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Position

  1. Top of page
  2. Position
  3. Background
  4. What is an EC?
  5. Availability of ECs
  6. Reasons for Suboptimal Use of ECs
  7. The Role of the Nurse
  8. REFERENCES

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) supports over-the-counter access to emergency contraceptives (ECs) without age restriction.

Background

  1. Top of page
  2. Position
  3. Background
  4. What is an EC?
  5. Availability of ECs
  6. Reasons for Suboptimal Use of ECs
  7. The Role of the Nurse
  8. REFERENCES

One-half of all pregnancies in the United States are unintended. For women 19 years and younger, more than 80% of pregnancies are unintended (Finer & Zolna, 2011). The rate of teen pregnancy is higher in the United States than in any other industrialized nation (United Nations, 2008). Reasons for unintended pregnancy include failure to use contraceptives, failure to use contraceptives correctly, unplanned consensual intercourse and rape (Devine, 2012).

The physical, social, and emotional implications of unintended pregnancy can be serious and long-term for the woman and her fetus. For example, compared to women who plan their pregnancies, women with unplanned pregnancies are at greater risk for preterm birth, postpartum depression, and physical abuse (National Campaign to Prevent Teen and Unplanned Pregnancy, 2008). Additionally, women who have unplanned pregnancies often do not receive preconception care. Evidence suggests that improving a woman's health before pregnancy (e.g., weight management and smoking cessation) can benefit the mother and infant. However, once a woman is pregnant, it may be too late to intervene. Even early prenatal care may not be enough to prevent certain health conditions (Centers for Disease Control and Prevention, 2006).

From social and economic perspectives, a woman who can delay the birth of her first child and plan the spacing of any subsequent children is less likely to drop out of school or live in poverty (Guttmacher Institute, 2004).

When pregnancies are properly spaced out, infant and maternal mortality can be reduced (World Health Organization [WHO], 2011). Contraceptive drugs and devices, including emergency contraception, allow women the option to space out or avoid pregnancies. Women who choose when and if to become pregnant protect themselves and their infants from the potential complications of unintended pregnancy, such as becoming pregnant while taking teratogenic medications or when a chronic illness is not properly managed (Ruhl, 2012).

What is an EC?

  1. Top of page
  2. Position
  3. Background
  4. What is an EC?
  5. Availability of ECs
  6. Reasons for Suboptimal Use of ECs
  7. The Role of the Nurse
  8. REFERENCES

Emergency contraceptives are available in two forms: an oral medication or a copper T intrauterine device (IUD). Both forms of ECs are safe and effective for preventing pregnancy after unprotected sex or contraceptive failure (Boonstra, 2002); however, the focus of this position statement is ECs in oral form.

Incorrectly referred to as the “morning after pill,” ECs can prevent pregnancy when taken up to five days after unprotected sex (Association of Reproductive Health Professionals, 2011). There are several different types of EC pills available in the United States that have varying degrees of effectiveness depending on the type of pill and when it is taken. While ECs may cause nausea, vomiting, headache, fatigue, abdominal pain, or unexpected bleeding, there are no serious or long term side effects (National Library of Medicine [NLM], 2011). In fact, the WHO stated that the benefits of EC pills outweigh the risks in all situations (2004). Emergency contraceptives are safe but are not recommended for routine contraceptive use because they are less effective at preventing pregnancies than most types of birth control (NLM).

Medical professionals consider a woman to be pregnant when a fertilized egg is implanted in the wall of the uterus (American College of Obstetricians and Gynecologists, 1998). The definition of pregnancy is important in understanding the distinction between contraceptives, which prevent pregnancy, and abortifaciant drugs (e.g. Mifepristone or RU-486), which terminate pregnancy. Emergency contraceptive pills primarily prevent pregnancy by delaying or inhibiting ovulation. Limited research also suggests that ECs alter the endometrium, but whether this change prevents a fertilized egg from implantation is not entirely understood (Association of Reproductive Health Professionals, 2011). Unlike Mifepristone, EC pills do not terminate or interfere with an established pregnancy (Trussell & Raymond, 2012).

