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.

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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

This policy brief explains the current Medicaid financing arrangements between federal, state and local governments, examines the role of Medicaid in federal and state budgets, and identifies severalimportant considerations on evaluating proposals to limit federal Medicaid spending.

• Policy Brief: Medicaid and Federal, State, and Local Budgets

This policy brief examines the projected impact of a 5% expenditure growth cap on Medicaid expenditures over the period 1996 to 2002. It highlights the differential implications that would result under this type of proposal.

• Policy Brief: The Impact of a Five Percent Medicaid Expenditure Growth Cap, A State Level Analysis

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

Medicaid, jointly financed by state and federal governments, is made up of over 50 separate programs with disparate populations covered and services offered. In an effort to better understand the implications of federal policy changes for the financing structure of Medicaid, the Kaiser Commission on the Future of Medicaid sponsored the Urban Institute analysis of state variations in Medicaid. The main findings of this analysis are highlighted in this policy brief.

• Policy Brief:

HIV and Managed Care, Special Supplement to JAIDS

Health policy and public health experts examine the politics, practice, and special considerations of providing AIDS/HIV care under a managed care health system. This work was published as a special supplement to JAIDS, the Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, and produced as part of the Kaiser Forums program, an ongoing series of issue-specific briefings at which policy makers, health experts, practitioners, and others discuss and debate controversial topics related to the Foundation’s core areas of interest.

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.

An analysis of the electorate and health reform that considers how American voters’ values influenced their support or opposition toward health reform proposals and how those attitudes shifted over the course of the debate. The study uses a novel typologyof the American people developed by the Times Mirror Center for the People and the Press that divides voters into ten groups of which three are pro-Republican, four are pro-Democrat, and the remainder are Independents. Among the values determined to be most significant in assessing public opinion on health reform were: attitudes toward government, attitudes toward the poor and needy, and attitudes toward business. Economic and political variables were also relevant. Times Mirror found similar values among different groups and differing values within the same group.

To gather early insights and timely information for state and federal policymakers concerning how the movement to managed care is affecting the poor and their access to care, the Henry J. Kaiser Family Foundation and The Commonwealth Fund are jointly sponsoring case studies and population surveys in five states that are currently restructuring their health care systems for the low-income population: California, Minnesota, New York, Oregon,and Tennessee. TennCare represents one of the most ambitious state-level efforts to restructure Medicaid and expand insurance coverage to the uninsured. The case study shows that the rapid change caused considerable confusion for patients, providers, and health plans. The TennCare experience provides early insights into the issues that states will face as they move to enroll more of their low-income populations into managed care arrangements.

Report (.pdf)

D. Knowledge of Teen Pregnancy

D1. Now I’m going to ask you some questions about teenagers, that is, young women between the ages of 12 and 19. Do you think that the percentage of teenagers in the United States who engage in sexual intercourse is increasing, decreasing, or is it about the same as ten years ago?

Asked only in the U.S.

USA18+ Increasing 73% Decreasing 9% Same 17% Not sure/Refused 1% D2. What percentage of (read each item) do you feel have had sexual intercourse? (Rotatewithin each group)

Asked only in the U.S.

USA18+ a. 14 year old females Mean: 44% b. 14 year old males Mean: 47% c. 18 year old females Mean: 70% d. 18 year old males Mean: 75% D3. What percentage of young women in the United States do you feel become pregnant before the age of twenty?

Asked only in the U.S. USA18+ Mean: 44% D4. What percentage of teen pregnancies do you feel end in abortion?

Asked only in the U.S. USA18+ Mean: 41% D5. Generally speaking, if a woman under 20 has a child in the United States, will she be more likely to (Read each item; Rotate), less likely, or will it have no effect?

Asked only in the U.S.

MoreLikely LessLikely No Effect Not Sure/Refused a. Complete her education USA 18+ 8% 84% 7% 1% b. Earn a good salary USA 18+ 4% 83% 12% 2% c. Go on welfare USA 18+ 85% 6% 7% 2% d. Get married USA 18+ 21% 43% 34% 2% D6. What percentage of all teenagers who have children in the United States do you think are (Read each item; Rotate)?

