Counseling for emergency contraception: time for a tiered approach
Typical counseling for emergency contraception (EC) does not take into account the relative effectiveness of the methods or client characteristics; new data and lessons from contraceptive counseling research suggest that it is time for this approach to change. The number of EC options available in the United States has grown in the last decade and now includes levonorgestrel (LNG) pills, ulipristal acetate (UPA) pills and a copper intrauterine device (IUD). Understanding of the relative effectiveness of EC options has also grown and is the subject of ongoing research. Similar to other contraceptive methods, there is a range of effectiveness for ECs, and user adherence impacts effectiveness .
More than for other contraceptives, the effectiveness of LNG and UPA pills differs by characteristics outside women's immediate control, such as body mass index (BMI) and the timing of ovulation. For example, Glasier et al.  showed that women are at a statistically significant increased risk of pregnancy after taking LNG or UPA when they:
- had a BMI ≥30 kg/m2 compared to a BMI <25 kg/m2,
- had unprotected sex the day before estimated ovulation compared to women outside their fertile window or
- had additional acts of unprotected intercourse after taking EC compared to women who did not.
For obese women, using LNG pills appeared to carry the same risk for pregnancy as taking no action. In contrast, the effectiveness of the copper IUD is similarly high (>99%) when used for emergency or interval contraception and does not vary with BMI . LNG effectiveness declines as the number of days after unprotected intercourse increases, with substantially diminished efficacy in days 4 and 5 . UPA and the copper IUD remain effective up to 5 days after unprotected intercourse [2, 3], and the copper IUD may be effective beyond 5 days .
While evidence on this topic continues to evolve, some are already integrating these findings into clinical practice guidelines. However, the American Academy of Pediatrics policy statement on EC (2012) has only one brief mention of the copper IUD as EC and says nothing about its efficacy compared to the alternatives . The US Centers for Disease Control and Prevention (CDC) Selected Practice Recommendations for Contraceptive Use (2013) do not include differences in the effectiveness of EC methods . The American College of Obstetricians and Gynecologists' Committee Opinion on EC (2012) emphasizes reducing barriers to all EC methods, but does not offer guidance on counseling .
Few women have perfect recall of their menstrual cycle, and the United States has a high and increasing prevalence of obesity, with 33% of women aged 15-C45 being classified by the CDC as obese (author's tabulation of 2006-C10 National Survey of Family Growth data). Both of these factors appear to affect the efficacy of LNG and UPA pills. Health care providers are women's most trusted source of information about EC  and have a unique opportunity to educate women presenting for EC about the relative effectiveness of their options. With a broader range of EC options, there is a need to explore counseling techniques, their impact on client knowledge and client preferences. Increasing evidence supports describing the effectiveness of contraceptive methods in categories or tiers for typical use, rather than by numeric failure rates . Studies included in this Cochrane review showed that this tiered approach improved client knowledge, and one study showed that clients preferred this method of contraceptive counseling .
Why not use a tiered approach with emergency contraceptive counseling? Fig. 1 shows a patient education tool based on the tiered approach developed by the University of California, San Francisco (UCSF) Bixby Center for Global Reproductive Health and Bedsider. Few providers offer the full range of EC options, with the copper IUD being the least accessible method . However, the tiered counseling approach is important even in settings where not all EC methods are available. In order for patients to give informed consent to use any type of EC, providers must inform them about all their options. Physicians cannot ethically restrict the treatments they discuss with patients to only those that they offer. A study in 40 Planned Parenthood clinics found that a majority of young women (69%) were interested to learn more about the copper IUD for EC . Studies of women presenting for EC in family planning clinics have shown that, when counseled on the full range of EC options, 11%-C40% choose a copper IUD [11, 12].
Fig. 1: A patient education tool for EC based on a tiered approach.
