Medicaid and Managed Care

June 1995

This year, Medicaid will finance health and long-term care services to more than 35 million low-income Americans. In its role as a purchaser of health services for low-income families, Medicaid increasingly relies on managed care to deliver care. Almost 8 million Medicaid beneficiaries, predominately poor children and their parents, now receive health care services through a broad array of managed care arrangements, including Health Maintenance Organizations (HMOs) and less structured primary care case management systems.

Virtually every state is increasing their reliance on managed care as a health care delivery model for its Medicaid population. As of June 30, 1994, 23 percent of Medicaid beneficiaries were enrolled in managed care arrangements, up from 14 percent in 1993. Due to the growing interest in managed care from both the State and Federal governments, the number of Medicaid beneficiaries enrolled in managed care is expected to continue to rise in the foreseeable future.

This brief summarizes current trends in Medicaid managed care enrollment, describes the major models of Medicaid managed care, and raises issues for consideration with regard to managed care for low-income populations.

Medicaid Managed Care Enrollment

In response to pressures to contain the growth of State and Federal Medicaid spending and to concerns about access to health care for low-income individuals, the use of managed care arrangements in Medicaid has grown dramatically in recent years. In 1983, 750,000 beneficiaries — 3 percent of the Medicaid population — were enrolled in managed care. In 1994, about 7.8 million beneficiaries — 23 percent of all Medicaid enrollees — were enrolled in managed care arrangements. The most significant growth occurred between 1993 and 1994, when Medicaid managed care enrollment grew 63 percent, from 4.8 million beneficiaries to 7.8 million (HCFA, 1994) (Figure 1).

The increase in the number of managed care enrollees is paralleled by a growth in the number of states moving toward managed care for their Medicaid population. In 1981, 85 percent of all Medicaid managed care enrollment took place in four states — California, Maryland, Michigan, and New York. By 1994, these states accounted for less than a quarter (24 percent) of the Medicaid managed care population. As of June 1994, all states except for Alaska, Connecticut, Maine, Nebraska, Oklahoma, Vermont, and Wyoming reported having at least one managed care program (HCFA, 1994). Appendix Table 1 displays the number of Medicaid enrollees in managed care plans by state as of June 1994.

The growth in Medicaid managed care mirrors private sector trends. It reflects the widely held belief that managed care can improve health care access as well as promote cost containment and budget control. Changes in federal policy designed to promote the use of Medicaid managed care also have made managed care appealing to many states.

Populations Enrolled In Medicaid Managed Care

The principal populations enrolled in Medicaid managed care have been children and adults in poor single-parent families who receive Aid to Families with Dependent Children (AFDC) and low-income pregnant women and children, rather than the elderly or disabled. While low-income adults and children accounted for 73 percent of the 32.1 million Medicaid beneficiaries, their health care costs accounted for 27 percent of total program spending in 1993. Compared to the elderly and disabled, the AFDC and poverty-related populations generally require fewer and less expensive services and are, therefore, less costly.

The shift to Medicaid managed care from fee for service for the elderly and disabled population has been less dramatic. Although 18 states offered managed care plans for disabled or elderly beneficiaries eligible for Supplemental Security Income (SSI) in 1993, only a small fraction of this population is enrolled in managed care. Some Medicaid managed care programs are also directed at services for beneficiaries with specific conditions such as AIDS, high-risk pregnancy, substance abuse, mental illness, and diabetes. Two states with statewide Medicaid demonstrations, Tennessee and Oregon, include in their mandatory managed care programs acute care services for the SSI disabled and elderly populations who are not in long term care institutions.

State Options For Medicaid Managed Care Enrollment

To establish Medicaid managed care programs, a state usually must obtain one of two types of waivers from HCFA — Section 1915(b) freedom-of-choice waivers and Section 1115 research and demonstration waivers. Section 1915(b) of the Social Security Act allows states to obtain waivers to certain federal Medicaid requirements without having to meet the formal requirements of a Section 1115 program. States need this waiver to require beneficiaries to select a primary care provider and to lock them into that provider for more than one month at a time. A 1915(b) waiver is also needed for a state to operate a program in only part of the state or a program that is limited to certain categories of beneficiaries. As of October 1994, 38 states and the District of Columbia had 71 Section 1915(b) waiver programs (HCFA, 1995).

States that are interested in testing new methods of administering Medicaid and other Social Security Act programs apply for waivers of Section 1115 of the Social Security Act. Section 1115 waivers permit the Secretary of the U.S. Department of Health and Human Services (HHS) to authorize states to develop statewide managed care systems that do not meet federal statutory requirements. Up until 1993, Arizona was the only state to have a statewide Medicaid managed care demonstration. Since a liberalization and revision of the Section 1115 review and approval process in 1993, the Secretary approved statewide managed care demonstrations in eight additional states (Florida, Hawaii, Kentucky, Ohio, Oregon, Rhode Island, South Carolina, and Tennessee). Besides shifting the traditional Medicaid population into mandatory managed care, all of the recently approved section 1115 waivers extend coverage to certain low-income individuals and families not currently eligible for Medicaid. Together, the five operational statewide waivers (Arizona, Hawaii, Oregon, Rhode Island, and Tennessee) cover an estimated 1.9 million beneficiaries. (For further information, see the Commission’s Discussion Brief, Medicaid Section 1115 Waivers, forthcoming)

Medicaid Managed Care Models

Generally speaking, managed care arrangements — whether under Medicaid, Medicare, or in the private sector — share certain features, including: formal enrollment by individual patients; formal contractual agreements between providers and payers; and some level of “gatekeeping” or utilization control performed either by a primary care physician or a separate administering arm of the payer, or both.

Medicaid managed care arrangements can be divided into three major types:

• Fee-for-service primary care case management (PCCM): In a PCCM, a specific provider, usually the patient’s primary care physician, is responsible for acting as a “gatekeeper” — that is, approving and monitoring the provision of virtually all covered services to beneficiaries assigned to him or her. PCCM providers or “gatekeepers” contract directly with State Medicaid agencies and are paid on a fee-for-service basis. Payment generally includes a per-patient monthly case management fee to compensate for the provider’s expanded administrative responsibilities. The PCCM providers do not assume financial risk for the provision of these services.
• Limited-risk Prepaid Health Plans (PHPs): Under limited risk arrangements, State Medicaid agencies contract with entities known as prepaid health plans (PHPs) to provide to enrolled beneficiaries a specified range of services. As in the case of full-risk plans, the PHP receives fixed monthly capitation payments for each eligible enrollee. The PHP often subcontracts with individual practitioners and clinics for the provision of the covered services, in the process shifting some of the financial risk to them. Additionally, some PHPs that meet the definition of an HMO are treated as PHPs through special statutory exemption.
• Full-risk plans (HMOs or HIOs): Under a fully capitated plan, State Medicaid agencies contract with a corporate entity for a fixed monthly fee per eligible enrollee for the delivery of a specified set of services. The contractor assumes the financial risk of providing all of the medically necessary services under the contract (the contractor will often reinsure against the risk of high-cost cases). The contractor often subcontracts with hospitals and other providers for the actual delivery of care, in the process shifting some of the financial risk to them. The major type of full-risk plans are Health Maintenance Organizations (HMOs), which may be Federally qualified or State certified, and in which the contracting entity and the providers are integrated into one plan. The other type of full-risk contractor is the Health Insuring Organization (HIO), which essentially operates as a fiscal intermediary and is not integrated with the provider network that actually delivers the services.