Asked only in the U.S.

USA18+ a. White Mean: 41% b. In the middle or upper class Mean: 37% E. Overall Knowledge about Reproduction and Birth Control

Now I have a few questions about pregnancy and birth control.

E1. When do you think a woman is most likely to get pregnant — about one week before her period starts, during her period, or about two weeks after her period starts?

USA18+ USA18-44 CAN18-44 NETH18-44 About one week before her period starts 35% 33% 30% 17% During her period 3% 4% 3% 2% About two weeks after her period starts 55% 60% 57% 71% Not sure/Refused 8% 4% 10% 11% E2. If 100 women who are not using birth control engage in sexual intercourse regularly, whatpercentage do you feel will get pregnant during one year?

USA18+ USA18-44 CAN18-44 NETH18-44 10% or less 5% 4% 4% 6% 11%-20% 6% 5% 4% 5% 21%-30% 10% 10% 7% 10% 31%-40% 8% 8% 6% 6% 41%-50% 18% 16% 19% 18% 51%-60% 9% 10% 8% 10% 61%-70% 8% 9% 9% 6% 71%-80% 18% 20% 18% 14% 81%-90% 7% 8% 7% 5% 91%-100% 7% 8% 9% 3% Mean 57 59 61 53 Standard error in mean 1 1 1 1 Median 59 60 61 52 Don’t know 4% 2% 9% 17% E3. What different methods of birth control have you heard of? What others? (Open-Ended — all responses were volunteered and multiple responses could be given)

Based on those under 65 years old. Asked only in the U.S. USA18+ a. Abortion 3% b. Abstinence 27% c. Birth control pills or oral contraceptives 85% d. Condoms or rubbers or female condoms 85% e. Contraceptive foams, creams, jellies, and suppositories 41% f. Contraceptive implant, or Norplant, or capsules under the arm 31% g. Depo-Provera (contraceptive injections in the arm/shots) 15% h. Diaphragms, sponges or cervical caps 50% i. Female sterilization such as tubal ligation, tubes tied or hysterectomy 16% j. IUDs 39% k. Male sterilization (vasectomy) 14% l. Rhythm method or natural family planning or calendar method 20% m. Withdrawal 5% n. None 2% o. Other 2% p. Not sure/Refused 3% E4. I would like to get your opinion about how effective various methods of birth control are at preventing pregnancy. Do you think that (read each item) is/are very effective at preventing pregnancy, somewhat effective, or not very effective?

Based on those under 65 years old.

VeryEffective SomewhatEffective Not Very Effective Not Sure/Refused a. Sterilization (such as vasectomy/tubal ligation, tubes tied or hysterectomy) USA 18+ 86% 10% 2% 1% USA 18-44 87% 9% 2% * CAN 18-44 83% 13% 2% 3% NETH 18-44 90% 7% 1% 1% b. Birth control pills USA 18+ 64% 29% 4% 1% USA 18-44 64% 31% 4% * CAN 18-44 73% 23% 3% 1% NETH 18-44 90% 9% * 1% c. Condoms USA 18+ 36% 53% 9% * USA 18-44 38% 53% 7% * CAN 18-44 40% 52% 7% 1% NETH 18-44 52% 44% 3% 1% d. Diaphragms USA 18+ 30% 57% 8% 4% USA 18-44 29% 59% 7% 3% CAN 18-44 18% 50% 19% 14% NETH 18-44 19% 43% 12% 26% e. Withdrawal USA 18+ 12% 26% 56% 4% USA 18-44 12% 26% 57% 3% CAN 18-44 9% 15% 69% 6% NETH 18-44 3% 8% 86% 3% f. Contraceptive foams, creams, jellies, and suppositories USA 18+ 10% 60% 24% 4% USA 18-44 9% 62% 24% 4% CAN 18-44 6% 42% 36% 16% NETH 18-44 5% 36% 37% 21% g. The rhythm method (also called natural family planning, or calendar method) USA 18+ 9% 43% 42% 4% USA 18-44 9% 42% 44% 3% CAN 18-44 7% 29% 57% 6% NETH 18-44 6% 16% 73% 5% E5. Would you say that (read each item) is/are very safe, somewhat safe, somewhat unsafe orvery unsafe for the health of the user?