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The largest structural barriers to offering the copper IUD for EC are the method¡¯s high up-front cost and the need to offer same-day placement. Costs are changing as the Affordable Care Act expands Medicaid and private insurance coverage, albeit not uniformly across states or employers. Relatively few providers now offer same-day IUD insertion , but this is slowly changing with provider training initiatives and increasing evidence that same-day placement is safe [14, 15].
Some health care providers are early adopters of the copper IUD for EC and are now integrating a tiered approach to EC into their counseling. For example, Planned Parenthood Federation of America has developed the EC4U algorithm to help its affiliated providers communicate to clients that the copper IUD is always the most effective option for EC. Use of the algorithm is also designed to rule out provision of LNG or UPA pills to clients for whom they are likely to be ineffective. Several members of the National Family Planning & Reproductive Health Association have started offering the copper IUD as EC and using a tiered counseling approach. Early unpublished results from these pilot tests show that it is feasible to offer the copper IUD as EC using a tiered counseling approach in a range of different contraceptive care settings and that clients chose this method when it was offered to them in this way.
We believe that there are several reasons to use a tiered approach for EC counseling, and we want to determine its impact on patient knowledge and health outcomes. Researchers at the UCSF Bixby Center are testing this patient education tool; others should consider testing additional tiered approaches to EC counseling. Funders have an important role in supporting this operations research, both to expand the evidence base about what works to reduce unintended pregnancy and to change clinical practice. Clinicians and health educators with experience using these and other tiered counseling approaches can provide important insights. Ultimately, we learn that a tiered approach to EC counseling improves client knowledge and is preferred; the efforts of clinicians, health educators, practice leaders and professional organizations will all be needed to shift clinical practice.
- Glasier, A., Cameron, S.T., Blithe, D., Scherrer, B., Mathe, H., Levy, D. et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011; 84: 363-C367
- Cleland, K., Zhu, H., Goldstuck, N., Cheng, L., and Trussell, J. The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience. Hum Reprod. 2012; 27: 1994-C2000
- Glasier, A. Emergency contraception: clinical outcomes. Contraception. 2013; 87: 309-C313
- Turok, D. Copper T380 intrauterine device for emergency contraception: highly effective at any time in the menstrual cycle. Hum Reprod. 2013; 28: 2672-C2676
- Committee on Adolescence. Emergency contraception. Pediatrics. 2012; 130: 1174-C1182
- Centers for Disease Control and Prevention (CDC). U.S. selected practice recommendations for contraceptive use. MMWR Recomm Rep. 2013; 62: 1-C60
- Committee on Health Care for Underserved Women. ACOG committee opinion number 542: access to emergency contraception. Obstet Gynecol. 2012; 120: 1250-C1253
- Harper, C.C., Thompson, K.M., Rocca, C., Darney, P., Trussell, J., and Speidel, J.J. The copper IUD for EC: have young women at risk of unintended pregnancy heard of the most effective form of emergency contraception?.Presented at the American Public Health Association annual meeting. San Francisco, CA, ; 31 October 2012
- Lopez, L.M., Steiner, M., Grimes, D.A., Hilgenberg, D., and Schulz, K.F. Strategies for communicating contraceptive effectiveness. Cochrane Database Syst Rev. 2013; 30: CD006964
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- Schwarz, E.B., Papic, M., Parisi, S.M., Baldauf, E., Rapkin, R., and Updike, G. Routine counseling about intrauterine contraception for women seeking emergency contraception. Contraception. 2014; 90: 66-C71
- Biggs, M.A., Arons, A., Turner, R., and Brindis, C.D. Same-day LARC insertion attitudes and practices.Contraception. 2013; 88: 629-C635
- Sufrin, C.B., Postlethwaite, D., Armstrong, M.A., Merchant, M., Wendt, J.M., and Steinauer, J.E. Neisseria gonorrheaand Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol. 2012; 120: 1314-C1321
- Wang, N.A., Papic, M., Parisi, S.M., Baldauf, E., Rapkin, R., and Schwarz, E.B. Same-day placement of intrauterine contraception for high-risk women. Obstet Gynecol. 2014; 123: 15S