Key words emergency contraceptive pill - women requesting pregnancy termination
Schlüsselwörter Pille danach - Frauen - die Abtreibung verlangen
Introduction
A reduction of the unintended pregnancy rate is a national health priority. Abortion
rate (i.e. the number of abortions per 1000 women of reproductive age) in Hungary
fell significantly from 35.6 in 1990 to 19.1 in 2006 in Hungary [1 ]; the corresponding data are lowest in Germany and Switzerland worldwide (≈ 7 per
1000 women in 2008) [2 ], [3 ]. Although more than every fourth pregnancy (28.2 %) in Hungary leads to abortion
[1 ], emergency contraception (ECP) has not yet been introduced as non-prescription medication,
highlighting the need for comprehensive medical counseling. The annual number of prescriptions
in Hungary is quite low, amounting to only approximately 25 000 (annual ECP use per
capita: 0.0025) (in-house statistics of the pharmaceutical company Richter, whereas
ECP is prescribed in Germany far more frequently, totaling about 400 000 prescriptions
per year [annual ECP use per capita: 0.00491]) [1 ], [3 ]. Although ECP is used to reduce the risk of pregnancy after unprotected intercourse
[4 ], [5 ], its OTC availability did not reduce abortion rate in the UK [6 ].
Awareness of ECP is not sufficient to use it [7 ]: recognition of the need and the knowledge of how to receive it are also important
factors. As far as the literature is concerned, there have been relatively few analyses
of the factors which promote the use of ECP rather than simply not applying any backup
contraceptive method after unprotected sexual contact. The purpose of this study was
to determine the factors influencing “the appropriate knowledge” [8 ] (i.e. the awareness of how to receive ECP and by what time it should be taken following
unprotected intercourse) through a comparison of ECP users with those who requested
abortion, in terms of contraceptive knowledge, attitude and specification.
Materials and Methods
Participants
In 2006, 940 (78.0 %) out of 1205 women taking ECP and 1592 (88.7 %) out of 1794 consecutively
recruited women requesting abortion voluntarily completed an anonymous multiple choice
questionnaire at a university hospital in Hungary.
Data collection
This structured, self-reported Hungarian-language questionnaire recorded the age,
type of residence, marital status, level of education, number of previous pregnancy
terminations and the number of live births of the recruited participants, and information
about their contraceptive use in the cycle when ECP had been used or in the cycle
resulting in their procured abortion (at the time of conception). The questions about
ECP dealt with their awareness of ECP (i.e. whether they know that ECP exists), their
knowledge of the time limit (i.e. an ECP can be applied within 3 days after an unprotected
sexual intercourse), the way to obtain ECP (i.e. through a prescription provided by
a gynecologist/general practitioner [GP]), previous ECP use and intended prospective
use of ECP. In Hungary, ECP containing levonorgestrel was available by prescription
during the time of the study. Method failures were considered according to WHO guidelines
on ECP use [4 ], [5 ] in the ECP group, and contraceptive method use is distinguished as patient and method
failures (when appropriate) in the termination of pregnancy sample. Patient failure
was justified when condom broke or slipped or the patient reported ejaculation in
the vagina or miscalculation of the abstinence period or missing to take pills in
time or delay in placing the vaginal ring.
Statistical analysis
Data were entered and analyzed by means of the statistical software package SPSS 17.0
(SPSS Inc., Chicago, IL, USA). Univariate comparisons were assessed by the unpaired
t-test and the χ2 test, while a logistic regression model was constructed to evaluate the factors simultaneously
influencing “the appropriate knowledge” [8 ] of ECP use. P-values < 0.05 were considered to be statistically significant. The
medical ethics committee of the University of Szeged had approved the study. Informed
consent was obtained from all participating women and from the legal guardians of
minors under 18 years of age. The study was carried out according to the principles
of the Declaration of Helsinki.
Results
Sociodemographic data and contraceptive use
The sociodemographic characteristics and contraceptive methods of the respondents
in the ECP group and women requesting abortion are detailed in [Table 1 ]. Women who sought abortion were significantly older than ECP users (median age in
the ECP group was 22 vs. 29 years in the abortion group) and a larger proportion of
them lived with a spouse (4.6 % in the ECP group vs. 49.6 % in the abortion group,
p < 0.001). Significantly more urban residents used ECP (80.4 % in the ECP group vs.
59.9 % in the abortion group, p < 0.001), whereas the two groups were similarly educated.