Of the 340 Medicaid managed care plans in operation in the spring of 1994, almost two-thirds were full-risk plans (HMOs or HIOs), 22 percent were limited risk PHPs, and 14 percent were PCCM arrangements. The trend among Medicaid managed care arrangements is moving away from limited-risk toward full-risk plans. As Figure 2 shows, the proportion of full-risk plans increased between 1993 and 1994 from 55 percent of total plans to 64 percent of all Medicaid managed care plans, while the proportion of PHPs declined from one third to one fifth of all plans.

Enrollment trends mirror this trend toward full-risk contracting. Of the 7.8 million Medicaid beneficiaries enrolled in managed care as of June, 1994, more than half were enrolled in full-risk contractors(HMOs or HIOs), almost one third were enrolled in PCCMs, and less than one sixth were enrolled in PHPs. Until recently, much of the growth in Medicaid managed care enrollment came from expanded enrollment in PCCMs. However, with most of the new statewide demonstrations requiring enrollment in full-risk plans, the proportion of managed care enrollees in HMOs appears to be growing. From 1993 to 1994, Medicaid beneficiary enrollment in HMOs and HIOs jumped from 44 percent to 54 percent of all Medicaid managed care enrollees (Figure 3).

Lessons From The Medicaid Managed Care Literiture

To provide some guideposts for the use of Medicaid and managed care in the future, the Kaiser Commission on the Future of Medicaid reviewed more than 130 journal articles and studies on Medicaid’s experiences with managed care to identify major findings and issues regarding access, cost, quality, and patient satisfaction. The literature reflects the diversity of approaches tried and the evolving nature of managed care. It shows that managed care is not a single model of delivering care, but rather a broad array of health care financing and delivery arrangements. The tremendous variety in the structure and scope of managed care and limitations in the study design of many of the projects make generalizations difficult. Results are often mixed across evaluations, but some common themes do emerge(Rowland and colleagues, 1995):

• Impact on access to care: There is evidence suggesting that managed care shifts the type of care and the site of care. Most studies show a decline in the use of specialist services and the use of emergency rooms as a service site. There is little evidence, however, to suggest that managed care either increases or decreases the number of physician visits, the use of preventive health services, or inpatient hospital care.
• Impact on health care costs: Evidence about cost savings are almost equally divided between studies that show program savings and those that show program costs similar to or above traditional fee for service. The literature suggests that when savings are achieved, they can range from five percent to 15 percent relative to fee for service.
• Impact on the quality of care and patient satisfaction: The quality of care in fee-for-service and managed care arrangements is about equal. Overall patient satisfaction with Medicaid and managed care is high. Satisfaction with medical care appears to be most affected by the beneficiaries’ ability to remain with their previous source of care.
• Impact on special populations: Medicaid covers a wide range of low-income individuals, including families with children, the elderly, people with disabilities, and those in need of long term care. Most of the studies of Medicaid enrollees in managed care are based on low-income families and do not include elderly or disabled beneficiaries. Therefore, the experience with managed care for special populations is extremely limited.

Implications And Issues In Medicaid Managed Care

Many of managed care’s principal features have the potential to improve access to care for the low-income population. By managing the beneficiary’s care and ensuring that services are integrated and coordinated, managed care can overcome the fragmentation often experienced in the fee-for-service system. By promoting early intervention and preventive care, it also can lead to better access to primary care and reduced reliance on emergency rooms as a site of care. Lastly, by increasing the availability of primary care, managed care can help reduce hospitalizations for conditions that could have been treated in an ambulatory setting.

For the low-income population, realizing the potential benefits of managed care is, however, a challenging task. As the move toward managed care in Medicaid continues, a number of key issues must be addressed.

• State Implementation: Care must be taken in designing and implementing managed care systems for low-income populations. Ensuring that plans have provider networks in place, educating both providers and beneficiaries on how managed care works, and understanding the unique needs and characteristics of the Medicaid population requires a considerable amount of time and effort.
• Monitoring and Oversight: Just as overutilization is a problem in fee-for-service systems, underutilization may be a problem in managed care because care incentives are reversed. In prepaid systems where providers are reimbursed a capitated payment per individual for a range of services, there is an incentive to limit service use, particularly inpatient and specialty care. Protections and adequate enforcement, therefore, are needed to assure quality and access to health care for low-income enrollees. It also is important that payment levels to participating providers are adequate to maintain quality.
• Populations Enrolled: Medicaid covers a diverse population, that includes nine million elderly and disabled individuals. States, however, have focused their managed care expansions on children and adults in low-income families rather than the elderly and disabled populations. Due to the complex and costly health care needs of elderly and disabled populations, setting capitation rates and finding plans willing to serve this population will require considerable more effort than has occurred with managed care expansions for children and adults in low-income families. It may be prudent to use managed care demonstration programs to gain experience in developing payment rates and in recruiting an appropriate mix of specialty and primary care providers before enrolling large numbers of elderly and disabled beneficiaries into managed care programs. Unless adequate attention is given to these issues, many individuals with serious medical needs could be at risk of not getting adequate health care.
• Cost Savings: The potential for cost savings for managed care in Medicaid should be carefully evaluated. Research suggests that, in the private sector, spending on insured services would have been reduced by 17 percent nationwide if all insured people had been enrolled in group/staff model HMOs or other equally effective HMOs in 1990 (CBO, 1995). In the Medicaid program, the most rigorously designed studies suggest that managed care savings are not assured. Evidence about cost savings was almost equally divided between studies that show program savings and those that show program costs similar to or above traditional fee for service. When savings occurred, they were in the range of five percent to 15 percent (Hurley, Freund, and Paul, 1993). Several reasons will likely account for less predictable managed care savings in the Medicaid program.

First, savings to overall Medicaid expenditures are likely to be modest because states are now primarily enrolling the least costly of the Medicaid population groups — children and adults in low-income families who primarily use acute care services. Acute care expenditures for low-income families accounted for 23 percent of total Medicaid spending in 1993 (Figure 4). Therefore, even if savings in Medicaid managed care programs are in the range of five percent to 15 percent relative to fee for service, as the literature suggests, and if all the adult and children beneficiaries were enrolled in managed care arrangements, overall Medicaid savings would amount to only one percent to two percent of total current expenditures (Holahan, 1995).

Second, operating under tight budget constraints, Medicaid has, in many cases, reimbursed providers at rates that are substantially below private sector rates. Given the low provider payment rates, savings from managed care are more difficult to achieve in Medicaid than in private health plans using discounted rates.

Finally, outreach efforts and care coordination may be more costly for a low-income population. Learning to navigate a managed care system is difficult for most health care consumers and potentially even more so for low-income individuals. Education and support services that are fairly limited in most commercial plans will be needed to provide effective health care to the low-income population.

Managed care is not an instant solution to improve access to health care for the Medicaid population and to save dollars. Making managed care work in Medicaid requires considerable attention to understanding the needs, cultural preferences, and characteristics of poor communities. Adequate time and resources in program design coupled with continuous monitoring and oversight of program implementation are needed to ensure that the potential benefits of managed care are realized.

The Kaiser Commission on the Future of Medicaid was established by the Henry J. Kaiser Family Foundation in 1991 to serve as a forum for analyzing, debating, and evaluating future directions for Medicaid reform. The Commission is not associated with the Kaiser Permanente Medical Care Program or the Kaiser Industries.

Both the Kaiser Commission on the Future of Medicaid and the Kaiser Family Foundation are involved in other analytic efforts in the area of Medicaid and managed care. The Kaiser Family Foundation, jointly with the Commonwealth Fund, is sponsoring case studies and consumer surveys in five states (California, Minnesota, New York, Oregon, and Tennessee) that are restructuring the delivery of health care to their Medicaid-eligible and uninsured populations by converting from fee for service to managed care. The Kaiser Family Foundation is also sponsoring a series of focus groups in the same states of low-income Medicaid beneficiaries concerning their experiences with, and attitudes toward, managed care.

