American Journal of Obstetrics and Gynecology (2004) 191, 150e6
www.elsevier.com/locate/ajog
Knowledge of emergency contraception among women aged 18 to 44 in California Diana G. Foster, PhD,a,* Cynthia C. Harper, PhD,a Julia J. Bley, MPH,a John J. Mikanda, MD, MPH,b Marta Induni, MA,c Elizabeth C. Saviano, RN, MSN, JD,d Felicia H. Stewart, MDa Center for Reproductive Health Research and Policy, University of California, San Franciscoa; Office of Family Planning, California State Department of Health Servicesb; Survey Research Group, Public Health Institutec; Consultant,d San Francisco, Calif Received for publication September 2, 2003; revised December 28, 2003; accepted January 6, 2004
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– KEY WORDS Emergency contraception Knowledge Socioeconomic factors Multivariate analysis California
Objective: The State of California has taken several steps to make emergency contraceptives (ECs) available to women in the state. By using data from the 1999-2001 California Women’s Health Survey, we estimated the knowledge of emergency contraception among adult women of reproductive age at risk of pregnancy (n = 6209). Study design: This study is based on 3 years of data (1999-2001) from the California Women’s Health Survey (CWHS), an annual population-based survey of more than 4000 randomly selected adult women (aged 18 years and older) in California. A total of 6198 women aged 18 to 44 responded to the 2 emergency contraception questions: ‘‘To the best of your knowledge, if a woman has unprotected sex is there anything she can do in the 3 days after intercourse that will prevent pregnancy?’’ and ‘‘What can she do?’’ Results: We find that 38% of California women were able to correctly identify emergency contraception. Most importantly, the women who are most likely to need emergency contraceptiondthose who are at risk of an unintended pregnancy but not using any method of contraceptiondhave among the lowest levels of knowledge (only 29% identified a method of ECs).
This research was supported in part by funds from the California Program on Access to Care (CPAC), California Policy Research Center, University of California, grant number 02GT15. The views and opinions expressed do not necessarily represent those of The Regents of the University of California, CPAC, its advisory board, or any state or county executive agency represented thereon. Data were provided by the California Women’s Health Survey (CWHS) Group. The CWHS is coordinated by the California Department of Health Services in collaboration with the California Department of Mental Health, the California Department of Alcohol and Drug Programs; California Medical Review, Inc; the Department of Social Services; and the Public Health Institute. Funding for the survey was provided by the collaborators and by a grant from the California Wellness Foundation. Analyses, findings and conclusions described in this article are not necessarily endorsed by the CWHS Group. * Reprint requests: Diana Foster, PhD, Center for Reproductive Health Research and Policy, University of California, San Francisco, 2356 Sutter St, Suite 200, UCSF Box 1744, San Francisco, CA 94143-1744 E-mail:
[email protected] 0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.01.004
151
Foster et al
Conclusion: Results show that family planning providers may be reaching their clients, but broader outreach to the public has not yet achieved sufficiently high information levels among women in greatest need of the method. Ó 2004 Elsevier Inc. All rights reserved.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
The State of California has taken several steps to make emergency contraceptives (ECs) available to women in the state. The 2000 Women’s Contraceptive Equity Act requires health care plans that offer prescription drug benefits to cover Food and Drug Administrationeapproved contraceptives, including ECs. For lowincome women without health insurance, the state’s family planning program, the Family Planning, Access, Care and Treatment Program (Family PACT) provides emergency contraception at no cost through pharmacies and clinician providers. In 2001, California passed legislation that authorized trained and certified pharmacists to provide emergency contraception directly to women without requiring the women to seek a physician’s prescription.* Starting in 2004, 2 new pieces of legislation will further streamline access to ECs through pharmacies by authorizing a statewide protocol for pharmacy dispensing and imposing a $10 cap on the pharmacistpatient consultation fee.y California has been the site of organized outreach and education about the availability of emergency contraception. Beginning in 1997, an education campaign that used television, radio, and print public service announcements was launched in Los Angeles and San Diego.1 In 1999, the Pharmacy Access Partnership began working to expand consumer awareness of ECs and how to directly obtain these in pharmacies in 7 counties: Los Angeles, Marin, San Diego, San Joaquin, San Francisco, San Luis Obispo, and Santa Cruz.z In 2000, a community outreach media campaign and provider education campaign was implemented by Population Services International in Sacramento County. Numerous other local and county health programs and organizations, including the California Family Health Council and Planned Parenthood, have undertaken provider and consumer outreach, education, and training efforts throughout the state. California women have more than 236,000 abortions2 each year and more than one-half million births,3 as many as a third of which may be unintended.4 Many of the more than 400,000 unintended pregnancies that * Only 4 other states have direct pharmacy access to ECs: Washington, New Mexico, Hawaii, and Alaska. y SB 490 authorizes the use of a statewide protocol and reduces pharmacist training to 1 hour. SB 545 imposes a mandatory cap of $10 on the pharmacist-patient consultation fee. These 2 bills are effective as of January 2004. z The Pharmacy Access Partnership maintains an emergency contraception Web site (ED-Help.org) and hotline (1-800-323-1336).