The percentage of women having at least one child was significantly higher in those
seeking abortion than in the ECP group (16.7 % in the ECP group vs. 35.0 % in the
abortion group, p < 0.001). Similary, the number of previous abortions was significantly
higher in their population compared to the ECP group (19.5 % in the ECP group vs.
55.6 % in the abortion group, p < 0.001). More ECP usersʼ partners wore a condom (59.4 %
in the ECP group vs. 26.4 % in the abortion group, p < 0.001) at the time of conception,
whereas combined oral contraceptives were almost equally used in the two groups (11.0 %
in the ECP group vs. 11.9 % in the abortion group, p > 0.05). More respondents in
the abortion group had experienced problems with periodic abstinence techniques (3.0 %
in the ECP group vs. 28.0 % in the abortion group, p < 0.001) or withdrawal (11.7 %
in the ECP group vs. 23.1 % in the abortion group, p < 0.001). Contraceptive ring,
patch and injection, intrauterine device, spermicides and vaginal douche were not
represented among those who used ECP, but these methods were employed by a small number
of the women who sought abortion. Only 13 women who requested abortion (0.8 %) had
used ECP unsuccessfully after the contraceptive mishap. The male partners of seven
(54 %) used a condom and 3 (23 %) of them had not had recourse to any method for occasional
intercourse, 2 (15.4 %) of them had experienced failure while taking OC, and one (7.7 %)
of them had a coitus interruptus failure.
Table 1 Sociodemographic and contraceptive characteristics of women attending for an ECP
prescription (ECP group, n = 940) or requesting pregnancy termination (n = 1 592)
at the Department of Obstetrics and Gynecology, University of Szeged, Hungary (January
1, 2005 – November 20, 2006).
Respondents in ECP group (n = 940)
Respondents in abortion group (n = 1 592)
p-value
OR (95 % CI)‡
n
%
n
%
† Patient failures are grouped according to WHO guidelines on ECP use [4 ], [5 ] in the ECP group, and contraceptive method use is distinguished as patient + method
failures (when appropriate) in the termination of pregnancy sample.‡ OR: Odds ratio, 95 % CI: 95 % confidence interval.
Demographic characteristics
Age
21.3 ± 4.0
28.0 ± 5.1
< 0.001
Urban residency
756
80.4
954
59.9
< 0.001
2.75 (2.27–3.32)
Living with a partner
43
4.6
790
49.6
< 0.001
0.05 (0.03–0.07)
Educational level
n. s.*
165
17.6
298
18.7
509
54.1
858
53.9
266
28.3
436
27.4
Previous induced abortion
183
19.5
885
55.6
< 0.001
0.19 (0.16–0.23)
Previous birth
157
16.7
557
35.0
< 0.001
0.37 (0.30–0.45)
Contraceptive failure at unprotected intercourse leading to ECP use or pregnancy termination†
Combined oral contraceptive
103
11.0
102 + 88
11.9
n. s.*
0.91 (0.70–1.17)
Progesterone-only pill
6
0.6
18 + 16
2.0
0.006
0.31 (0.13–0.75)
Intrauterine device
0
0
50
3.1
< 0.001
1.03 (1.02–1.04)
Contraceptive ring
0
0
1 + 8
0.6
0.031
1.01 (1.01–1.01)
Contraceptive patch
0
0
1
0.1
n. s.*
1.00 (0.9–1.01)
Contraceptive injection
0
0
1
0.1
n. s.*
1.00 (0.9–1.01)
Condom
558
59.4
216 + 205
26.4
< 0.001
4.06 (3.42–4.82)
Withdrawal
110
11.7
94 + 273
23.1
< 0.001
0.44 (0.35–0.56)
Periodic abstinence
28
3.0
191 + 254
28.0
< 0.001
0.08 (0.05–0.12)
No method
135
14.4
68
4.3
< 0.001
3.76 (2.77–5.09)
Spermicides
0
0
5
0.3
n. s.*
1.01 (1.0–1.01)
Vaginal douche
0
0
1
0.1
n. s.*
1.00 (0.9–1.01)
Knowledge, attitudes, and use of ECP
[Table 2 ] presents an overview of the ECP-related questions. An important finding was that
the study groups had applied the ECP similarly at an early stage (33.0 % in the ECP
group vs. 31.5 % in the abortion group, p > 0.05), though awareness was lower among
women who sought abortion (p < 0.001). As expected, knowledge of correct timing (77.9 %
in the ECP group vs. 59.0 % in the abortion group, p < 0.001) and the ability to obtain
ECP (78.9 % in the ECP group vs. 20.0 % in the abortion group, p < 0.001) were also
significantly more favorable among ECP users. A positive attitude toward ECP use was
generally expressed in both groups, despite the fact that many abortion seekers (n = 759)
had not realized the need for ECP (this amounts to 48 % as patient failures that might
have been avoided through the use of ECP). The women who presented for abortion and
who had previously used ECP were asked about the reason for not using it this time:
the most important motivations were that they had not realized the need for using
ECP and the neglect of the possibility of conception (data are not shown in table),
as described in a Swedish study [9 ], [10 ].
