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

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.

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

National Survey of Public Opinion on Welfare: Views of Americans With or Without Welfare Experience

A report from the Kaiser-Harvard program on the Public and Health/Social Policy on differences in opinions of Americans with welfare experience compared with those without such experience on the welfare system and welfare reform. This report represents further analysis of the Kaiser/Harvard random-sample national survey of 1200 adults, conducted December 27 and 29, 1994, on public knowledge and attitudes about welfare (see #1001).

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.

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

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

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:

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.

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.

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)