occur in California could be prevented if women at risk of unintended pregnancy knew about emergency contraception. EC pills, also known as ‘‘morning after pills,’’ can prevent pregnancy when taken within 120 hours of unprotected sex.5 Progestin-only EC pills reduce the chance of pregnancy by 85% after an act of unprotected intercourse and combined hormone EC pills by 57% when taken within 72 hours.6 Insertion of a Copper T intrauterine device (IUD) reduces the chance of pregnancy by more than 99%.7 Until the knowledge of emergency contraception is widespread, the potential of ECs to prevent unintended pregnancy will not be fully realized. This study measures the knowledge of emergency contraception among women in California and analyzes the risk factors for the lack of knowledge of the method. In particular, we look for significant differences in awareness of emergency contraception by sociodemographic factors, health insurance status, and access to care. Other studies have found lower levels of knowledge about emergency contraception among older women and low-income minority women.8 This study confirms these findings for California and adds to the literature on emergency contraception by assessing the impact of health insurance status and access to family planning services on emergency contraception knowledge.
Material and methods This study is based on 3 years of data (1999-2001) from the California Women’s Health Survey (CWHS), an annual population-based survey of more than 4000 randomly selected adult women (aged 18 years and older) in California. The CWHS began in March 1997 as a collaborative effort between the California Departments of Health Services, Mental Health, Alcohol and Drug Programs, and Social Services; the California Medical Review, Inc; and the Public Health Institute. Data are collected in English and Spanish through a computer-assisted telephone survey of more than 200 demographic, health care access, and health insurance coverage questions. In 1999, 2 questions about emergency contraception were added to the CWHS. The emergency contraception questions were asked of all women who had ever had sexual intercourse but had not had a hysterectomy. A total of 6698 women of reproductive age participated in the CWHS between 1999 and 2001. Of those, 6198 re-
152
Foster et al
Table I Emergency contraception question 1: If a woman has unprotected sex is there anything she can do in the 3 days after intercourse that will prevent pregnancy? (n = 6209) Response
Respondents
Percentage*
No Yes Don’t know Refused Total
2239 3265 694 11
36.5 51.7 11.6 0.2 100
Data: California Women’s Health Survey, 1999-2001. * Weighted to reflect California Census 2000 female population.