References

Congressional Budget Office. 1995. The Effects of Managed Care and Managed Competition, CBO Memorandum, February.

Congressional Research Service. 1993. Medicaid Source Book: Background Data and Analysis (A 1993 Update), House Commerce Committee Print 103-A, January, pp. 1009-1038.

General Accounting Office. 1993. Medicaid States Turn to Managed Care to Improve Access and Control Costs, GAO/HRD-93-46, March.

Health Care Financing Administration, Medicaid Bureau. 1993. Medicaid Managed Care Enrollment Report Summary Statistics as of June 30, 1993, Washington, DC: U.S. Department of Health and Human Services.

Health Care Financing Administration, Office of Managed Care. 1994. Medicaid Managed Care Enrollment Report Summary Statistics as of June 30, 1994, Washington, DC: U.S. Department of Health and Human Services.

Holahan, John. 1995. The Implications of Past Medicaid Spending Growth for Future Debates, The Urban Institute, January.

Hurley, Robert, Freund, Deborah, and Paul, John. 1993. Managed Care in Medicaid, Ann Arbor, Michigan: Health Administration Press.

Rowland, Diane, Rosenbaum, Sara, Simon, Lois, and Chait, Elizabeth. 1995. Medicaid and Managed Care: Lessons from the Literature, Kaiser Commission on the Future of Medicaid, March.

The Kaiser Family Foundation Survey on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy:

Contraceptive Use and Decision Making: The Role of Men

— Questionnaire and Top Lines —

The Kaiser Family Foundation Survey on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy was a random-sample, telephone survey of adults nationwide. The national sample consisted of 2,002 adults (1002 men and 1000 women), 18 years and older, and was conducted between October 12 and November 13, 1994 by Louis Harris and Associates, Inc. The margin of error in the national sample is plus or minus 2 percent.

(Ask Q1a if sexually active — ask everyone Q1b)

Q1. Do you think that (read each item; do not rotate) for preventing unplanned pregnancy, or not?

National Yes No Not Applicable (vol.) Not Sure a. Your current or most recent partner was responsible enough 84% 11% 4% 1% b. Most men are responsible enough 28% 70% * 2%

Men Yes No Not Applicable (vol.) Not Sure a. Your current or most recent partner was responsible enough 87% 7% 5% 1% b. Your current or most recent partner was responsible enough 32% 66% * 1%

Women Yes No Not Applicable (vol.) Not Sure a. Your current or most recent partner was responsible enough 82% 15% 3% * b. Your current or most recent partner was responsible enough 24% 73% * 3%

If “no” to Q1 item b, ask Q2 — all others, skip to Q3

Q2. Why do you think most men are not involved in preventing unplanned pregnancy?

(Multiple record)

National Men Women Female takes responsibility 4% 3% 6% He feels it’s female’s responsibility 26% 21% 30% He doesn’t care 41% 45% 37% He doesn’t think it matters 9% 12% 7% He is not educated 4% 3% 4% He doesn’t become pregnant/not his body 14% 9% 18% He wants to have a baby * He doesn’t think partner needs birth control 1% * 1% Not sure 4% Other 2%

Q3. Who (read each item; rotate) — you or your current or most recent partner?

National Respondent Partner Shared (Vol.) Neither (vol.) Not Sure a. Pays/paid for birth control 40% 22% 30% 7% 1% b. Makes/made sure that birth control is/was used 39% 19% 39% 1% 2% c. Initiates/initiated discussions about birth control 36% 18% 39% 5% 2% d. Chooses/chose the type of birth control 43% 23% 31% 2% 1%

Men Respondent Partner Shared (Vol.) Neither (vol.) Not Sure a. Pays/paid for birth control 45% 20% 27% 6% 2% b. Makes/made sure that birth control is/was used 24% 35% 42% 1% 3% c. Initiates/initiated discussions about birth control 26% 27% 39% 6% 2% d. Chooses/chose the type of birth control 28% 37% 32% 2% 1%

Women Respondent Partner Shared (Vol.) Neither (vol.) Not Sure a. Pays/paid for birth control 33% 25% 33% 9% * b. Makes/made sure that birth control is/was used 57% 7% 35% 1% 1% c. Initiates/initiated discussions about birth control 47% 7% 40% 5% 1% d. Chooses/chose the type of birth control 60% 7% 30% 1% *

94-1427-04b

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Survey on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy:Press Release Survey

A report summarizing the findings of in-depths interviews conducted with Members of Congress and their staff who were actively involved in the health care reform debate about their opinions about what factors influenced the debate and shaped their views. The report finds that, among media sources, talk radio had the greatest influence in the debate and that public opinion trailed only Administration failures in terms of perceived influence on the debate’s outcome.

Overwhelming Majority of Women Feel Most Men Are Not Responsible Enough For Preventing Unplanned Pregnancy

The Top Two Reasons Why: Men “Don’t Care” or Think It’s the Woman’s Responsibility

The Majority of Women Say They Alone Make Sure Birth Control Is Used

Embargoed For Release: 4:00 p.m. EST, Monday, May 22, 1995

For further information contact: Matt James Tina Hoff (415) 854-9400

Washington, D.C. — Three quarters (73%) of American women say most men are not responsible enough for preventing unplanned pregnancy — and, two thirds of men agree — with the leading reason being that most men “don’t care,” according to a new national survey of public knowledge and attitudes regarding contraception and unplanned pregnancy by the Kaiser Family Foundation. The survey was designed by the Kaiser Family Foundation and Louis Harris and Associates, and conducted by Louis Harris and Associates. It was released today at a seminar on “Men and Condom Use” as part of the Kaiser Family Foundation’s joint initiative with the American Enterprise Institute on “Sexuality and American Social Policy.”

The four top reasons given by Americans as to why they think most men are not responsible enough for preventing unplanned pregnancy are:

1. “[They] don’t care” (37% of women and 45% of men).

• “[They feel] it is the female’s responsibility” (30% women, 21% men);
• “[They can’t] become pregnant/not his body” (18% women, 9% men); and
• “[They don’t] think it matters” (7% women, 12% men).

In contrast to their views about men in general, a large majority of American women (82%) say their own most recent partner was “responsible enough” for preventing unplanned pregnancy. But when asked about actual behavior, the majority of women who use birth control (57%) say they alone are the one to make sure contraception is used. A third (35%) say the responsibility is shared with their partner. And, only 7 percent of women say their partner alone takes the responsibility.

“If we are to begin to reduce the numbers of unplanned pregnancies in this country, men (and women) must get beyond the notion that preventing unplanned pregnancy is only a woman’s responsibility,” said Drew E. Altman, President, Kaiser Family Foundation.

Contraceptive Decision Making

Who Talks About It? Nearly half (47%) of women who currently use birth control say they initiated the discussion about contraception with their most recent partner — another 40 percent say both they and their partner do, and only 7 percent say their partner did. Men are more likely to say they and their partner both initiate such discussions (39%). Almost equal percentages of men — about a quarter — say their partner does (27%) or they themselves do (26%).

Who Chooses? Six out of ten American women who currently use birth control say they alone chose the method (37 percent of men say their partner chose). Approximately a third of women and men say the choice of birth control is a joint one (30% and 32%, respectively). Although 28 percent of men say they alone chose the method of contraception they use, only 7 percent of women say their partner did.

Who Pays? Equal proportions of women — a third each — say either they pay for the birth control they use or the cost is shared with their partner. A quarter of women say their partner pays. Close to half of men (45%) say they pay for birth control, 27 percent say the cost is shared with their partner, and 20% say they alone pay. (9% of women and 7% of men say neither they nor their partner directly pay for birth control.)

