure prophylaxis for HIV/AIDS and 80% of the women between the ages of 15-45 had emergency contraception. One hundred and ninety seven (71.1%) did not receive any psychological support. Rape is common. Measures should be put in place to improve the clinical management of survivors.Impact statementWhat is already known on this subject? Rape is common in Gombe, Nigeria, and a standard management protocol has been developed with a view to reduce the adverse consequences associated with it.What the results of this study add? The results of this study show that survivors of rape in the developing countries like ours do not receive adequate clinical and psychological care when they present at the hospital.What the implications are of these findings for clinical practice and/or further research? Given the results, there is the need for physicians managing rape cases to pay attention to details so as to minimise both immediate and long-term complications associated with rape.

Scoping Review of Access to Emergency Contraception for Sexual Assault Victims in Emergency Departments in the United States.

OBJECTIVE: We conducted a scoping review of the literature to assess the prevalence of hospital policies regarding emergency contraception (EC) and the frequency that U.S. emergency departments (EDs) provide EC to sexual assault survivors. STUDY DESIGN: We searched PubMed, Embase, the Cochrane Library, and CINAHL from inception to January 2019 for studies that assessed access to EC for sexual assault survivors in EDs. We included English-language studies that surveyed ED staff at U.S. hospitals and reported the weighted mean of the percentage of hospitals with an EC policy for sexual assault survivors and the percentage that provided EC counseling, offered or dispensed EC onsite. Secondary outcomes were rates of testing and prophylaxis for sexually transmitted infections (STIs) and HIV. RESULTS: From 390 articles retrieved, 14 studies met the inclusion criteria; all studies were published between 2000 and 2013. Eligible studies surveyed staff at 3,314 hospitals. Overall, 60% (weighted mean) of hospitals had a policy on EC, 75% provided EC counseling, 44% offered EC, and 62% had EC available to dispense onsite. Four studies reported secondary outcomes: 81% of hospitals provided STI testing, 84% provided STI prophylaxis, 64% provided HIV testing, and 53% provided HIV prophylaxis. CONCLUSION: Existing literature demonstrates significant variability in EC policies and practices for sexual assault survivors in U.S. hospital EDs. Future research should assess whether EC access for survivors has improved in ED settings as well as evaluate persistent or new barriers to access.

Emergency contraception from the pharmacy 20 years on: a mystery shopper study.

BACKGROUND: Emergency contraception (EC) was approved in the UK as a pharmacy medicine for purchase without prescription in 2001. Twenty years later we conducted a study to characterise routine practice pharmacy provision of EC. STUDY DESIGN: Mystery shopper study of 30 pharmacies in Edinburgh, Dundee and London participating in a clinical trial of contraception after EC. METHODS: Mystery shoppers, aged ≥16 years, followed a standard scenario requesting EC. After the pharmacy visit, they completed a proforma recording the duration of the consultation, where it took place, and whether advice was given to them about the importance of ongoing contraception after EC. RESULTS: Fifty-five mystery shopper visits were conducted. The median reported duration of the consultation with the pharmacist was 6 (range 1-18) min. Consultations took place in a private room in 34 cases (62%) and at the shop counter in the remainder. In 27 cases (49%) women received advice about ongoing contraception. Eleven women (20%) left the pharmacy without EC due to lack of supplies or of a trained pharmacist. Most women were generally positive about the consultation. CONCLUSIONS: While availability of EC from UK pharmacies has undoubtedly improved access, the necessity to have a consultation, however helpful, with a pharmacist introduces delays and around one in five of our mystery shoppers left without getting EC. Consultations in private are not always possible and little advice is given about ongoing contraception. It is time to make EC available without a pharmacy consultation.

Accessing emergency contraception pills from pharmacies: the experience of young women in London.

INTRODUCTION: Over-the-counter provision of emergency contraception pills (ECP) has increased since deregulation of progestogen-only formulations and is now the most common public health service provided by UK pharmacists. Important questions relate to women's perceptions of their experience of receiving ECPs from pharmacists. METHODS: Qualitative study: in-depth interviews with young women reporting ECP use, recruited from clinic (10); pharmacy (6) and community settings (5) in London. RESULTS: Key advantages of pharmacy provision were ease and speed of access and convenience. Disadvantages included a less personal service, inadequate attention to information needs and to prevention of recurrence of ECP need, and unsupportive attitudes of pharmacy staff. Suggested service improvements included increasing privacy, providing more contraceptive advice, adopting a more empathetic approach and signposting follow-up services. CONCLUSION: Pharmacies are important in the choice of settings from which ECPs can be obtained and many aspects of pharmacy provision are appreciated by young women. There is scope to further enhance pharmacists' role.

