Key words
emergency contraception - emergency department - levonorgestrel - ulipristal acetate
Schlüsselwörter
Nofallkontrazeption - Notfallambulanz - Levonorgestrel - Ulipristal-Acetat
Introduction
Hormone-based emergency oral contraceptives are currently available in over 140 countries
worldwide and do not require a prescription in 44 of them [1]. This pill should be taken within 72 hours of unprotected sex and within 5 days
for the newer drugs [2]. Consequently, round-the-clock prescribing is not absolutely necessary, even at
weekends, for example in emergency departments; however for the women/couples affected,
it is preferable for peace of mind.
Current studies show that the (correct) taking of an emergency contraceptive after
unprotected sexual intercourse can prevent an unwanted pregnancy with a success rate
of up to 94 % [3].
The broader use of the “morning-after pill” may be able to prevent more unwanted pregnancies
and especially terminations.
The morning-after pill, as it is known, is currently being prescribed around 400 000
times per year in Germany [4]. In 2007, a survey of girls in Germany who stated they had had sexual intercourse
on more than one occasion revealed that 12 % of them had already taken an emergency
contraceptive [5].
The aim of this study was to analyse the uptake of services in the emergency department
of a major city in relation to the “morning-after pill”. The data analysis focused
on three main questions:
-
What can be determined from the age, insurance status and migration background of
the (potential) users of the “morning-after pill” (socio-demographic profile)?
-
When is the emergency department used to obtain a prescription for emergency contraceptives
(chronological profile)?
-
What reasons do the women give for needing emergency contraception (motivational profile)?
Methods and Patient Collective
Methods and Patient Collective
A retrospective analysis was carried out of all the triage sheets in the emergency
department of the Campus Virchow Hospital/Charité University Hospital, Berlin, over
a four-year period from 2007 to 2010 that were coded with the ICD diagnosis Z30 (= contraception
advice). As a relatively standardised documentation sheet, the triage sheets are created
on computer as part of the care process. They contain details of the reason for and
the time of the attendance, the history taken, the course of medical consultation
and any investigations and treatment carried out. The triage sheets also document
administrative data relating to the patientʼs insurance status, address and nationality.
It is however acknowledged that these details do not provide adequate information
about any migration background. On the other hand, most German hospitals document
virtually no other administrative data regarding the migration history. Consequently,
a supplementary surname analysis was used to
attempt to determine whether there might be a migration background. The surname analysis
is a valid method in migration research which, in the absence of other indicators
or documentation of additional information, allows relatively reliable differentiation
of the largest migrant groups [6], [7]. It provides good indicators of ethnicity, but not the duration of the migration
or the migration generation.
Inclusion and exclusion criteria: Only women who were given counselling regarding
emergency contraception by a doctor in the emergency department of the Campus Virchow
Hospital/Charité were included in the study.
Women who wanted a prescription for their usual oral contraceptive, who attended due
to problems with their intra-uterine pessary, etc., were excluded from the study.
Also excluded were all cases of prescriptions for emergency contraception given in
the context of sexual assault.
Results
Out of the total of 1030 triage sheets marked with the diagnosis “Contraception advice”,
170 had to be excluded from the data analysis for the reasons set out above, which
means that ultimately 860 cases remained for analysis and descriptive data representation.
Socio-demographic profile: The mean age of women who attended the emergency department wanting to obtain the
“morning-after pill” was 25.1 years (range 14–57, median 24 years). 79 % of women
had statutory insurance, and 21 % had private insurance or were self-paying. Historical
details regarding parity were available for fewer than half of the women in the study
collective: 79 % had no children, 12 % had one child and 8 % had a least two children.
It is assumed from this that the proportion of users with a migration background accounted
for around 43 % of the overall collective.
Chronological profile: Out of the 860 consultations for emergency contraception, the majority took place
at the weekend (ranking of the three busiest days: Saturday, Sunday, Friday). The
number of prescriptions issued during the week was significantly lower by comparison
([Fig. 1]). There was also evidence of fluctuations based on the time of day, regardless of
which day of the week it was: by far the largest number of women attended between
midday and 6 p. m. to seek advice and possibly obtain a prescription ([Fig. 2]). If the seasonal prescribing frequency is also considered, during the 4-year period
over which the study extended, the months of May, July and December were found to
have a slightly higher rate of prescribing ([Fig. 3]).
Fig. 1 Prescribing frequency/frequencies of emergency contraceptives according to day of
the week.
Fig. 2 Number of cases registered in relation to various times of the day.
Fig. 3 Average daily prescribing frequency of the “morning-after pill” in the emergency
department during the study period, by month.
In 729 out of 860 cases (84.8 %), details of the time that had elapsed since the unprotected
intercourse and the attendance at the emergency department for a prescription of an
emergency contraceptive were documented. [Fig. 4] shows that around half of the women who attended the department did so within 12
hours of having had sex.
Fig. 4 Presentation of users to the rescue point depending on the time since unprotected
sexual intercourse (in %).
Motivational profile: The three main reasons cited by the women who attended for wanting emergency contraception
were (ranking): (1) unprotected sexual intercourse, (2) condom failure and (3) forgetting
to take their usual oral contraceptive ([Fig. 5]). The “Others” category in the figure includes rare cases in which it was assumed
that the usual oral contraceptive was impaired due to the simultaneous use of antibiotics,
or when a Nuva-Ring® had been used incorrectly.