The Facts About Unplanned Pregnancies in the United States

Previously released Kaiser Family Foundation survey findings indicate that Americans overwhelmingly believe unplanned pregnancy is a major problem facing this country. The facts on unplanned pregnancy are:

• Approximately 3.5 million unplanned pregnancies occur each year in the United States.
• Current estimates indicate that close to 60 percent of pregnancies and 40 percent of births among American women are unplanned.
• Women in the United States are twice as likely as women in Great Britain to face an unplanned pregnancy and three times as likely as women in the Netherlands to face an unplanned pregnancy.
• While slightly more than half of unplanned pregnancies in the United States occur among the 10 percent of women who do not use any contraception, 1.7 million (47%) occur among women who experience contraceptive failure or improperly use birth control.

Methodology:

The Kaiser Family Foundation Survey on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy was a random-sample, telephone survey of adults nationwide. The national sample consisted of 2,002 adults, 18 years and older, and was conducted between October 12 and November 13, 1994. The margin of error in the national sample is plus or minus 2 percent. The questions pertaining to contraceptive use draw from a sub-sample of the national population that currently uses birth control. The margin of error for this sample is plus or minus 3 percent.

Reports have been released to date from data collected in this survey on public knowledge and attitudes about abortion rates, teen sexuality and pregnancy, and emergency contraceptive pills. To receive summaries of any of these three reports, call the Kaiser Family Foundation publications request line at 1-800-956-4533.

The Kaiser Family Foundation, based in Menlo Park, California, is a non-profit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. The Foundation’s work is focused on four main areas: health policy, reproductive health, HIV, and health and development in South Africa.

Topline: Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy: Men and Women

A report and press release summarizing the findings of 14 focus groups held in eight cities nationwide to explore the attitudes and experiences of Medicare beneficiaries in managed care programs, particularly health maintenance organizations (HMOs), and those with traditional fee-for-service coverage, as well as pre-Medicare beneficiaries aged 60-65. A fact sheet on Medicare and managed care is included.

This is a special issue of Health Services Research on the role of race and ethnicity in health services research. Based on a December 1992 conference sponsored by the Association of American Medical Colleges, the issue contains eight papers and as editorial preface by Mark Smith and Pancho Chang.

Note: This publication is no longer in circulation. However, a few copies may still exist in the Foundation’s internal library that could be xeroxed. Please email order@kff.org if you would like to pursue this option.”

Note: This publication is not available on our website. However, the data from these surveys is still available through the Public Opinion and Media Research Group. Please email kaiserpolls@kff.org for more information.

EMERGENCY CONTRACEPTION:

The Answer to America’s Unplanned Pregnancy Problem?

March, 1995

OVERVIEW

For approximately 20 years, emergency contraceptive pills (ECPs), high-dose oral contraceptivesalso referred to as “morning-after pills,” have been known to prevent pregnancy after unprotectedsex and available in the United States. Findings from a new Kaiser Family Foundation/LouisHarris and Associates, Inc. national public knowledge and opinion survey, however, indicate thatmost American women are uninformed or misinformed about the contraceptive alternative andfew have ever used it. Many reproductive health experts believe that the number of unplannedpregnancies in this country could be significantly reduced by wide-spread use of ECPs. Furthermore, a companion Kaiser Family Foundation/Fact Finders, Inc. survey finds that whilemost obstetricians/gynecologists practicing in the United States consider ECPs safe and effectiveand the vast majority have no objections or concerns about prescribing them, most haveprescribed them for only a handful of their patients.

Some believe the fact that no manufacturer of oral contraceptives has sought approval from theFood and Drug Administration (FDA) to re-label their product for emergency use is a majorfactor contributing to Americans’ lack of knowledge about ECPs and physicians’ reasons for notprescribing them more widely. While physicians may legally prescribe oral contraceptives for anoff-label use such as emergency contraception, additional liability issues are raised when drugs areprescribed for unlabeled purposes–those may make some clinicians reluctant toprescribe them. Furthermore, because pharmaceutical companies cannot advertise products forunlabeled purposes, many of the usual public and professional sources of information aboutcontraception are not available for ECPs.

ECPs engender opposition from some on health and moral grounds. Some are concerned aboutthe potential health risks to women in taking high doses of hormones or the potential for ECPs toreplace a woman’s regular method of contraception. Others have moral objections to anyprocedure that may interfere with the course of a potential pregnancy.

Those who believe knowledge of and access to ECPs should be increased are employing a varietyof strategies, including: petitioning the FDA to re-label oral contraceptives for emergency use;distributing ECPs as a part of regular reproductive health care; advocating over-the-counteravailability of ECPs; anddeveloping directories of providers of ECPs to provide referrals to women who need them.

This brief explores the policy issues regarding ECPs in the United States, reasons behind theirlimited use, and the potential for wider use of emergency contraception to reduce the number ofunplanned pregnancies.

WHAT ARE EMERGENCYCONTRACEPTIVE PILLS?

I. The Potential Impact on Reducing UnplannedPregnacies

II. Public and Provider Knowledge andAttitudes

• Knowledge and Attitudes Among American Public
• Attitudes and Practices Among Health Professionals
• Likelihood of American Women Most Likely to Face an Unplanned Pregnancy to use ECPs
• Who is likely to use ECPs?
• Most Americans Do Not Have Ethical or Safety Concerns
• Physicians’ Who Don’t Perform Abortions, Do Not Have Objections or Concerns AboutPrescribing ECPs

III. Political, Economic, and Policy Factors Contributing toLimited Use

• Off-Label Use and the FDA
• Liability Fears
• Reluctance From Manufacturers
• Limited Access

IV. Strategies by Proponents to Increase Use

• Distribution of ECPs as Part of Regular Reproductive Health Care
• Over-the-Counter Availibility
• Petitioning the FDA For Re-Labeling
• A Directory of Providers of ECPs
• A Bibliography

WHAT ARE EMERGENCY CONTRACEPTIVE PILLS?

Emergency contraceptive pills must be taken within 72 hours of unprotected sex, followed with asecond dose 12 hours later to prevent pregnancy. ECPs must be taken before a fertilized egg isimplanted in the uterine lining, which usually occurs approximately 5-7 days after intercourse. Emergency contraception prevents pregnancy by temporarily disrupting a woman’s hormonalpatterns. High-dose oral contraceptives are the most commonly used form of emergencycontraceptive pills. The efficacy and side-effectsof ECPs have been studied extensively in other countries, including Canada and the Netherlands. Nausea (50%) and vomiting (20%) are common among women using emergency contraceptivepill treatment.Webb AMC, Russell J, Elstein M. Comparison of Yuzpe regimen,danazol and mifepristone (RU 486) in oral postcoital contraception. British Medical Journal. 1992;305(6859).

Over-the-counter remedies for nausea are available and can be given to women undergoing ECPtreatment.A number of drugs other than oral contraceptives can also be used as emergency contraceptivepills. Mifepristone (also known as “RU-486”) can be used as an emergency contraceptive pill,though it is more commonly usedas an abortifacient – a drug that induces medical abortions – and iscurrently under trial in the United States for both uses. Other forms of emergency contraceptivepills include drug therapies such as danazol and progestin-only mini-pills. Intrauterine devices(IUDs) inserted within 5-7 days after unprotected intercourse can also reduce the risk ofpregnancy by more than 99.9 percent.Trussell J and Ellertson C. Efficacy of Emergency Contraception. Fertility Control Reviews. 1995;4(2)(forthcoming).This brief focuses on high-dose oral contraceptives, which are currently available and the mostcommonly used form of emergency contraception.

Scroll Down for More of the Issue Brief or Return tothe Outline.