sponded to the 2 emergency contraception questions, 211 reported never having had sex, 273 reported having had a hysterectomy, and 11 refused to answer the question. Because the CWHS does not survey women younger than age 18, this analysis is limited to women aged 18 to 44 years. Results are weighted to reflect sample design and the age and racial/ethnic composition of California in the 2000 census. All women eligible for the emergency contraception questions were first asked: ‘‘To the best of your knowledge, if a woman has unprotected sex is there anything she can do in the 3 days after intercourse that will prevent pregnancy?’’ Women who responded ‘‘yes’’ were then asked a second, open-ended question: ‘‘What can she do?’’ This analysis examines the responses to these questions and categorizes the women into 3 groups on the basis of their responses: those who do not know about emergency contraception; those who correctly identified emergency contraception; and those who gave an ambiguous answer, such as ‘‘seek medical attention.’’ Ambiguous answers such as ‘‘seek medical attention’’ or ‘‘a pill, don’t know name’’ were not considered as having knowledge of emergency contraception, although they might lead a woman to sources of the method. For this study we sought to measure the personal knowledge of emergency contraception, rather than potential ability to access the method. We use bivariate and multivariate analysis to estimate differences in knowledge of emergency contraception. In the bivariate analysis, we used c2 statistics to measure differences by sociodemographic factors (age, race/ethnicity, income, education, marital status, native, or foreign born); health insurance status (private insurance, Medi-Cal, no insurance); and visits to family planning providers in the past year. Race/ethnicity categories for the analyses include white, Hispanic, black/African American, North Asian, South/Southeast (S/SE) Asian, and other (including American Indian and Pacific Islanders). The North Asian group includes Korean, Chinese, and Japanese women. The S/SE Asian group includes Filipina, Vietnamese, Cambodian, Laotian, East Indian, and Indonesian women. Age is coded as a categorical variable (18-19, 20-24, 25-29, 30-34, 35-
39, and 40-44 years). In the multivariate logistic regression analysis, an awareness of emergency contraception is coded dichotomously and we examined predictive factors, including sociodemographic factors, health insurance, and access to care. We present data on the knowledge of emergency contraception among all women and among those at risk of an unintended pregnancy. Women are considered to be at risk of unintended pregnancy if they are sexually active (sex with a male partner in the past 12 months), fecund, and do not want to become pregnant. Among women who are at risk of unintended pregnancy, some are using reversible contraceptive methods and may become pregnant because of user error or method failure, whereas others are using no method of contraception.
Results More than half of California women (51.7%) stated that there was something a woman could do in the 3 days after unprotected intercourse to prevent pregnancy. Thirty-seven percent of women said that nothing could be done, and 11.6% said they did not know if anything could be done (Table I). The 3265 women who answered that there was something a woman could do to prevent pregnancy after unprotected sex, were asked, ‘‘what can she do?’’ Only 2.5% of respondents referred to the method as ‘‘emergency contraception.’’ ‘‘Take the ‘morning after’ pill’’ was the most common response, at 66% (Table II). Correct responses included: use emergency contraception; take the ‘‘morning after’’ pill; have an IUD inserted; take high dose/extra/several birth control pills; or take birth control pills. The most common incorrect response was that a woman could take RU486 to prevent pregnancy within 3 days after unprotected intercourse (8.9%).x Seven percent of women gave an ambiguous answer; 5.1% indicated a pill; however, they did not know the name of the pill. Our index of EC knowledge, shown in Table III, provides a synthesis of the responses to the 2 questions. Thirty-eight percent of California women were able to correctly identify a method of emergency contraception. Younger women are significantly more likely to know about emergency contraception than older woman. Almost half of women under the age of 25 know about emergency contraception compared with fewer than 40% of women aged 25 and older (P = .000) (Table IV). Knowledge of emergency contraception varies significantly among racial/ethnic groups. Hispanic and S/SE Asian women are less likely than women in other x Although mifepristone is effective as a postcoital contraceptive, we assume that this response stems from confusion between emergency contraception and medical abortion.
153
Foster et al Table II Emergency contraception question 2: What can she do? (asked of those who said ‘‘yes’’ to question 1)
Table III Knowledge of emergency contraception among California women aged 18 to 44 (n = 6198)*
Response
Respondents
Knows emergency contraception Take the morning after pill Take high dose/extra/several birth control pills Use emergency contraception Take birth control pills Have an IUD inserted Does not know emergency contraception Take RU486 Don’t know/not sure Other Douche Injection Have an abortion Pray Herbal remedies Ambiguous response Pill, don’t know name Seek medical help Missing data Refused Total
2413 2166 93
73.7 66.0 2.7
Knowledge of emergency contraception
Respondents
Percentage*
75 72 7 627
2.5 2.4 0.2 18.9
No Yes Ambiguous response Total
3566 2413 219 6198
58.2 38.2 3.7 100.0
324 189 34 27 25 20 4 4 219 168 51 6 3265
8.9 6.3 1.1 0.9 0.9 0.7 0.1 0.1 7.1 5.1 2.0 0.2 100.0
Percentage*
Data: California Women’s Health Survey, 1999-2001. * Weighted to reflect California Census 2000 female population.