VerySafe SomewhatSafe SomewhatUnsafe VeryUnsafe Not Sure/Refused a. Birth control pills USA 18+ 18% 49% 23% 7% 1% USA 18-44 17% 50% 24% 7% 1% CAN 18-44 21% 46% 23% 8% 3% NETH 18-44 40% 34% 20% 3% 3% b. Condoms USA 18+ 53% 34% 7% 3% 1% USA 18-44 56% 33% 7% 2% * CAN 18-44 66% 26% 5% 2% 2% NETH 18-44 82% 14% 3% * 1% c. Contraceptive foams, creams jellies, and suppositories USA 18+ 17% 49% 20% 8% 4% USA 18-44 16% 52% 20% 7% 3% CAN 18-44 16% 35% 21% 9% 19% NETH 18-44 15% 22% 25% 6% 32% d. Diaphragms USA 18+ 25% 43% 20% 7% 4% USA 18-44 24% 44% 21% 6% 3% CAN 18-44 21% 37% 21% 9% 13% NETH 18-44 26% 27% 18% 3% 26% e. IUDs USA 18+ 5% 33% 32% 18% 10% USA 18-44 4% 34% 33% 18% 9% CAN 18-44 9% 31% 25% 20% 16% NETH 18-44 21% 33% 29% 6% 11% f. Female sterilization (tubal ligation, tubes tied or hysterectomy) USA 18+ 41% 35% 14% 5% 2% USA 18-44 35% 39% 17% 5% 2% CAN 18-44 40% 33% 14% 6% 7% NETH 18-44 59% 21% 11% 3% 8% g. Male sterilization (vasectomy) USA 18+ 53% 29% 9% 4% 2% USA 18-44 48% 33% 10% 4% 2% CAN 18-44 53% 28% 9% 4% 5% NETH 18-44 66% 20% 7% 2% 5% F. Personal Experiences

Now I’m going to ask you some questions about your personal experiences. Once again, I want to reassure you of the complete confidentiality of all of your responses. Researchers will analyze this information in summary form and will never associate you with any of your responses.

F1. Have you had sexual intercourse in the last twelve months, or not?

USA18+ USA18-44 CAN18-44 NETH18-44 Yes 75% 89% 88% 91% No 22% 9% 11% 7% Not applic. (Vol.) 1% * * 1% Not sure/Refused 2% 1% 1% 1% F2. Do you or your partner currently use any type of birth control, or not? (If no current partner, probe: Did you or your most recent partner use any type of birth control?)

Based on those who have had sexual intercourse in the last 12 months.

USA18+ USA18-44 CAN18-44 NETH18-44 Yes 48% 60% 62% 80% No 48% 38% 36% 20% Not applic. (Vol.) 4% 2% 1% 1% Not sure/Refused * * * * F2a. Why don’t you use birth control? (Do not read list — multiple record)

Based on those who do not use birth control.

USA18+ USA18-44 CAN18-44 NETH18-44 Would like to become pregnant 9% 17% 17% 20% Currently pregnant 5% 8% 6% 22% Need to get prescription from doctor * * * * Don’t like contraceptives/uncomfortable 2% 4% 2% 10% Spoils moment/interferes 1% 2% 1% 2% No longer necessary 70% 51% 63% 25% Other 8% 8% 11% 17% Not sure/Refused 5% 8% 4% 5% F3. What form(s) of birth control do you or your partner use? (Do not read list — multiple record)

Based on those who currently use birth control.