I. THE POTENTIAL IMPACT ON REDUCING UNPLANNEDPREGNANCIES

Americans overwhelmingly believe unplanned pregnancies are a major problem facing this country(Kaiser/Harris Survey on Contraception and Unplanned Pregnancy, 1995). In fact, women in theUnited States are almost twice as likely as women in the Netherlands.

Jones EF, Forrest JD, Henshaw SK, Silverman J and Torres A. Unintended Pregnancy, Contraceptive Practice and Family Planning Services in DevelopedCountries. Family Planning Perspectives 1988;20(2):53.

Approximately 3.5 million unplanned pregnancies occur each year in the United States. Whileslightly more than half of unplannedpregnancies in the United States occur among the 10 percent of women who do not use anycontraception, 1.7 million (47%) occur among women who experience contraceptive failure orimproperly use contraceptives. It is estimated that ECPs could be theoretically used by about 75percent of women whose pregnancies result from method failure or improper use, and by allwomen whose pregnancies result from non-use of contraception.

Trussell J, Stewart F, Guest F, Hatcher RA. Emergencycontraceptive pills: A simple proposal to reduce unintended pregnancies. Family PlanningPerspectives 1992;24(6):269-273.The results of ten published studies indicate that emergency contraceptive pill treatment reducesthe risk of pregnancy by approximately 75 percent.

Trussell J, Stewart F. The effectiveness of postcoital hormonalcontraception. Family Planning Perspectives 1992;24(6):262-264.

Trussell J, Ellertson C, Stewart F. The effectiveness of the Yuzpe regimen of postcoitalcontraception. Princeton, NJ: Office of Population Research, Princeton University,1994.

While ECPs may be highly effective from a clinical standpoint — that is, assuming perfect use –they may not be a viable practical alternative for some women, for example, those who experiencepregnancies from unnoticed contraceptive failure. Furthermore, sexually active women notseeking pregnancy who nevertheless do notuse contraception may also not elect to use ECPs.

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II. PUBLIC AND PROVIDER KNOWLEDGE ANDATTITUDES

Because ECPs are intended to be used as a back-up method for contraceptive emergencies – suchas failure of a regular method or failure to use any method – their potential use relies heavily on aninformed public. A woman must be aware that something is possible to prevent pregnancy afterunprotected sex in order to seek the care of a clinician.

The Kaiser Family Foundation investigated Americans’ knowledge about ECPs as part of anational survey on public knowledge and attitudes on contraception and unplanned pregnancy. American adults were questioned about their familiarity with emergency contraception; whetheror not they had ethical concerns with the method; and, their previous use of and future likelihoodto use ECPs. The Foundation also surveyed obstetrician/gynecologists to assess their attitudesand practices regarding emergency contraception as part of a broader survey on attitudes andpractices relating to contraception and family planning.

KNOWLEDGE AND ATTITUDES AMONG AMERICAN PUBLIC

Slightly more than five out of ten Americans (54%) say they have “heard of” emergencycontraceptive pills (ECPs) — also referred to as “morning-after pills.”

ECPs are commonly known as “morning after pills,” though experts nowprefer to use the term “emergency contraceptive pills” to avoid the incorrect implication that thetreatment must be delayed until the morning following unprotected intercourse, or that it must betaken within 24 hours. Yet, only a little more than a third (36%) indicate that they, in fact, know”anything” could be done within a few days after unprotected sex to prevent pregnancy. ECPs area contraceptive method that can prevent pregnancy up to 72 hours after intercourse. (A quarterhave both heard of ECPs and know anything can be done.)

Among those who say they have heard of ECPs, only 9% know that the method is effective up to72 hours after intercourse — most (69%) believe pills must be taken in 24 hours or less (16% arenot sure), indicating that among those who have heard of ECPs, few understand how it works.

METHODOLOGY:

The Kaiser/Harris Survey on Public Knowledge and Attitudeson Contraception and Unplanned Pregnancy was a random-sample, telephone survey of adultsnationwide. The national sample consisted of 2,002 adults, 18 years and older. It was conductedbetween October 12 and November 13, 1994 for the Foundation by Louis Harris and Associates,Inc. The margin of error in the national sample is plus or minus 3 percent. The margin of erroramong the sample of women “at risk” of unplanned pregnancy is plus or minus 6 percent.

ATTITUDES AND PRACTICES AMONG HEALTH PROFESSIONALS

Obstetricians/gynecologists are “familiar” with the emergency contraceptive option (77.5% say”very familiar” and 22% “somewhat familiar”) and most do not have “objections or concerns”about prescribing ECPs (72%). Among those who say they are “very familiar” with the method,the overwhelming majority consider ECPsto be “very safe” (88%) and “very effective” (85%).

Seven out of ten the obstetricians/gynecologists surveyed say they have prescribed ECPs withinthe last year, but on a very infrequent basis: more than three quarters of those who prescribedECPs did so five or fewer times (77%). Even among physicians who say they have “objections orconcerns about prescribing [ECPs],” an overwhelming majority (70%) have done so at least oncewithin thelast year.

Obstetricians/gynecologists questioned in the Kaiser/Fact Finders, Inc. survey say that discussionsabout ECPs with their patients generally occurred in response to an emergency situation ratherthan during routine contraceptive counseling. Because ECPs are intended to be used as a back-upmethod for contraceptive emergencies — such as failure of a regular method or failure to use anymethod — their potential use relies heavily on an informed public: anindividual must be aware that something is possible to prevent pregnancy after unprotected sex inorder to seek the care of a clinician in the first place. The public knowledge survey finds thatmost women are unaware of this emergency contraceptive option.

METHODOLOGY:

The Kaiser/Fact Finders, Inc. Survey onObstetricians/Gynecologists’ Attitudes and Practices on Contraception and Family Planning was arandom-sample, telephone survey of obstetricians/gynecologists drawn from lists purchased froma company licensed by the American Medical Association to maintain the AMA PhysiciansMasterfile. The national sampleconsisted of 300 obstetricians/gynecologists, and was conducted between February 1 and March21, 1995. The margin of error ranges from plus or minus 3.4 and 5.7 percent.

LIKELIHOOD OF AMERICAN WOMEN MOST LIKELY TO FACE AN UNPLANNEDPREGNANCY TO USE ECPs

At any given time, two thirds of American women of reproductive age – some 39 million women -have the potential of experiencing an unplanned pregnancy, defined as those who are sexuallyactive, fertile (and whose partners are fertile), and not pregnant or trying to get pregnant.

After being told “morning-after pills (ECPs) are a particular kind of birth control pills that aretaken after sexual intercourse [and that] if several of the pills are taken at the same time within 72hours of sex, they may reduce the chance of pregnancy by up to 75 percent,” these women wereasked: “would you be very likely, somewhat likely, or not at all likely to take them if you hadunprotected sex and wanted to prevent pregnancy?” More than half of the women (52%) whohad never previously heard of ECPs say they would in fact be likely to use them to prevent anunplanned pregnancy (25% say “very,” 27%, “somewhat”).

WHO IS LIKELY TO USE ECPs?

Although single women are more likely to have unplanned pregnancies (69% of pregnancies toformerly married women and 88% of pregnancies to never-married women are unplanned), 4 in10 of pregnancies to married women are unplanned.

Nearly six in ten currently unmarried women (57%) say that they would be either “very” or”somewhat” likely to use ECPs. By comparison, only 3 out ECPs are women who live with butare not married to their partners (77%).

Adolescents are not the only age group to have high unplanned pregnancy rates (82%): morethan three-quarters (77%) of pregnancies to women 40-44 are unplanned compared with four often (42%) of those to women 30-34.

Women of all age groups are generally equally likely to use ECPs – half of those under 30 years ofage said they would be likely to use ECPs (52%).