Table 2 ECP-related questions answered by women attending for an ECP prescription (ECP group,
n = 940) or requesting pregnancy termination (n = 1 592) at the Department of Obstetrics
and Gynecology, University of Szeged, Hungary (January 1, 2005 – November 20, 2006).
Respondents in ECP group (n = 940)
Respondents in abortion group (n = 1 592)
p-value
OR (95 % CI)†
n
%
n
† OR: Odds ratio, 95 % CI: 95 % confidence interval.‡ Appropriate knowledge of ECP: awareness of how to obtain ECP and when it must be
taken after unprotected intercourse, i.e, both questions were correctly answered [8 ].
Questions relating to the knowledge, attitudes, and use of ECP
Awareness of ECP
940
100
1 400
87.9
< 0.001
1.14 (1.12–1.16)
Previous ECP use
310
33.0
501
31.5
n. s.*
1.07 (0.9–1.27)
Knowledge of time limit for ECP treatment
732
77.9
939
59.0
< 0.001
2.45 (2.04–2.94)
Knowledge of how to obtain ECP
742
78.9
319
20.0
< 0.001
14.9 (12.2–18.2)
Good knowledge of ECP‡
594
63.2
682
42.8
< 0.001
2.3 (1.9–2.71)
Intended future ECP use
634
67.4
1 212
76.1
< 0.001
0.65 (0.54–0.77)
Source of information for ECP
[Table 3 ] lists the data relating to the acquisition of information regarding ECP. The sources
of information were significantly different in the two groups; the media, friends
and health-care providers were identified as the main sources of information concerning
ECP by most respondents.
Table 3 Source of information regarding ECP of women attending for an ECP prescription (ECP
group, n = 940) or requesting pregnancy termination (n = 1 592) at the Department
of Obstetrics and Gynecology, University of Szeged, Hungary (January 1, 2005 – November
20, 2006).
Respondents in ECP group (n = 940)
Respondents in abortion group (n = 1 592)
p-value
OR (95 % CI) †
n
%
n
%
† OR: Odds ratio, 95 % CI: 95 % confidence interval.‡ Source of information was asked from those who had ever heard of ECP (n = 1 400)
in the termination of pregnancy group.
Source of information for ECP‡
Friends
442
47.0
588
42.0
0.02
1.23 (1.04–1.45)
Family
123
13.1
20
1.4
< 0.001
10.4 (6.42–16.8)
Sexual partner
70
7.4
8
0.6
< 0.001
14.0 (6.70–29.8)
Gynecologist
138
14.7
712
50.9
< 0.001
0.17 (0.13–0.20)
Other health-care providers
386
41.1
235
16.8
< 0.001
3.45 (2.85–4.18)
Printed media
208
22.1
25
1.8
< 0.001
15.6 (10.22–23.8)
Electronic media
630
67.0
944
67.4
n. s.*
0.98 (0.82–1.17)
School, education
208
22.1
19
1.4
< 0.001
20.6 (12.8–33.3)
Appropriate knowledge about ECP of women requesting pregnancy termination
Multivariate logistic regression analysis revealed that previous ECP use (adjusted
odds ratio [AOR]: 4.01, 95 % CI: 2.31–6.54) and the information primarily obtained
from electronic media (AOR: 3.29, 95 % CI: 1.48–5.20), health-care providers (AOR:
3.91, 95 % CI: 1.83–7.22) and sexual education in school (AOR: 1.83, 95 % CI: 1.11–3.21)
promoted “the proper knowledge” of ECP usage among the abortees most significantly.
The contraceptive failure with a condom was also related to a higher knowledge of
the correct management of access to ECP (AOR: 2.1, 95 % CI: 1.83–3.82). Higher age
(AOR: 1.3, 95 % CI: 1.05–1.89) and living without a partner (AOR: 5.55, 95 % CI: 2.77–9.09)
made the awareness of the correct management of ECP use more likely ([Fig. 1 ]).