USA18+ USA18-44 CAN18-44 NETH18-44 a. Abortion * * * * b. Abstinence * * * * c. Birth control pills or oral contraceptives 34% 38% 43% 65% d. Condoms or rubbers or female condoms 39% 43% 46% 21% e. Contraceptive foams, creams, jellies, and suppositories 4% 3% 3% * f. Contraceptive implant, or Norplant, or capsules under the arm 2% 2% * * g. Depo-Provera (contraceptive injections in the arm/shots) 3% 3% * * h. Diaphragms, sponges or cervical caps 5% 5% 2% * I. Female sterilization such as tubal ligation, tubes tied or hysterectomy 14% 11% 11% 5% j. IUDs 1% 1% 3% 3% k. Male sterilization (vasectomy) 12% 9% 10% 11% l. Rhythm method or natural family planning or calendar method 2% 2% 2% * m. Withdrawal 1% 1% 2% * n. Other * * 3% * o. Not sure/Refused 1% 1% 2% * F4. Who (read each item) — you or your current or most recent partner?

Based on those who currently use birth control.

Respondent Partner Shared Neither Not sure/Refused a. Pays/paid for birth control USA 18+ 40% 22% 30% 7% 1% USA 18-44 38% 23% 31% 7% 1% CAN 18-44 29% 19% 38% 12% 3% NETH 18-44 20% 13% 41% 26% 1% b. Makes/made sure that birth control is/was used USA 18+ 39% 19% 39% 1% 2% USA 18-44 40% 18% 40% * 2% CAN 18-44 24% 21% 49% 3% 2% NETH 18-44 32% 29% 38% 1% * c. Initiates/initiated discussions about birth control USA 18+ 36% 18% 39% 5% 2% USA 18-44 36% 17% 41% 4% 2% CAN 18-44 23% 15% 51% 7% 4% NETH 18-44 27% 14% 51% 6% 3% d. Chooses/chose the type of birth control USA 18+ 43% 23% 31% 2% 1% USA 18-44 42% 23% 33% 1% 1% CAN 18-44 29% 24% 43% 3% 2% NETH 18-44 30% 25% 39% 5% 1% F5. Do you think that (read each item) for preventing unplanned pregnancy, or not? (Do not rotate)

Based on those who are sexually active.

Yes No Not Applic.(Vol.) Not sure/Refused a. Your current or most recent partner was responsible enough USA 18+ 84% 11% 4% 1% USA 18-44 86% 12% 2% * CAN 18-44 87% 7% 4% 1% NETH 18-44 90% 6% 4% 1% All respondents asked. b. Most men are responsible enough USA 18+ 28% 70% * 2% USA 18-44 26% 73% * 1% CAN 18-44 31% 63% * 5% NETH 18-44 39% 44% 1% 16% F6. Why do you think most men are not involved in preventing unplanned pregnancy? (Multiple Record)

Based on those who do not think most men are responsible enough. Asked only in the U.S. USA18+ USA18-44 Female takes responsibility 4% 4% He feels it’s female’s responsibility 26% 28% He doesn’t care 41% 39% He doesn’t think it matters 9% 10% He is not educated 4% 4% He doesn’t become pregnant/not his body 14% 17% He wants to have a baby * 1% He doesn’t think partner needs birth control 1% 1% Other 11% 11% Not sure/Refused 4% 2%

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Surveys on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy:Survey Part One Part Two Part Three

Kaiser Family Foundation Surveys on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy in the United States, Canada, and the Netherlands1995

Unplanned pregnancy is a major problem facing Americans today. Approximately 3.5 million unplanned pregnancies occur each year in the United States. Women in the United States are almost twice as likely as women in Great Britain and three times as likely as women in the Netherlands to face an unplanned pregnancy.

Research has explored public opinion on these issues, but none has measured public knowledge. Hoping to help explain some of the variation in unplanned pregnancy rates between the U.S. and other developed nations, the Kaiser Family Foundation commissioned telephone surveys with adults in Canada, the Netherlands, and the U.S. to assess differences in public knowledge, opinions, and practices related to pregnancy and birth control. Canada was selected for comparison because it represents a culture similar to that of the United States, but has an unplanned pregnancy rate two-thirds that of the U.S. The Netherlands was selected because its culture is considered very different in its attitudes toward sexuality than the U.S. and it has an extremely low unplanned pregnancy rate — only one-tenth of the U.S. rate.

