8/3/2016

“To Be or Not to Be” Unintended Pregnancy & Emergency Contraception

Unintended Pregnancy

a Significant and Costly Public Health Issue

Kit S. Devine, DNP, WHNP WHNP--BC, APRN

Scope of the Problem

General Fertility Rates in US 1990--2014 1990 CDC/NCHS, National Vital Statistics System

System. System

Teens & Sex 

> 40% 1515-19yo sexually active



Majority report using condoms condoms, ocps ocps,, w/d (all methods with high failure rates)

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80% of teen pregnancies unintended

Background Rationale Even the most reliable contraceptive methods can fail ~ Condoms break or are forgotten ~ Pills run out and cost money to replace ~ Sexual activity may not be anticipated ~

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Collateral Costs of Unintended Pregnancy Higher risk for infant and child abuse (Nat’l

Not a New Problem !

In 1988, 56% of pregnancies were unintended

Academy of Sciences, 1995; DHHS, 2011)

(Forrest, 1994)

IOM Report (1995) concluded:

Higher off prepre-term birth Afable-Hi h iincidence id t bi th (Afable Munsuz & Braveman, 2008)

“the imposing “th consequences off unintended i t d d pregnancy are serious, i i i appreciable i bl burdens on children, women, men, and families. All pregnancies should be intended.” In 2011, less than 45% were unintended (Finer & Zolna, olna, 2016)

Higher incidence of IPV

(O’Donnell et al, 2009)

Less likely to receive prenatal care and breast feed (Joyce, Kaestner, & Korenman, 2000)

Healthy People 2020 “Unintended pregnancies are associated with many negative health and economic outcomes. Unintended pregnancies include pregnancies that are reported p by y women as being g mistimed or unwanted. In 2001, almost half of all pregnancies in the United States were unintended. The rate of unintended pregnancies declined significantly between 1987 and 1994; however, since then, the rate has remained stable.” DHHS, Healthy People 2020

Tragic Reality About 2 million unplanned pregnancies occur every year in the U.S. 42% of them lead to abortion (Finer & Zolna Zolna,, 2016)

Emergency Contraception Clinical Intervention to Address Unintended Pregnancy

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Evolution of Emergency Contraception 1974 -ECP developed ~ Yuzpe method (coc pills & progestin--only pills) progestin  1976 – copper IUD first used for EC

What Emergency Contraceptive Pills are

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midmid id-1980’s 1980’ – ECPs ECP used d in i some European E and d Asian A i countries  1997 -ECP approved by FDA (Rx) 

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2006 -FDA approved ECP (OTC) for women 18 and older

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2009 -FDA approved ECP (OTC) for women 17 and minors) older (remains by prescription for younger minors)

What ECPs are NOT 

Pharmaceutical (“medical”) abortion

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Intended for long term birth control

Synthetic hormones that block ovulation, prevent fertilization of an egg, and may prevent implantation if an egg has already been fertilized Described by scientists as “safer than aspirin” (PharmacyAccess Partnership, 2005)

Pharmacodynamics of ECP Progesterone agonist/antagonist (receptor modulator) which postpones follicular rupture and may alter endometrial thickness Will NOT adversely affect an existing pregnancy May delay or hasten next menses by 2.5 days

Characteristics of ECP       

Taken within 72 hours of IC, highly effective in PREVENTION of pregnancy (89%) “Ella” effective up p to 120 hours but requires q Rx Will not disturb an existing pregnancy Rare and minor side effects “Plan B” aka “Next Choice”~ not require HCP visit or Rx if >17yo Confidential ~ $35 “Plan B one one--step”, ~$38 “Next Choice” ~ $ 41“Ella”

Utilization of ECP in US Study of 7,643 American women age 1515-44 : 3% reported that HCP had discussed EC 4% reported IC ever had ever used EC 4% who saw GYN provider in previous year had counseling about EC

(Kavanaugh & Swarz, 2008)

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Most Often Counseled/Prescribed Victims of sexual assault who present to an ER Women who can access a family planning agency (Planned Parenthood, Family Planning clinics in health departments) and know to do so

Major Factor in Underutilization Lack of awareness and counseling in traditional women’s healthcare encounters among ALL providers!!!! Women’s lack of knowledge

(WHO -International Consortium for Emergency Contraception, 2010)

Intrauterine Devices Progesterone or Copper

Practice “Pearl” We should not assume that because a patient has been prescribed a certain method of contraception, she is consistently or correctly using it!

Mechanism of Action  Released

progesterone or copper alters cervical mucus that negatively affects sperm p and makes them immobile  The lining of the uterus is altered preventing implantation should fertilization occur

Advantages of IUDs/LARC (long(long-acting, reversible contraceptives) 

Highly effective

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Can be used in nulliparous adolescents

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Requires visit with clinician

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Endorsed by WHO, AWHONN, NPWH, AAP, ACOG ?????

?????

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Disadvantages of IUDs

A Project to Effect Change

 Requires

clinician visit ????  For EC, must be placed within 5 days of IC (WHO 2004) (WHO,2004)  Cost ($200($200-400)  May cause AUB and cramping  Minors would have to disclose in many instances (Skyla endorsed by AAP for young teens)

How Can APNs Foster Change? Examine attitudes and practices of providers who care for women  Increase knowledge of EC and its role in the prevention of unintended pregnancy and its sequelae ~ teach those who teach APNs  Promote best practices 

Design and Specifics of Project Goals: 

examine attitudes & practices regarding EC

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increase knowledge of EC

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promote best practices related to EC

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Create sustainable educational resources for APNs

Dual Approach to Project 

Pilot study to assess APNs’ knowledge and practice patterns re: EC (with repeated measures after education) 

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Pilot Study 

Dinner presentation EC - 11/29/11 (grant from Watson Pharm Pharm))

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Kaiser Permanente survey tool

IRB approval from Bellarmine University, #1111--2, 2011 #1111

Creation of curricular resources for distribution to graduate nursing programs

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Pretest familiarity with EC, % Not at all familiar Somewhat familiar Familiar Very familiar

Changes in Familiarity With EC

20 27 20 33

1 mo Post-test 1 familiarity with EC, % Not at all familiar Somewhat familiar Familiar Very familiar

0 13 53 33

Post-test 2 familiarity with EC, % Not at all familiar Somewhat familiar Familiar Very familiar

0 6.7 60 33

Results of Curriculum Provision (KY)        

Bellarmine UL WKU EKU UK Frontier NKU Spalding

Significant (p< .05) Results of Pilot Study

Familiarity with EC increased p=.021 EC will discourage routine oc use p=.36 Knowledge of when to take EC (two dose regimen) p=.05 EC will not cause BD in pregnancy p=.046

3 mo p=.029 p=.025 p=.018 p=.046

Increased knowledge but continued to have minimal knowledge of which meds were efficacious and modes of action

The Ireland Experience

yes yes y yes review review yes yes (vacant position)

Results of Curriculum Provision (Ireland (Ireland))

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Univ College Dublin

yes

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Dublin City Univ

yes



Univ of Limerick

yes

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Nat’l Univ Ireland/Galway

Prof. Carmel Bradshaw University of Limerick

probably

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Prof. Marianne Collins Limerick Maternity Hospital

Drs. Maria Healey & Abby Hyde University College of Dublin

Dr. Maura Dowling National University of Ireland/Galway

Summary 

More research on EC utilization needed, specifically with APNs

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Scholarly activities to increase awareness and correct misconceptions

Ultimate Goals :That Every Pregnancy Be Wanted and Every Child Treasured

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