Current data are not available for the rates at which women of different races experienceunplanned pregnancy. However, other data indicate that Hispanic and black women experiencegreater numbers of unplanned births (among births, 48% and 66% were unplanned, repsectively)than their white counterparts (among births, 37% were unplanned). Furthermore, while theoverall abortion rate in 1988 was 27.3 per 1,000 women, 57/1,000 nonwhite as compared to21/1,000 white women underwent abortion.

A majority of black and hispanic women would be willing to consider ECPs (56%): among blackwomen, 39 percent say “very likely” and 17 percent say “somewhat likely” and among Hispanicwomen, 34 percent say “very” and 20 percent say “somewhat.” In comparison, white womenwere slightly less likely to use ECPs, although four in ten (41%) still say they would (15% use”very”, 26% “somewhat”) Three quarters of pregnancies to women below 100 percent of thepovertylevel are unplanned, compared with 45 percent of those at 200 percent or above. Few differencesin likelihood of use exist among women with different household incomes. Slightly less than half(46%) of women with household incomes below $15,000 would be likely to use ECPs. Womenwith higher household incomes are similarly likely (52% of women with incomes of$15,001-35,000 are likely, while 45% of women with incomes of $35,000 plus are likely).

MOST AMERICANS DO NOT HAVE ETHICAL OR SAFETY CONCERNS …

Nearly two-thirds of Americans say emergency contraception poses no “ethical concerns” forthem (61% say it does not vs. 36% say it does). Among those who expressed an ethical concernabout ECPs, a third still say they are likely to use the method if potentially faced with a pregnancythey wanted to prevent.

Among Americans who think birth control pills are “somewhat unsafe,” 45% say they would belikely to use ECPs if faced with a pregnancy they wanted to prevent. Forty percent of those whothink the pill is very unsafe also would be likely to use the method. Most (55%) Americans whoview the pill as somewhat or very safe would be likely to use ECPs.Most Americans (58%) think ECPs should be available only by prescription, as opposed to being”widely available, like condoms.”

PHYSICIANS’ WHO DON’T PERFORM ABORTIONS, DO NOT HAVE OBJECTIONSOR CONCERNS ABOUT PRESCRIBING ECPS …

Of the two-thirds of obstetricians/ gynecologists who say in their own practice they do not “everperform abortions as elective terminations of pregnancy” – with more than a third (35%) citingmoral or religious objections as a main reason – a majority (64%) say they have no “objections orconcerns” about prescribing ECPs for their patients. In fact, two-thirds (65%) of the physiciansciting an objection or concern did prescribe ECPs at least once within the last year.

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III. POLITICAL, ECONOMIC, AND POLICY FACTORSCONTRIBUTING TO LIMITED USE

The previous section of this brief reported on surveys indicating that many American women,once informed, say they would be likely to use ECPs and that most obstetricians/gynecologistsbelieve the method is safe and effective and have no objections or concerns about prescribing it. Yet, pharmaceutical companies havebeen reluctant to seek FDA relabeling of oral contraceptives which would allow them to marketthem as an emergency contraceptive product. And, although physicians may prescribe oralcontraceptives for emergency purposes, most do so on a limited basis. Most physicians makeonly a handful of their patients aware of ECPs and then, generally, in response to an emergencysituation rather thanduring routine counseling. A number of factors contribute to this limited use:

OFF-LABEL USE AND THE FDA

The use of oral contraceptives as emergencycontraception is not yet approved by the FDA. In general, however, health care providers withprescribing privileges can prescribe any drug licensed by the FDA for unlabeled purposes. Forexample, oral contraceptives are often prescribed to correct menstrual irregularities or to treatacne. A drug manufacturer is not allowed to advertise any of itsproducts for unlabeled purposesto doctors or to the general public, which increasingly has been the target of direct advertising byprescription drug manufacturers. To secure FDA approval for a new indication, a drug companymust submit a formal application, including clinical studies demonstrating the safetyand efficacy ofa proposed indication.

LIABILITY FEARS

Even if a clinician knows about emergency contraceptive pills,legal concerns may make her or him hesitant to prescribe them. Although clinicians withprescribing privileges may prescribe an approved drug for an unlabeled purpose, in doing so, theresponsibility for liability rests with the physician rather than the manufacturer of the drug. Though there is no evidence that a fetus exposed to ECPs will experience birth defects, along-term scientific study has yet to be done. A study of the risk of congenital malformationsfrom oral contraceptive exposure in early pregnancy found a lack of an association between oralcontraceptives and birth defects.Bracken, MB. Oral Contraception and Congenital Malformations inOffspring: A Review and Meta-Analysis of the Prospective Studies. Obstetrics and Gynecology1990;76(3 part 2):552-557.Furthermore, women who have contraindications for oral contraceptives such as history of strokeor heart attack will have the same contraindications for ECPs and under many circumstancesshould not take them, although some clinicians may make exceptions for some women for onetime use. While this fear of legal liability may prevent others from prescribing emergencycontraceptive pills (Trussell, et al., 1992), it may also contribute to a reluctanceamong manufacturers to relabel their oral contraceptive products for emergency use.

RELUCTANCE FROM MANUFACTURERS

There are several reasons why nopharmaceutical company has sought approval for relabeling from the FDA: that many physiciansalready use oral contraceptives as emergency contraceptive pills; that from a business standpointmanufacturers would prefer women become regular pill users rather than emergency users; and,that the considerable costs of gathering data for an application for approval are not likely to beoffset by increased sales. In addition, pharmaceutical companies worry that marketing oralcontraceptive pills for this use will increase their vulnerability to product liability suits (overunknown affects onthe fetus that may come to term) and encourage a boycott of their products by anti-abortioncustomers objecting to any drug treatment that may interfere with the course of a potentialpregnancy. No other manufacturers have come forward.

LIMITED ACCESS

Women’s access to emergency contraceptive is impeded inpractice by many factors, including the need for a clinician to write a prescription and someclinicians’requirements for physical exams and pregnancy tests prior to prescription. For women who havelimited access to health care in general, who are uninsured and have no established relationshipwith a health provider, these requirements can be an overwhelming obstacle. Even for thosewomen with insurance, coverage isoften limited to FDA approved drugs and regimens.

There is little information about where women can get ECPs. Past research has indicated thatuniversity health services provide ECPs regularly. ECPs are also thought to be available in asmall number of family planning organizations and private physicians offices. Other clinics andemergency rooms offer ECPs only to women who claim to be victims of rape. Catholic healthsystems (which deliver16% of the health care services in the United States) tend to view ECPs as abortifacients; in suchcases, for women seeking or in need of emergency contraception from these providers within theirsystems, neither prescriptions nor referrals for ECPs are available.

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IV. STRATEGIES BY PROPONENTS TO INCREASE USE

Organizations seeking to expand awareness and access to emergency contraceptive pills haveemployed a variety of strategies toward this end. Some examples of

DISTRIBUTION OF ECPs AS PART OF REGULAR REPRODUCTIVE HEALTHCARE

Except among a few family planning organizations, ECPs have been given to women only at thetime of emergency; that is, within 72 hours of unprotected sex. Some experts argue that ifwomen had greater access to emergency contraceptive pills, that is, before an emergency occurs,they would be more likely to take them when they are needed.Trussell J, Stewart F, Guest F, Hatcher RA. Emergencycontraceptive pills: A simple proposal to reduce unintended pregnancies. Family Planning Perspectives 1992;24(6):269-273.This kind of access could be facilitated by prescribing ECPsin non-emergency situations, such as during a patients annual exam, for future possibleemergencies.