Provider Practices and Young Women's Experiences with Provider Self-disclosure during Emergency Contraceptive Visits.

BACKGROUND: Research on the impact of providers disclosing personal contraceptive experiences with patients is limited. In this study, we examine patient and provider perspectives about provider self-disclosure (PSD) of personal contraceptive experiences and its effects on contraceptive decision making and the provider-patient relationship. METHODS: We conducted 18 one-on-one telephone interviews with clinicians who provide contraceptive services to young women and 17 patients seeking emergency contraception from three Bay Area community-based, youth-friendly clinics regarding their contraceptive counseling practices and experiences, respectively. After transcribing and coding all interviews, we summarized structural codes related to contraceptive counseling and PSD. RESULTS: Although providers noted that PSD could help to build rapport and increase patient comfort, most did not report self-disclosing their contraceptive experiences, primarily owing to concerns that it might cross professional boundaries or compromise patient autonomy. All patients held positive attitudes toward and welcomed PSD practices, with many noting that it increased their comfort and trust in their provider. CONCLUSIONS: There were notable differences between patient and provider attitudes toward PSD of contraceptive method use, with patients expressing more positive feelings about the practice than providers. Community-based providers should consider that many young women welcome self-disclosure of provider contraceptive experiences and that more research is needed to understand the effects of PSD practices around contraception on the patient-provider relationship and autonomous contraceptive decision making.

Emergency contraceptive pill use among women in Denmark, Norway and Sweden: Population-based survey.

INTRODUCTION: Emergency contraceptive pill (ECP) use is reported to have increased in several countries over time. In this multi-country population-based questionnaire study, we aimed to describe the patterns of ECP use and identify factors associated with its use. MATERIAL AND METHODS: In 2011-2012, women aged 18-45 years were randomly selected from national registers in Denmark, Norway and Sweden and invited to respond to questions related to lifestyle and contraceptive use. We used generalized logistic models to estimate odds ratios (ORs) and 95% confidence intervals (CI) comparing women who had used ECP with women who had never used ECP. RESULTS: Of the 45 445 women, 33.9% (Denmark = 32.3%, Norway = 35.1%, Sweden = 34.6%) had used ECP at least once in their lifetime. Among ECP users, 15.8% had used ECP within the last year and 50.0% had used ECP more than once in their life. After adjusting for country, age at response and response type, ECP use was associated with higher education (OR 2.09, 95% CI 1.54-2.84) and being single, divorced or widowed (OR 3.17, 95% CI 2.87-3.49). Binge drinking and smoking increased the odds of ECP use. Furthermore, early age at first intercourse (OR 1.29, 95% CI 1.08-1.55), having a new partner in the last 6 months (≥3 partners: OR 6.44, 95% CI 5.46-7.60) and lack of condom use with a recent new partner (OR 1.42, 95% CI 1.22-1.66) were found to be associated with ECP use. CONCLUSIONS: Our study shows that ECP use is common among Scandinavian women. Higher education and being single were associated with increased odds of ECP use. Risk behaviors such as smoking and early age at first sex were also associated with increased odds of ECP use. Since ECP use is not protective against sexually transmitted infections, our findings highlight the need to encourage awareness and regular use of condoms to prevent sexually transmitted diseases in women.

Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study.

BACKGROUND: Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon. METHODS: From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception. RESULTS: Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use. CONCLUSIONS: Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights.

Reconceptualizing Measurement of Emergency Contraceptive Use: Comparison of Approaches to Estimate the Use of Emergency Contraception.