Fig. 1 Logistic regression model on “the appropriate knowledge” about ECP of women requesting
pregnancy termination (n = 459) at the Department of Obstetrics and Gynecology, University
of Szeged, Hungary (January 1, 2005 – November 20, 2006). Correct answers to both
questions (the timeframe of use of ECP and the method of obtaining it) among women
seeking abortion [8 ]. Data were adjusted for age.
Discussion
Our more striking results are that ECP users favor different contraceptive methods
(predominantly barrier method, withdrawal and patient failure with OC) than abortion
seekers (periodic abstinence, withdrawal and condom) which reflect mainly the different
sociodemographic characteristics of the groups. The contraceptive patterns of ECP
users in Hungary differ in Germany where ECP is prioritized mainly after an unprotected
intercourse (55 %), condom failure (34 %) and method failure of OC usage (10 %) [11 ]. ECP proved to be preferred by young women in our region as in Germany [11 ], but in contrast with the finding of Sørensen et al. [12 ] that ECP users were generally older than women with an unwanted pregnancy after
unprotected intercourse. Furthermore, education was not a distinguishable factor in
opting for ECP, likewise in contrast with the conclusion of the Danish study [12 ]. Moreover, abortion seekers were more likely to be unaware of ECP as a backup method
and were not well informed upon the availability of the ECP, whereas more ECP users
lived in an unstable relationship. By contrast, previous use of ECP was of similarly
low prevalence in the two groups.
Gaining information from reliable sources (education, health-care providers and media
campaigns) was an important influential factor promoting a good knowledge about the
management of ECP use, which seems to be in contrast with the literature findings
[13 ], [14 ]. It seems that condom users know the correct employment of the ECP as in a French
study [15 ], and they commonly live without a partner (503 out of 558 [90.1 %] lived without
a spouse, not presented in the tables). Our logistic regression demonstrated that
correct knowledge of ECP was promoted by a higher age and previous ECP use.
The prescription status of ECP might act as a moderate obstacle to access ECP in Hungary
in view of the small number of abortion seekers who had administered it. Interestingly,
almost half of the abortion seekers (43 %) experienced a contraceptive failure that
might have been avoided if they had sought ECP (i.e. patient failure of the contraceptives),
even though the vast majority (87.9 %) were aware of ECP, as in other countries [8 ], [12 ], [16 ], [17 ], and nearly one-third of them (31.5 %) might even have been able to prevent a contraceptive
mishap since they used ECP before. Although the female population requesting abortion
in Hungary [7 ] is aware of the ECP, specific knowledge of the time span between unprotected intercourse
and access to ECP usage is rather poor among women who sought abortion, as in Sweden
[9 ]. Altogether, these data suggest that more effective and individual contraceptive
counseling is required after abortion, exploring factors associated with the contraceptive
problem. Such tailored counseling including advice on future ECP use should focus
on contraceptive mishaps appropriate for seeking ECP, timing-related efficacy of ECP
use after unprotected intercourse and the awareness about the procedure to obtain
the drug, since 76 % of the abortion seekers intended to use it in the future, but
only 20 % knows how to receive it. Similarly, Siebert and Steyn found that women requesting
pregnancy termination were on average highly educated, but had a poor knowledge of
ECP and were ill-informed about contraception, while teenagers were most at risk [12 ].
Failure rate of ECP in our study was only 1.38 % (13 out of 940), which corresponds
to a literature finding (1.5 %) [5 ].
As in a Swedish study [9 ], discussions with health-care providers and the electronic media may promote more
preventive behavior, and apart from this, health education at school is cited very
frequently in Hungary. Other potential sources should therefore be concentrated on,
so as to increase public awareness and the use of ECP.
Apart from limited access, the obstacles to ECP use such as low awareness and doubtful
attitudes have been eliminated, but the predominant persisting obstacle is the unawareness
of the risk of pregnancy. The main outcome of our study is that the recognition of
the need for ECP by the patients seeking abortion is strikingly deficient, as reported
by other authors [9 ].
Conclusions for Clinical Practice
Conclusions for Clinical Practice
Only few abortion seekers had used ECP and they did not recognize the need of the
ECP in most of the cases, even though they were aware of it and had a positive attitude
towards it. Like Larsson et al. [9 ], we suggest that new contraceptive counselling strategies should be developed for
women presenting for induced abortion, providing them with the details of appropriate
ECP use so as to avoid unwanted pregnancy in the future.
It would be beneficial to improve public knowledge about the timing-related efficacy
of the ECP and the contraceptive failures for which ECP can be used. A specific media
campaign is required, targeting women of advanced age and who have experienced a previous
unwanted pregnancy, focusing on the fertility risk with contraceptive failure and
the usefulness of ECP.