racial/ethnic groups to know about emergency contraception, 21% and 28%, respectively, (P = .000). In contrast, 53% of white women and 50% of North Asian women have knowledge of emergency contraception. African American women fall in between, with 42% reporting knowledge of emergency contraception. Women who are at risk of an unintended pregnancydthose who are fertile, sexually active, and do not want to become pregnantdare the potential users of emergency contraception. We find the lowest levels of knowledge about emergency contraception among women at risk who are not using a method of contraception (29%), and the highest levels of knowledge about emergency contraception among women who are at risk of an unintended pregnancy but are using contraception, 45% (P = .000). Knowledge of emergency contraception varies by health insurance coverage and access to care. Forty-five percent of women with private insurance, 23% of women on Medi-Cal, and 26% of uninsured women know about emergency contraception (P = .000). Women who have been to a family planning provider in the past year are more likely to know about the method than women who have not (45% vs 33%, respectively). The lowest levels of knowledge about emergency contraception are women with no high school education (11% know about emergency contraception) and women whose income falls below the federal poverty
Data: California Women’s Health Survey, 1999-2001. * Weighted to reflect California Census 2000 female population.
level (FPL) (17% know about emergency contraception). A multivariate logistic regression analysis reveals the significant factors predicting knowledge of emergency contraception. This logistic regression model predicts a woman’s correct identification of emergency contraception (the ‘‘knows emergency contraception’’ group presented in analyses previously). It is based on the responses from 5873 women for whom data were complete across all predictor variables. This model explains 16% of the variation in knowledge of emergency contraception (Table V). Race/ethnicity is a significant predictor of knowledge of emergency contraception. White and North Asian women are most likely to know about emergency contraception. African American women are 31% less likely to know about emergency contraception than white women; Hispanic women and S/SE Asian women are about half as likely to know about emergency contraception as white women. Foreign-born women are more than 40% less likely to know about emergency contraception than native-born women. The multivariate model confirms the age effect, with women in the youngest age group (18-19 years) twice as likely (odds ratio [OR] = 1.75) and women 30 to 44 years, 25% to 50% less likely to know about emergency contraception than women 30 to 34 years. Unmarried women (those part of an unmarried couple and those not in unions) are more likely to know about emergency contraception than married women. The multivariate model shows lower levels of knowledge among women in disadvantaged socioeconomic groups. Women with no high school education are half as likely to know about emergency contraception as women with a diploma (OR = 0.28). Women below the FPL are half as likely (OR = 0.40) and those below twice the FPL are 30% less likely (OR = 0.71) to know about emergency contraception than women with family incomes above 200% FPL. Two indicators of health care access show mixed results. Health insurance does not have a significant relationship with knowledge of emergency contraception, controlling for other factors, including poverty status.
154
Foster et al
Table IV California women aged 18 to 44 knowledge of emergency contraception by age, race/ ethnicity, and risk for unintended pregnancy* Total
N
38.2
Ambiguous response (%) 3.7
100
6,198
47.3 48.0 57.0 60.6 65.9 60.1
48.4 48.9 39.0 37.3 30.0 35.2
4.3 3.1 4.0 2.2 4.1 4.7
100 100 100 100 100 100
242 798 1171 1375 1409 1203
43.4 76.7 54.8 41.4 67.2 61.7
53.1 20.5 41.6 49.6 28.3 33.3
3.5 2.8 3.7 9.0 4.5 5.1
100 100 100 100 100 100
3004 2187 363 177 223 244
85.6 55.7 44.1
10.9 40.9 51.7
3.5 3.4 4.3
100 100 100
1131 3288 1779
79.5 62.2 46.9
17.1 33.7 49.4
3.4 4.1 3.7
100 100 100
1147 1203 3523
61.8 55.0 52.3 67.7
33.8 41.9 44.6 29.2
4.3 3.1 3.1 3.1
100 100 100 100
2961 3213 2700 513
71.0 70.4 51.9
26.3 23.4 44.7
2.7 6.2 3.5
100 100 100
1219 700 4279
63.4 51.6
32.6 45.3
4.1 3.2
100 100
3458 2740
Knowledge of EC
No (%)
Yes (%)
Total
58.2
Age (y) 18-19 20-24 25-29 30-34 35-39 40-44 Race/ethnicity White Hispanic African American North Asian S/SE Asian Other Education No high school education High school diploma College education Poverty level Below 100% FPL Between 100-200% FPL Above 200% FPL Risk for pregnancy Not at risky At risk of unintended pregnancy/total At risk/using reversible method of contraceptionz At risk/not using contraception Health insurance status Uninsured Medi-Cal Private insurance Access to family planning provider No family planning visit in past year Family planning visit in past year
P value
.000
.000
.000
.000
.000
.000
.000
Data: California Women’s Health Survey, 1999-2001. * Weighted to reflect California 2000 population. y Women who are not at risk of unintended pregnancy are infertile, menopausal, not sexually active, pregnant/postpartum, seeking pregnancy, sterilized, or have had a hysterectomy. z Reversible methods of contraception include intrauterine contraceptives, implants, injectables, oral contraceptives, barrier methods, and natural family planning methods.