The three national telephone surveys were designed and analyzed by the Kaiser Family Foundation and Louis Harris and Associates, Inc. and conducted by Louis Harris and Associates, Inc. (A complete methodology is on the opposite page.) The surveys examined public knowledge of and attitudes toward issues related to unplanned pregnancy and contraception, including emergency contraception. Survey respondents were asked, for example, about such things as their perceptions about the magnitude of the problem of unplanned pregnancy in their country and their awareness of different contraceptive options.

Press releases have been issued from the data collected in the U.S. survey on public knowledge and attitudes about emergency contraceptive pills, abortion rates, men and contraception, teen sexuality and pregnancy, and other aspects of contraception and reproduction. To obtain the press releases and additional information on these topics, call the Kaiser Family Foundation’s publications request line at 1-800-656-4533.

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, and HIV policy inthe United States, and health and development in South Africa.

Methodology

The Kaiser Surveys on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy are three separate random-sample telephone surveys of adults ages 18 and older living in the United States, Canada, and the Netherlands. The survey was designed by the Henry J. Kaiser Family Foundation in association with Louis Harris and Associates, Inc.

The sampling procedure was designed to produce representative samples of adults in telephone households in all three countries. Random digit selection was used to assure equal representation ofpeople in households that are listed and “unlisted” in telephone directories. An effort was made to match interviewers of the same sex as the randomly selected respondents. Interviews were conducted in English and Spanish in the United States. For the Canadian and Dutch surveys, the survey instrument was translated into French and Dutch, using culturally appropriate wording, and back-translated into English for verification.

The U.S. sample consisted of 2,002 adults in the 48 contiguous United States (excluding Alaska and Hawaii) and was conducted between October 12 and November 13, 1994. The margin of error in the nationwide U.S. sample is plus or minus 2 percent and plus or minus 3 percent for respondents of “reproductive age,” that is men and women age 18-44 (1,140 respondents). The Canadian sample consisted of 1,002 adults and interviews were conducted between December 9, 1994 and January 3, 1995. The margin of error for the Canadian sample is plus or minus 3 percent and plus or minus 4 percent for respondents of reproductive age (594 respondents). The Dutch sample consisted of 1,001 adults and interviews were conducted between December 15, 1994 and January 19, 1995. The margin of error for the Dutch sample is plus or minus 3 percent and plus or minus 4 percent for respondents of reproductive age (536 respondents).

Questionnaire and Toplines

I. Gender of Respondents

USA18+ USA18-44 CAN18-44 NETH18-44 Male 50% 49% 51% 51% Female 50% 51% 49% 49% II. Age of Respondents

USA18+ USA18-44 CAN18-44 NETH18-44 18-29 21% 18-24 22% 20% 24% 30-49 43% 25-34 40% 42% 39% 50-64 18% 35-44 38% 39% 37% 65 and over 17% A. Talking with Your Doctor

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.)

A1. 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?

USA18+ USA18-44 CAN18-44 NETH18-44 Yes, discussed 21% 33% 34% 25% No, did not discuss 71% 63% 65% 73% Not applicable (Vol.) 9% 4% 1% 2% Not sure/Refused * * * * A2. Have you ever discussed birth control with a doctor or another health professional, or not?

Based on those who did not discuss or were not sure whether they discussed birth control with a doctor in the past two years.

USA18+ USA18-44 CAN18-44 NETH18-44 Yes, discussed 38% 40% 45% 36% No, never discussed 61% 60% 55% 62% Not applic. (Vol.) 1% * 2% * Not sure/Refused * * * * A3. Has a doctor ever been the one to raise the subject of birth control, or not?

Based on those who have discussed birth control with a doctor. Asked only in the U.S.

