National Partnership for Women & Families

Monthly Women's Health Research Review

Study Compares Effects of Emergency Contraception Access via Call Center, Office Visit

Summary of "Reproductive Health Outcomes of Insured Adolescent and Adult Women Who Access Oral Levonorgestrel Emergency Contraception," Raine-Bennett et al., Obstetrics & Gynecology, April, 2015.

Introduction

"Increasing timely access to emergency contraception is important because it can prevent pregnancy after unprotected intercourse and it is more effective the sooner it is administered," according to Tina Raine-Bennett of Kaiser Permanente Northern California's Division of Research and colleagues.

Though EC is available over-the-counter, the researchers write that "many adolescents and women still obtain oral [EC] through a clinician to obtain medical advice, to avoid out-of-pocket costs, or both." In turn, "health care providers have created more convenient access routes such as on-call services to allow patients to obtain a prescription without an in-person visit with a clinician."

Overall, "[l]ittle is known" about women who seek EC and their reproductive health outcomes, or whether a woman who accessed EC through the "more convenient access routes, in which a full range of services is not available" had outcomes similar to those of women who had office visits. The researchers write that their study aims to "gain an understanding of the level of risk for adolescents and women who seek [EC] through various clinical routes and assess opportunities for improved care provision."

Methodology

For the study, researchers used electronic health record data on women and adolescents insured via Kaiser Permanente Northern California [KPNC]. KPNC members can access EC without an in-person visit by contacting nurses through "the regional appointment and advice call centers."

Specifically, the researchers used data on women ages 15 to 44 who had one or more prescriptions for oral levonorgestrel EC between Jan. 1, 2010 and Dec. 31, 2011. The data were sorted into two groups: One group consisted of data on individuals who had an in-person visit, while the other consisted of data on individuals who used the call center.

The researchers' "primary outcome of interest" was "initiation of very effective contraception (intrauterine contraceptive, implant, or sterilization ... )" on the day EC was prescribed "or in the subsequent 12 months." Secondary outcomes were "new short-acting contraception dispensed, chlamydia and gonorrhea tests, and pregnancies."

Results

The researchers found that of 21,421 "index prescriptions," or initial EC prescriptions an individual received during the study period, 14,531 (67.8%) prescriptions were obtained via the call center. According to the study, 92.4% of the EC prescribed via the call center was dispensed, compared with 79.3% of the EC prescribed via an office visit.

The researchers also found that 92.6% of women and adolescents "had not had [EC] dispensed" within the 12 months prior to accessing EC, while 40.7% had obtained "any prior short-acting contraceptive." According to the study, individuals who accessed EC via the call centers were more likely to have previously obtained short-acting contraception (45.9%) compared with those who accessed EC via an office visit (29.8%).

In addition, the study found that most individuals who accessed EC had visited with an obstetrician-gynecologist or primary care provider within 12 months beforehand (89.9%). The researchers noted that 7.8% of study participants who underwent chlamydia or gonorrhea testing at least 12 months before accessing EC were found to have at least one of the sexually transmitted infections. Similarly, 9.4% of individuals age 25 or younger who were tested for those STIs at least a year before accessing EC also were found to have at least one of the infections.

Meanwhile, the researchers found that 47.6% of the individuals who accessed EC did so at least once more within 12 months after their initial prescription. Further, 47% of those who had not taken short-acting contraception within 12 months prior to the EC consultation "had a new short-acting contraceptive method dispensed either on the day or in the subsequent 12 months after [EC] was accessed." Overall, individuals who accessed EC via an office visit were more likely to have EC dispensed within 12 months after accessing it (54.4%) than those who accessed EC via the call centers (37.7%).

According to the study, 10.6% of women and adolescents began using a "very effective" contraceptive -- such as an IUD, implant or sterilization -- within 12 months of accessing EC, with those who accessed EC via the call centers being similarly likely as those who accessed it via an office visit to do so.

The researchers also found that the majority of individuals visited either an ob-gyn (67.2%) or primary or pediatric care provider (90.6%) within 12 months of accessing EC. They added that 9.5% of individuals age 25 and younger and 7.9% of all study participants who had a chlamydia or gonorrhea test within 12 months of accessing EC tested positive.

Overall, the study found that 9.6% of individuals became pregnant within six months of accessing EC. According to the researchers, 64.9% of pregnancies that occurred within three months "were reported as [unintended] at the time of conception." Individuals who obtained EC via a call center and who experienced a pregnancy within three months were somewhat less likely to have an abortion (1.9%) than those who obtained EC via an office visit (3.2%).

Meanwhile, 4.4% of individuals became pregnant within four-to-six months after accessing EC, with individuals who accessed EC via the call center being more likely to become pregnant in that timeframe (5%) than those who accessed EC via an office visit (3.3%). Of those pregnancies, 57.8% were reported as unintended at the time of conception.

Overall, the researchers found that women in the call center group were less likely to become pregnant within three months of accessing EC, but more likely to become pregnant within four-to-six months, than women in the office visit group.

Discussion

The authors wrote that the data "revealed increased risk for unintended pregnancy and sexually transmitted infections in the subsequent 6-12 months among [those] who accessed [EC] through the call center or an office visit." They added that "protocols to routinely address unmet needs for contraception at all" call centers and office visits "should be investigated" because a "considerable proportion" of study participants visited an ob-gyn or primary care provider "before and after accessing [EC]."

Meanwhile, the researchers noted that individuals who accessed EC via a call center or office visit "were equally as likely to initiate very effective contraception in the subsequent 12 months," but that the "overall proportion of adolescents and women who initiated intrauterine contraception and implants (9.6%) is modest" compared with national averages.

However, they noted that individuals who accessed EC via office visits were "more likely to have a new short-acting contraception dispensed in the subsequent 12 months with the largest difference being on the day [EC] was accessed." The researchers found that people who obtained EC via office visits were more likely to have a short-acting contraception dispensed, perhaps because those who had an office visit "may have been seeking" such contraception or because providers "may have been more likely to offer it" in person than via phone. The researchers suggested that call centers "incorporate counseling and immediate access to prescriptions for an ongoing contraceptive method."

Meanwhile, the researchers noted that "[t]he proportion of pregnancies … reported as [unintended] at the time of conception" during the four-to-six months after accessing EC via a call center or an office visit "is indicative of an overall ongoing unmet need for contraception among these adolescents and women."

The authors also addressed the rate of gonorrhea and chlamydia, noting that the positive rate among women who were tested within 12 months before or after accessing EC was twice KPNC's overall rate. Further, the researchers write that the "findings add to other studies that suggest that adolescents and women who use [EC] are more likely to be from demographic groups [who] are higher risk," suggesting that chlamydia and gonorrhea testing "should be offered routinely to adolescents and women seeking [EC]."