Estimated use of emergency contraception (EC) remains low, and one reason is measurement challenges. The study aims to compare EC use estimates using five approaches. Data come from Performance Monitoring and Accountability 2020 surveys from 10 countries, representative sample surveys of women aged 15 to 49 years. We explore EC use employing the five definitions and calculate absolute differences between a reference definition (percentage of women currently using EC as the most effective method) and each of the subsequent four, including the most inclusive (percentage of women having used EC in the past year). Across the 17 geographies, estimated use varies greatly by definition and EC use employing the most inclusive definition is statistically significantly higher than the reference estimate. Impact of using various definitions is most pronounced among unmarried sexually active women. The conventional definition of EC use likely underestimates the magnitude of EC use, which has unique programmatic implications.

Response to requests for contraception in one direct-to-consumer telemedicine service.

OBJECTIVE: To describe real-world care seeking and contraception provision in one direct to consumer telemedicine platform. STUDY DESIGN: We described encounters with reproductive age female patients between July 2016 and July 2018 seeking contraception on the American Well telemedicine platform. RESULTS: Of 126,712 total encounters with reproductive age women, 682 were with women seeking contraception, and 83% received it. The mean encounter length was 4.4 min versus 5.0 min for non-contraceptive visits. Insurance information was provided for 78% of contraceptive encounters versus 85% of non-contraceptive encounters, p < 0.001. Of the 27 encounters in which the patient requested emergency contraception, three did not result in such a prescription. CONCLUSION: Direct to consumer telemedicine may increase access to contraceptives, yet overall use was uncommon. Most women seeking contraception via direct to consumer telemedicine on this platform received it. Three women who requested emergency contraception did not receive it, yet reasons for this are unknown.

"My BMI is too high for Plan B." A changing population of women seeking ulipristal acetate emergency contraception online.

Emergency contraceptive (EC) pills may be less effective for women with higher body mass index (BMI), but little is known about public response to the fact that EC may lose efficacy as weight increases. In November 2013, European authorities changed the label for a levonorgestrel EC product to warn of a reduction in effectiveness for women with higher BMI, garnering significant media coverage in the United States. Ulipristal acetate (UPA) EC may be more effective than levonorgestrel for women with BMI levels designated as obese. Among 8,019 women who received UPA from the online pharmacy KwikMed from 2011 to 2015 and self-reported their height, weight and reasons for seeking UPA online, we analyzed changes in the proportion of women in different BMI categories before and after the label change. For the 25 month-period after the label change, the proportion of women in the obese category rose by 26.7 percentage points relative to the 35 months before (B = 0.2665, p < .01). Mean BMI (25.5 versus 29.4, p < .001) and average weight (148.6 pounds versus 175.5 pounds, p < .001) of users were higher after the label change. Some women appear to have acted on the information that EC efficacy may be associated with body weight.

Provision of Contraception in New York City School-Based Health Centers: Impact on Teenage Pregnancy and Avoided Costs, 2008-2017.

CONTEXT: Since 2008, the School-Based Health Center Reproductive Health Project (SBHC RHP) has supported SBHCs in New York City (NYC) to increase the availability of effective contraception; however, its impact on teenage pregnancy and avoided costs has not been estimated. METHODS: The impact of the SBHC RHP on patterns of contraceptive use and on the numbers of pregnancies, abortions and births averted in 2008-2017 was estimated using program data and public data from the NYC Bureau of Vital Statistics and Youth Risk Behavior Survey. Data from the Guttmacher Institute on the cost of publicly funded births and abortions were used to estimate costs avoided; NYC-specific teenage pregnancy outcome data were employed to estimate the proportion of overall declines attributable to the SBHC RHP. RESULTS: Between 2008 and 2017, the SBHC RHP supported a substantial increase in the proportion of sexually active female clients using effective contraceptives. Most dramatically, 14% of clients in the SBHC RHP method mix used LARCs in 2017, compared with 2% in the non-SBHC RHP mix. The project averted an estimated 5,376 pregnancies, 2,104 births and 3,085 abortions, leading to an estimated $30,360,352 in avoided one-time costs of publicly funded births and abortions. These averted events accounted for 26-28% of the decline in teenage pregnancies, births and abortions in NYC. CONCLUSIONS: When comprehensive reproductive health services are available in SBHCs, teenagers use them, resulting in substantially fewer pregnancies, abortions and births, and lower costs to public health systems.

Pragmatic cluster randomised cohort cross-over trial to determine the effectiveness of bridging from emergency to regular contraception: the Bridge-It study protocol.