USA18+ Yes, doctor raised subject 32% No, doctor did not 67% Not sure/Refused 1% B. Information Sources

B1. 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)

USA18+ USA18-44 CAN18-44 NETH18-44 1. Health care professionals 63% 64% 68% 79% 2. Magazines 20% 23% 15% 13% 3. Your friends or peers 12% 14% 6% 5% 4. Television 11% 13% 8% 9% 5. Your family 9% 10% 5% 5% 6. Health and sex education courses in school 8% 10% 5% 3% 7. Reference books/medical journals/library 5% 5% 5% 3% 8. Church, clergyman 2% 2% * * 9. Newspaper 2% 2% * * 10. Planned Parenthood/ family planning agencies 2% 2% * * 11. Your spouse or partner 2% 2% 1% 1% 12. Pamphlets 1% 2% 2% 2% 13. Nowhere — don’t want/need/get any information 1% * 2% * 14. Other 3% 5% 13% 16% 15. Not sure/Refused 13% 9% 3% 8% C. Knowledge of Unplanned Pregnancy Problem

C1. Unplanned pregnancy is a pregnancy that a woman is not actively trying to have. It could be unintended, a mistake, unwanted, or not at the right time. Do you think unplanned pregnancies are a very big problem, a somewhat big problem, not a very big problem, or not a problem at all in your country?

USA18+ USA18-44 CAN18-44 NETH18-44 Very big problem 60% 60% 36% 6% Somewhat big problem 30% 33% 45% 35% Not a very big problem 5% 4% 13% 49% Not a problem at all 2% 2% 3% 4% Not sure/Refused 3% 1% 3% 5% C2. Compared with 10 years ago, do you feel the percentage of women in the your country who have unplanned pregnancies is now much higher, higher, about the same, lower or much lower?

USA18+ USA18-44 CAN18-44 NETH18-44 Much higher 27% 30% 14% 1% Higher 42% 42% 32% 13% About the same 20% 19% 28% 29% Lower 8% 7% 15% 45% Much lower 1% * 1% 5% Not sure/Refused 2% 1% 10% 6% C3. Do you feel that (Rotate: married women or unmarried women) are more likely to haveunplanned pregnancies?

Asked only in the U.S.

USA18+ Married women 9% Unmarried women 82% No difference (Vol.) 6% Not sure/Refused 2% C4. Do you feel that (Rotote: teenagers or women over the age of 19) are more likely to haveunplanned pregnancies?

Asked only in the U.S.

USA18+ Teenagers 86% Women over the age of 19 11% No difference (Vol.) 2% Not sure/Refused 2% C5. Do you think that (Rotate: Women in the United States or women in other developed countries, such as Canada, Great Britain or Germany) are more likely to have unplanned pregnancies?

Asked only in the U.S.

USA18+ United States 69% Other developed countries 11% Same (Vol.) 7% Not sure/Refused 13% C6. Would you say that (read each item) contributes to unplanned pregnancies very much,somewhat, or not at all?

Very Much Somewhat Not At All Not Sure/Refused a. A decline in moral standards USA 18+ 53% 36% 10% 1% USA 18-44 48% 40% 12% * CAN 18-44 29% 39% 28% 4% NETH 18-44 15% 33% 39% 12% b. Lack of education in general USA 18+ 48% 39% 12% 1% USA 18-44 46% 41% 13% * CAN 18-44 41% 38% 20% 1% NETH 18-44 16% 38% 44% 2% c. Lack of understanding about how to use birth control USA 18+ 27% 50% 22% 2% USA 18-44 26% 51% 22% * CAN 18-44 25% 45% 28% 2% NETH 18-44 14% 36% 47% 3% d. An inability to get birth control USA 18+ 21% 45% 33% 2% USA 18-44 21% 45% 34% * CAN 18-44 15% 36% 47% 2% NETH 18-44 13% 20% 64% 3% e. The cost of birth control USA 18+ 14% 40% 45% 2% USA 18-44 12% 40% 47% 1% CAN 18-44 14% 32% 49% 5% NETH 18-44 5% 29% 59% 7% f. A genuine desire to have children USA 18+ 12% 48% 37% 4% USA 18-44 11% 52% 36% 2% CAN 18-44 15% 37% 41% 7% NETH 18-44 8% 32% 42% 17%

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Surveys on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy:Survey Part One Part Two Part Three