However, women who have had a recent visit to a health care provider to discuss or receive family planning services are significantly more likely to know about emergency contraception than women who have not had a visit in the past year.
Comment Population-based surveys from England show emergency contraception awareness to be far higher (approx-
imately 90%of women of reproductive age are aware of the method) and unintended pregnancies lower than in America.9-12 The higher level of knowledge in England is a good goal for US EC knowledge campaigns. A US national survey measured knowledge levels in 1997 and found that 66% of women aged 18 to 44 years had heard of EC pills.8 This survey found racial/ethnic differences in awareness, with 71% of white women reporting having heard of the method compared with 51% of African American and Hispanic women. Women with higher education levels were also far more
155
Foster et al likely to have heard of emergency contraception, as were those with higher household income. The higher level of awareness in Europe provides an excellent target for domestic emergency contraception education campaigns. Thirty-eight percent of California women surveyed can identify what women can do to prevent pregnancy within 72 hours of unprotected intercourse. However, women who are most likely to need emergency contraceptiondwomen at risk of an unintended pregnancy who are not using any method of contraceptiondhave among the lowest levels of knowledge of emergency contraception (only 29% identified a method of emergency contraception). We find large racial/ethnic disparities in knowledge of emergency contraception. As other studies that are based on the California data have found, Hispanic women have particularly low levels of knowledge, even after controlling for educational level.13 We also find significant diversity within the larger Asian community, with S/SE Asian women having far less knowledge than North Asian women, controlling for education and foreign-born status. Those women who have the fewest resources to manage an unplanned pregnancydwomen without a high school education and women with incomes below the FPLdalso exhibit low levels of knowledge of emergency contraception. Emergency contraception education campaigns in California need to continue to reach out to women who are not aware of the method’s existence and purpose. Women who have had a family planning visit in the past year are more likely to know about emergency contraception. This may indicate that family planning providers in the state are educating women about this method of contraception. A 2001 Kaiser Family Foundation survey found low levels of counseling on emergency contraception among a national sample of providers; only 25% of obstetrician-gynecologists and 14% of family physicians reported they discussed emergency contraception ‘‘most’’ or ‘‘all of the time’’ as part of routine contraceptive counseling; however, more than half of the providers reported that they discussed emergency contraception as a part of routine counseling ‘‘sometimes,’’ and in general, the frequency of provider discussions has increased in the past few years.14 Women who are motivated to seek reproductive health care may also tend to notice or retain health-related information. Family planning clients are an important group at risk of unintended pregnancy and may be a relatively easy population for providers to educate. Many of the California policies designed to increase women’s access to emergency contraception were implemented during the same survey years we use to measure knowledge of emergency contraception (1999-2001). The Family PACT Program began in 1997, the Women’s Contraceptive Equity Act became effective in January 2000, and California authorized the direct
Table V Logistic regression predicting knowledge of emergency contraception among California women (n = 5873) Variable Race/ethnicity White Hispanic African American North Asian S/SE Asian Other Place of Birth Native born Foreign born Age (y) 18-19 20-24 25-30 30-34 35-39 40-44 Union status Not in a union Part of unmarried couple Married Education No high school education High school diploma College education Poverty level Below 100% FPL Between 100%-200% FPL Above 200% FPL Family planning visits in past year No family planning visit At least 1 family planning visit Health insurance status No health insurance Medi-Cal coverage Private insurance
OR
95% CI
Reference 0.48* 0.69* 1.30 0.50* 0.70*
(0.40-0.58) (0.53-0.89) (0.90-1.86) (0.35-0.71) (0.52-0.95)
Reference 0.57*
(0.48-0.69)
1.75* 1.49* Reference 0.76* 0.50* 0.66*
(1.20-2.54) (1.18-1.88)
1.40* 1.39* Reference
(1.20-1.63) (1.10-1.78)
0.28* 0.64* Reference
(0.22-0.37) (0.55-0.75)
0.40* 0.71* Reference
(0.31-0.51) (0.59-0.85)
0.73* Reference
(0.64-0.83)
1.02 0.95 Reference
(0.83-1.24) (0.74-1.23)
(0.62-0.92) (0.41-0.62) (0.53-0.82)
Data: California Women’s Health Survey, 1999-2001. LR c2 (20) = 748.47. Pseudo R2 = 0.1554. * Significant at .05 level.