Availability of ECs

  1. Top of page
  2. Position
  3. Background
  4. What is an EC?
  5. Availability of ECs
  6. Reasons for Suboptimal Use of ECs
  7. The Role of the Nurse
  8. REFERENCES

All EC pills are kept behind pharmacy counters, and certain brands are available without a prescription for women and men ages 17 or older. These brands require a prescription for anyone 16 or younger. Several states have enacted laws that allow women 16 and younger to access ECs directly from a pharmacist without visiting a health care provider for a prescription (Reproductive Health Technologies Project, 2010). In contrast, one type of EC pill, Ella (ulipristal acetate), has a different mechanism of action and is available by prescription only for all women regardless of age.

In 2011, the Center for Drug Evaluation and Research (CDER) at the Food and Drug Administration (FDA) reviewed the safety and efficacy data associated with Plan B One-Step, one type of EC pill, and concluded that the product was “safe and effective in adolescent females, that adolescent females understood the product was not for routine use, and…the data supported a finding that adolescent females could use Plan B One-Step properly without the intervention of a healthcare provider” (FDA, 2011, p. 1). However, CDER's conclusion about safety and efficacy was overruled by the Secretary of Health and Human Services. The data indicating that adolescents understand instructions on medical labels as well as adults were not regarded as determinative.

Reasons for Suboptimal Use of ECs

  1. Top of page
  2. Position
  3. Background
  4. What is an EC?
  5. Availability of ECs
  6. Reasons for Suboptimal Use of ECs
  7. The Role of the Nurse
  8. REFERENCES

The suboptimal use of ECs in the United States has been attributed to women's lack of awareness of and knowledge about EC use. For women that are aware of ECs, numerous challenges remain, including concerns about privacy, cost, and in some settings, the ability to find a pharmacy with EC pills in stock (Westley & Schwarz, 2012). Research suggests that health care providers also have a role in suboptimal EC use. Their lack of knowledge about ECs or discomfort with educating women and prescribing ECs has been demonstrated in several studies (Kelly, Sable, Schwartz, Lisbon, & Hall, 2008; Wallace, Wu, Weinstein, Gorenflo, & Fetters, 2004).

Despite the fact that low income women have a more than five times higher rate of unplanned pregnancy than women in the highest income brackets, some states have restricted access to ECs by excluding them from state mandated benefits or from Medicaid coverage (Finer & Zolna, 2011).

The Role of the Nurse

  1. Top of page
  2. Position
  3. Background
  4. What is an EC?
  5. Availability of ECs
  6. Reasons for Suboptimal Use of ECs
  7. The Role of the Nurse
  8. REFERENCES

AWHONN supports the protection of an individual nurse's right to choose to participate in any reproductive health care service or research activity (AWHONN, 2009). However, nurses have a professional responsibility to provide nonjudgmental nursing care to all patients, either directly or through appropriate and timely referrals. This responsibility includes ensuring that appropriate family planning education and services are provided to patients that cover the full range of family planning options (AWHONN).

Nurses who provide reproductive health care should ensure that women and adolescents receive comprehensive contraceptive education, including information on the use, indications, side effects, and ways to obtain ECs. Nurses can play an important role in correcting misconceptions about ECs and increasing awareness of their value and how they work to prevent pregnancy. Special attention should be given to teenagers and women who may not know to ask for ECs, including those seeking pregnancy testing or testing for sexually transmitted infections and those who have been raped (Westley & Schwarz, 2012).

Nurses can promote appropriate access to ECs by advocating their availability in their health systems, local health clinics, and hospital emergency departments. Nurses can learn about and advocate for state laws that promote appropriate access to ECs, especially for those in their states most likely to experience unintended pregnancy.

Rising rates of maternal morbidity and mortality in the United State increase the urgency for nurses to use all opportunities to counsel women about what they can do to plan and space pregnancies appropriately and facilitate their access to ECs and other contraceptive methods, thus decreasing their risks for pregnancy and birth complications (Ruhl, 2012).

REFERENCES

  1. Top of page
  2. Position
  3. Background
  4. What is an EC?
  5. Availability of ECs
  6. Reasons for Suboptimal Use of ECs
  7. The Role of the Nurse
  8. REFERENCES