The National Medical Committee of Planned Parenthood Federation of America recentlyapproved a policy to allow local affiliates to provide ECPs on an on-demand basis, includingdispensing them to women who do not have an immediate need but wish to have such a resourceavailable without having to visit a medicalprovider at the time of emergency. This policy recommendation provides a unique opportunity tocollect data on how such emergency contraceptives work in day-to-day practice.

OVER-THE-COUNTER AVAILABILITY

Access to the regimen could be increased by providing it without prescription. This way, a womanat risk for an unwanted pregnancy need not seek the care of a physician within 72 hours ofunprotected intercourse. This change in policy is likely to be dependent on the prescription statusof oral contraceptives.

While there is currently no organized effort to change policy, many in the reproductive healthcommunity have argued for and against over the counter availability for oral contraceptives. Bothsides’ arguments hinge, in part, on their views of emergency contraception.

PETITIONING THE FDA FOR RE-LABELING

The Center for Reproductive Law and Policy is representing the American Medical Women’sAssociation, Planned Parenthood of New York City, and the American Public Health Associationin a petition to the FDA to require relabeling of several oral contraceptives for use as emergencycontraceptive pills. The mechanisms for enforcing this “requirement” are not clear.

A DIRECTORY OF PROVIDERS OF ECPs

The authors of Emergency Contraception: The Nation’s Best Kept Secret have developed anational directory of providers willing to counsel about and prescribe emergency contraception. The directory is also available on the internet and the authors hope to make it accessible throughan 800 number service. The intention of the book and the directory is to inform women aboutECPs and provide referral to information and services in their own communities.

Bibliography

(to include, potentially):

• 2 Trussell articles
• U Health Study (not in yet)
• Princeton Study
• Sharon Camp international report
• Harris Survey
• Fact Finders Survey
• CRLP petition news coverage

Survey on OB/GYN Practice/Attitudes on Emergency Contraceptives:Press Release Survey Policy Brief

Kaiser Family Foundation Survey on Public Knowledge and Attitudes Regarding Contraception and Unplanned Pregnancy:

Emergency Contraceptive Pills

— Questionnaire and Top Lines —

The Kaiser Family Foundation Survey on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy was a random-sample, telephone survey of adults nationwide. The national sample consisted of 2,002 adults (1002 men and 1000 women), 18 years and older, and was conducted between October 12 and November 13, 1994. Responses for a sub-set of the national population — American women most likely to experience an unplanned pregnancy, defined as those who are sexually active, fertile (and whose partners are fertile), and not pregnant or trying to get pregnant (270 out of the 1000 women surveyed) — are also referenced below. The margin of error in the national sample is plus or minus 2 percent. The margin of error among the sub-set of women at-risk is plus or minus 6 percent.

Q1. If a woman has just had sex and thinks she might become pregnant, is there anything that she could do in the next few days to prevent pregnancy, or not?

National Women at Risk Yes, there is something 36% 32% No, there is not anything 47% 64% Too late to prevent pregnancy (vol.) 1% * Not sure 17% 4% Q2. Have you ever heard of morning-after pills, also called emergency contraceptive pills, or not?

National Women at Risk Yes, have heard of it 54% (Ask Q3) 60% No, have not heard of it 45% (Skip to Q5) 40% Not sure * * Q3. How soon after sexual intercourse do morning-after pills have to be taken — immediately, within 12 hours, within 24 hours, within 72 hours, or within one week?

National Women at Risk Immediately 10% 12% Within 12 hours 31% 30% Within 24 hours 28% 30% Within 72 hours 9% 12% Within one week 5% 5% Not sure 16% 11% Q4. (Ask Females: Have you/ Ask Males: Has your current or most recent partner) ever used morning-after pills, or not?

National Women at Risk Yes, have taken 1% 1% No, have not taken 98% 99% Not sure 1% *

Q5. Ask Everyone: (Read intro if never heard of morning-after pill if Q.J2; Morning-after pills are a particular kind of birth control pills that are taken after sexual intercourse. If several of the pills are taken at the same time within 72 hours of sex, they may reduce the chance of pregnancy by up to 75%.)

From what you know about morning-after pills, would you say (you/your current or recent partner) would be very likely, somewhat likely, or not at all likely to take them if you had unprotected sex and wanted to prevent pregnancy?

National Women at Risk Very likely 23% 22% Somewhat likely 20% 25% Not at all likely 47% 52% Not applicable (vol) 7% * Not sure 3% 1% Q6. Do you think morning-after pills should be widely available, like condoms or tightly controlled like drugs that require a prescription from you doctor?

National Women at Risk Widely available 37% 31% Tightly controlled 58% 66% Not sure 5% 3% Q7. Would a method of birth control that is taken soon after intercourse, such as morning-after pills, pose ethical concerns for you, or not?

National Women at Risk Yes, would pose concerns 36% 47% No, would not 61% 50% Not sure 3% 2%

Now I’d like to ask you a few questions about your discussions with health care professionals. (If Necessary: If any question is not applicable to you, please say so, and we’ll move past it.)

Q8. In the past two years, have you discussed birth control such as the use of condoms or birth control pills with your doctor or another health professional, or not?

National Women at Risk Yes, discussed 21% (Skip to Q10) 73% No, did not discuss 71% (Ask Q9) 26% Not applicable (vol.) 9% (Skip to Q11) 1% Not sure * * Q9. Have you ever discussed birth control with a doctor or another health professional, or not?

National Women at Risk Yes, discussed 38% (Ask Q10) 74% No, never discussed 61% (Skip to Q11) 26% Not applic (vol.) 1% (Skip to Q11) * Not sure * * Q10. Has a doctor ever been the one to raise the subject of birth control, or not?

National Women at Risk Yes, doctor raised subject 32% 45% Doctor did not 67% 54% Not sure 1% 1% Q11. People can get information about birth control from a variety of sources. What sources would you say that you most typically rely on for information about birth control? What else? (Do not read list — Multiple Record)

National Women at Risk a. Your family 9% N/A b. Health care professionals 63% c. Your friends or peers 12% d. Health and sex education courses in school 8% e. Television 11% f. Magazines 20% g. Your spouse or partner 2% Not sure 13% Other 3%

94-1427B-03d

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Survey on OB/GYN Practice/Attitudes on Emergency Contraceptives:Press Release Survey Policy Brief

Two New Surveys of American Public and Physicians:

American Women Are Misinformed About Emergency Contraceptive Option; Once Explained, Many Say Would Be Likely to Use

–Ethical and Safety Concerns Not Major Factors In Stated Likelihood to Use “Morning-After” Pills —

OB/GYNS Consider “Morning-After” Pills to be Safe and Effective; While Most Have Prescribed Within LastYear, Only to Handful of Patients

— Most Physicians Who Do Not Perform Abortions State No “Objections or Concerns” Prescribing Emergency Contraceptive Pills —

Embargoed for Release Until: Wednesday, A.M., March 29, 1995

For further information contact: Matt James or Tina Hoff (415) 854-9400

Although nearly half (47%) of adult American women with the potential of facing an unplanned pregnancy say they would be likely to use “morning-after” pills, many are uninformed or misinformed about this emergency contraceptive alternative and few have ever used it, according to a new national survey on public knowledge and attitudes on contraception and unplanned pregnancy conducted by the Kaiser Family Foundation and Louis Harris & Associates, Inc.

Six out of ten women with the potential of facing an unplanned pregnancy say they have “heard of” emergency contraceptive pills (ECPs), also referred to as “morning-after” pills. Yet, only a third indicate that they, in fact, know if “anything” can be done within a few days after unprotected sex to prevent pregnancy.