distribution of emergency contraception under collaborative drug therapy agreements in 2002. The California Women’s Health Survey reveals that there is a significant knowledge base to take advantage of these improvements in access to emergency contraception. Further improvements in education about emergency contraception will enable women to take advantage of these policies and may decrease the incidence of unintended pregnancy in the state. California’s large, diverse population is a microcosm of the nation as a whole. Disparities in knowledge of emergency contraception that have been identified in
156 California may need to be addressed in national and other regional emergency contraception education campaigns. This study is the only large population-based to measure knowledge of emergency contraception through an open-ended, nonprompted question, an approach that has revealed considerable confusion between RU486 and emergency contraception. Given the politics and many women’s conflicting feelings about abortion, clarifying the differences between emergency contraception and medical abortion may increase acceptability and willingness to use emergency contraception in California and nationwide.15
Foster et al
6.
7.
8.
9.
10.
References 1. Trussell J, Koenig J, Vaughan B, Stewart F. Evaluation of a media campaign to increase knowledge about emergency contraception. Contraception 2001;63:81-7. 2. Henshaw SK, Finer LB. Abortion incidence and services in the United States in 2000. Perspect Sex Reprod Health 2003;35:6-15. 3. US Bureau of the Census. Population division: estimated components of state population change: July 1, 2001, to July 1, 2002. Washington, DC: US Bureau of the Census; 2002. Table STEST2002-04. 4. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24-9, 46. 5. Ellertson C, Evans M, Ferden S, Leadbetter C, Spears A, Johnstone K, et al. Extending the time limit for starting the
11.
12. 13. 14.
15.
Yuzpe regimen of EC to 120 hours. Obstet Gynecol 2003;101: 1068-71. Task Force on Postovulatory Methods of Fertility Regulation. Randomised controlled trial of levonorgestrel versus the Yuzpe regimen of combined oral contraceptives for emergency contraception. Lancet 2003;352:428-33. Van Look PFA, Stewart F. Emergency contraception. In: Hatcher R, Trussell J, Stewart F, Cates W Jr, Stewart GK, Guest F, et al, editors. Contraceptive technology. 17th rev ed. New York: Ardent Media, Inc; 1998. p. 281-2. Delbanco S, Stewart F, Koenig J, Parker ML, Hoff T, McIntosh M. Are we making progress with emergency contraception? Recent findings on American adults. J Am Med Women Assoc 1998;53: 242-6. Ellertson C, Shochet T, Blanchard K, Trussell J. Emergency contraception: a review of the programmatic and social science literature. Contraception 2000;61:145-86. Graham A, Green L, Glasier A. Teenagers’ knowledge of emergency contraception: questionnaire survey in southeast Scotland. BMJ 1996;312:1567-9. Smith B, Gurney E, Aboulela L, Templeton A. Emergency contraception: a survey of women’s knowledge and attitudes. Br J Obstet Gynaecol 1996;103:1109-16. Crosier A. Women’s knowledge and awareness of emergency contraception. Br J Fam Plann 1996;22:87-90. Harper C, Minnis A, Padian N. Male sexual partners and the use of emergency contraception. Am J Obstet Gynecol 2003;189:1093-9. Kaiser Family Foundation. 2001 National survey of women’s health care providers on reproductive health. Survey Snapshot June 2003. Breckenridge A, Gould H. What’s in a pill? Clarifying the differences between EC and RU486. American Sexuality Magazine [serial online] 2003;1(7):doc 4.