Fig. 5 Distribution of reasons given for the need for emergency contraception (n = 631,
in %).
During the 2007–2010 study period, only two drugs were prescribed for emergency contraception
at the Berlin emergency department: levonorgestrel (Unofem®) and ulipristal acetate
(EllaOne®). [Fig. 6] shows the prescribing frequency of Unofem® and EllaOne® for each quarter between
2007 and 2010. Since the market launch of EllaOne® marketing at the end of the third
quarter of 2009, both preparations have been offered at the end of each consultation,
and the patient then decides herself. All in all, emergency contraception with ulipristal
acetate accounts for only a small proportion of the prescriptions; the levonorgestrel
preparation is accordingly the drug of choice in everyday clinical practice.
Fig. 6 Comparison of prescribing frequency/frequencies of Unofem® and EllaOne® between 2007
and 2010 (market launch of EllaOne® around mid-2009).
14 out of 860 women (1.63 %) decided against obtaining a prescription for emergency
contraception following their consultation with the doctor.
Discussion
There are no current systematic studies from the field of healthcare research on the
“morning-after pill” in Germany. Our retrospective study uses routine data to present
information regarding user profiles, motives for use and the usage of services in
a (major city) emergency department.
The data analysis shows that during the analysis period from 2007 to 2010, the emergency
department at the Charitéʼs Virchow Hospital Campus in the centre of Berlin was primarily
used for the prescription of the “morning-after pill” at the weekend. The prescribing
frequency in German general practices follows the results of the prescriber® study,
which systematically and exclusively surveys prescriptions by general practitioners
in Germany, virtually exactly. There is a “prescribing peak” on a Monday, while the
prescribing frequency over the following weekdays is lower; at the weekend, the number
of prescriptions for the “morning-after pill” issued by general practitioners is lowest
in line with the usual opening hours of doctorsʼ practice [4].
Our study results on the time of day that the services are used also show that many
women clearly attend the rescue point at times that suit them, i.e. during the day
between midday and 6 p. m. Since the studies from the 1990s that indicate the effectiveness
of emergency contraception reduces in a linear fashion to the time after unprotected
sexual intercourse [8] have not been confirmed, rather a recent review demonstrates excellent effectiveness
for levonorgestrol or ulipristal acetate up to 72 or 120 hours later [9], this can also be tolerated.
Checa et al. (2004) reported seasonal variations in the prescribing frequency of/demand
for emergency contraception. The demand for the “morning-after pill” in an emergency
department in Barcelona/Spain was evidently higher in the months of July and August
than in the other months. They explain this with corresponding fluctuations in sexual
activity. This may also explain peaks in demand around the weekend [10].
The average age of the users is 25.1 years, within the same range of European publications
on the same subject (Edinburgh: 26 years [1]; Barcelona: 23 years [10]; Madrid: 23 years [11]).
A migration background can be assumed for a significant proportion (43 %) of women
who attended the emergency department for a prescription of the “morning-after pill”.
Current statistics from the Berlin Senate indicate that 24.9 % of the female population
of the city has a migration background. In the Berlin inner city district of Mitte/Wedding,
which is where the Charité emergency department/Virchow Hospital Campus is located,
this percentage is even higher; here, around 44 % of the women of childbearing age
are believed to be migrants [12].
A current representative study by the German Centre for Health Education (BZgA) reports
that only 37 % of the Turkish women surveyed knew about the “morning-after pill” as
a form of emergency contraception, whereas 61 % of the 820 Eastern European migrants
and 94 % of the West German women surveyed knew about it. This knowledge is dependent
on the migration generation and education [13]. A further and more detailed breakdown of our data according to ethnicity was unfortunately
not possible due to the limited data available. Ward et al. (2010) also reported a
significant relationship between marked cultural adaptation (known as acculturation),
income and education with the awareness and use of emergency contraception among young
female migrants of Hispano-American origin in the USA [14].
The most common reason given for wanting the morning-after pill in the Berlin emergency
department was “unprotected sexual intercourse”, followed by condom failure. Similar
surveys in emergency departments in other European countries unsurprisingly also see
these two reasons as the two most common ones; the order in these countries varies
according to the customary frequency with which condoms are used, with the figures
for this reason varying between 42 and 91 % [1], [10], [11], [15].
Lukic et al. (2000) rightly point out that women who present only to a emergency department
for advice on and a prescription for emergency contraception may in individual cases
be given only limited information about how the morning-after pill is used and its
side effects due to the particular staffing and clinical demands of this setting and
due to the understandable priorities of the doctors/gynaecologists who work there,
as well as possibly longer waiting times [16].
One alternative would otherwise be simply to dispense with or at least relax the prescribing
requirement for the “morning-after pill”, as is already the case in many European
countries and the USA [1], although this is a move that is currently being vehemently rejected by the German
Association of Gynaecologists, for example [17].
Conclusion for Clinical Practice
Conclusion for Clinical Practice
The data presented illustrate that counselling about and the prescription of the “morning-after
pill” following the provision of the relevant information represents a significant
element of the range of duties of an emergency department as an important point of
contact, especially at the weekend. Women requesting this service should be given
adequate advice and support in accordance with their individual situation.