ECPs are high-dose oral contraceptives known for approximately 20 years to be effective in preventing pregnancy if taken within 72 hours after unprotected sex. (Nausea and vomiting are common side-effects among women using emergency contraceptive pills. Contraindications for oral contraceptives, such as history of stroke or heart attack, also apply to potential ECP users, although clinicians may make exceptions for some women for one time use.) Although oral contraceptives have not been approved by the Food and Drug Administration (FDA) for emergency contraception purposes, doctors and other health providers who can write prescriptions may use any drug licensed by the FDA for unlabeled purposes — that is, oral contraceptives may be prescribed as an emergency contraceptive.

Health professionals are identified by most women (83%) as a source they rely on for information on “birth control.” However, preliminary findings from a new survey by the Kaiser Family Foundation and Fact Finders, Inc. indicate that obstetricians/gynecologists have made only a handful of their female patients “aware of” ECPs and do so, generally, in response to an emergency situation rather than during routine contraceptive counseling. Because ECPs are intended to be used as a back-up method for contraceptive emergencies — such as failure of a regular method or failure to use any method — their potential use relies heavily on an informed public: an individual must be aware that something is possible to prevent pregnancy after unprotected sex to seek the care of a clinician in the first place.

Furthermore, most women who have heard of ECPs are misinformed about the time period during which they are effective: nearly half (48%) believe the pills must be taken 24 hours or sooner after intercourse to prevent pregnancy and 10% are not sure. Only 20 percent know that the method is effective up to 72 hours after unprotected sex. (To avoid confusion about how soon after intercourse the pills must be taken to prevent pregnancy, reproductive health experts now prefer the term “emergency contraceptive pills” instead of the more commonly known label “morning-after” pills.)

Physicians’ Views and Practices

The Kaiser/Fact Finders survey indicates that obstetricians/gynecologists are “familiar” with emergency contraceptive pills (77.5% say “very familiar” and 22% “somewhat familiar”) and most do not have “objections or concerns” about prescribing ECPs (72%). Among those who say they are “very familiar” with the method, the overwhelming majority consider ECPs to be “very safe” (88%) and “very effective” (85%). Overall, seven out of ten the obstetricians/ gynecologists surveyed say they have prescribed ECPs within the last year, but on a very infrequent basis: more than three quarters (77%) of those who prescribed ECPs did so five or fewer times.

The survey also indicates that physicians make a distinction between abortion and emergency contraception. Of the two-thirds of obstetricians/ gynecologists who say in their own practice they do not “ever perform abortions as elective terminations of pregnancy,” a majority (64%) say they have no “objections or concerns” about prescribing ECPs for their patients and, in fact, 65 percent did prescribe ECPs at least once in the last year. Among the more than half (56%) of physicians who cite ethical, moral, or religious objections as a main reason why they do not perform abortions, the vast majority — 84 percent — do not have the same objections about prescribing ECPs. Nearly half (48%) of physicians who do not perform abortions for ethical, moral, or religious reasons prescribed ECPs at least once in the last year.

“Our surveys indicate that many American women are interested in emergency contraceptive pills if faced with a potential pregnancy they want to prevent and most obstetricians/gynecologists find ECPs to be a safe and effective contraceptive alternative. Clearly, this option merits a closer look by both providers and policymakers,” said Mark D. Smith, executive vice president, Kaiser Family Foundation.

Views of American Women Most Likely to Experience An Unplanned Pregnancy

This section reports survey results for women considered most likely to experience an unplanned pregnancy, defined as those who are sexually active, fertile (and whose partners are fertile), and not pregnant or trying to get pregnant. According to the Alan Guttmacher Institute, at any given point in time, two-thirds of American women of reproductive age — some 39 million women — have the potential to experience an unplanned pregnancy. Ninety percent of these women use some method of birth control. And, while slightly more than half of unplanned pregnancies in the United States occur among the 10 percent of women who do not use any contraception, 47 percent occur among women who experience contraceptive failure or improperly use contraceptives.

Ninety-nine percent of women who have heard of ECPs say they have never used them, although four out of ten (44%) say they would if faced with a potential pregnancy they wanted to prevent. Women who had not heard of ECPs were told “‘morning-after’ pills (ECPs) are a particular kind of birth control pills that are taken after sexual intercourse [and that] if several of the pills are taken at the same time within 72 hours of sex, they may reduce the chance of pregnancy by up to 75 percent,” and then were asked: “would you be very likely, somewhat likely, or not at all likely to take them if you had unprotected sex and wanted to prevent pregnancy?” More than half of the women who had never previously heard of ECPs responded that they would be likely to use them to prevent a potential unplanned pregnancy (25% say “very likely,” 27%, “somewhat likely”).

The women are almost evenly divided as to whether or not emergency contraception poses “ethical concerns” for them: a slight majority (51%) say it does not vs. 47 percent who say it does. The survey found, however, that ethical concerns do not always translate into resistance to using ECPs. More than a third (37%) of the women who expressed an ethical concern about ECPs still say they would be likely to use the method if faced with a potential pregnancy they wanted to prevent. Likewise, almost equal proportions of women expressing concerns about the safety of “the pill,” as those who have none, say they would use ECPs.

Among all groups of women — including those citing no ethical problems with ECPs — there remain at least 40 percent who say they are “not at all likely” to use ECPs. And, most women (66%) think ECPs should continue to be available by prescription, as opposed to being “widely available, like condoms.”

Previous research has indicated that ECPs are widely available on college campuses through student health services. The results of the Kaiser/Harris survey find, in fact, that among women of all ages, races, and income levels, a higher degree of education corresponds to a greater level of awareness about emergency contraception and ECPs. A majority (51%) of college-educated women know pregnancy can be prevented after sex and have heard of ECPs. By comparison, only 11 percent of those who did not graduate from high school are equally informed. The majority of those who did not graduate from high school (58%) neither know anything is possible to prevent pregnancy after unprotected sex, nor have heard of ECPs.

Women who had heard of ECPs were more likely than those who had not to list sources of information on contraception in addition to health professionals. For example, more than three quarters (78%) of women who had heard of ECPs listed “magazines” as a source of information on contraception as compared with fewer than a quarter (22%) of those who were not aware of the method.

The survey results are being presented Wednesday, March 29, at a briefing for journalists on emergency contraception sponsored by the Kaiser Family Foundation and the Washington Journalism Center.

The Kaiser/Harris Survey on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy was a random-sample, telephone survey of adults nationwide. The national sample consisted of 2,002 adults, 18 years and older, and was conducted between October 12 and November 13, 1994. The margin of error in the national sample is plus or minus 2 percent. The margin of error among the sample referenced throughout this release — 270 American women most likely to experience an unplanned pregnancy — is plus or minus 6 percent. Reports have been released from data collected in this survey on public knowledge and attitudes about abortion rates and teen sexuality. Future reports will be issued on talking with children about sexuality and other sensitive issues, men and contraception, and other aspects of contraception and reproduction.

The Kaiser/Fact Finders Survey on Obstetricians/Gynecologists’ Attitudes and Practices Related to Contraception and Family Planning was a random-sample, telephone survey of obstetricians/gynecologists drawn from the American Medical Association’s Physicians Masterfile. The national sample consisted of 300 obstetricians/gynecologists, and was conducted between February 1 and March 21, 1995. The margin of error ranges from plus or minus 3.4 and 5.7 percent. A companion survey of physicians in Family Practice is also being conducted. Future reports will be issued on physician attitudes and practices on other aspects of contraception and family planning, including preferred contraceptive methods, RU-486, abortion, teen sexuality, and general findings on contraceptive counseling and patient-physician communication.

The Kaiser Family Foundation, based in Menlo Park, California, is a non-profit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. The Foundation’s work is focused on four main areas: health policy, reproductive health, HIV, and health and development in South Africa.

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Topline: Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy in the US, Canada and the Netherlands 1995