INTRODUCTION: Oral emergency contraception (EC) can prevent unintended pregnancy but it is important to start a regular method of contraception. Women in the UK usually access EC from a pharmacy but then need a subsequent appointment with a general practitioner or a sexual and reproductive health (SRH) service to access regular contraception. Unintended pregnancies can occur during this time. METHODS AND ANALYSIS: Bridge-It is a pragmatic cluster randomised cohort cross-over trial designed to determine whether pharmacist provision of a bridging supply of a progestogen-only pill (POP) plus rapid access to a local SRH clinic, results in increased uptake of effective contraception and prevents more unintended pregnancies than provision of EC alone. Bridge-It involves 31 pharmacies in three UK regions (London, Lothian and Tayside) aiming to recruit 626-737 women. Pharmacies will give EC (levonorgestrel) according to normal practice and recruit women to both intervention and the control phases of the study. In the intervention phase, pharmacists will provide the POP (desogestrel) and offer rapid access to an SRH clinic. In the control phase, pharmacists will advise women to attend a contraceptive provider for contraception (standard care).Women will be asked 4 months later about contraceptive use. Data linkage to abortion registries will provide abortion rates over 12 months. The sample size is calculated on the primary outcome of effective contraception use at 4 months (yes/no) with 90% power and a 5% level of significance. Abortion rates will be an exploratory secondary analysis. Process evaluation includes interviews with pharmacists, SRH clinicians and women. Cost-effectiveness analysis will use a healthcare system perspective and be expressed as incremental cost-effectiveness ratio. ETHICS AND DISSEMINATION: Ethical approval was received from South East Scotland REC June 2017. Results will be published in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: ISRCTN70616901.

Utilization and associated factors of emergency contraception among women seeking abortion services in health institutions of Dessie town, North East Ethiopia, 2018.

OBJECTIVE: The aim of the study was to assess utilization and associated factors of emergency contraception among women seeking abortion services in Health Institutions of Dessie town, North East Ethiopia, 2018. RESULTS: Among the interviewed 784 women 400 (51%) utilized emergency contraception. Women's age of 20-24 years [AOR: 2.10, (95% CI 1.200,3.671)], urban residence [AOR: 2.02 (95% CI 1.273, 3.218], being single [AOR: 1.71, (95% CI 1.176, 2.485)], being knowledgeable on emergency contraception [AOR: 5.66, (95% CI 3.976,8.070)], and having favorable attitude towards emergency contraception [AOR: 2.75 (95% CI 1.946, 3.881)] were significantly associated factors with the utilization of emergency contraceptives. Emphasis has to give on health education on emergency contraceptives focusing on those women who are from the rural area, older and married women.

Emergency contraception: Links between providers' counseling choices, prescribing behaviors, and sociopolitical context.

Healthcare decisions depend on the characteristics of patients and providers. However, how these decisions are influenced by provider interpretations of biological processes and the sociopolitical context in which they work remains unclear. To answer these questions, we explore providers' prescribing of emergency contraception (EC), methods that can prevent pregnancy after sex has already occurred. Despite the consensus mainstream medical definition that pregnancy begins after a fertilized egg implants in the uterus, an alternative perspective holds that pregnancy instead begins when a sperm fertilizes an egg. How providers define pregnancy may affect their willingness to prescribe EC. However, the ability of providers to recommend treatments consistent with their understandings of medical processes may depend on the sociopolitical context in which the patient-provider interaction occurs. We test whether EC prescribing practices vary by providers' definition of pregnancy and the interaction of this definition with the sociopolitical context in which they practice. Data from U.S. medical providers were collected as part of a survey on EC knowledge and practices (N = 1308). We merged voting results from the county in which the provider practices to data on provider EC prescribing and pregnancy counseling practices. Because recent Republican party platforms have explicitly endorsed a definition of pregnancy that begins at fertilization and party advocacy frequently uses this definition, we use the county vote share for the Republican presidential candidate as a contextual measure of views that pregnancy begins at fertilization. We find a significant interaction such that providers who counsel that pregnancy begins at fertilization are significantly less likely to prescribe EC if they practice in counties with higher Republican vote shares. Our results highlight that patient access to EC may depend on both place of residence and provider views and that providers' EC prescribing may depend jointly on their understanding of pregnancy and sociopolitical context.