PEDIATRICS Vol. 107 No. 2 February 2001, pp. 287-292

Emergency Contraception: Pediatricians' Knowledge, Attitudes, and Opinions

Neville H. Golden, MD^*, Warren M. Seigel, MD, Martin Fisher, MD^§, Marcie Schneider, MD^§, Emilyn Quijano, MD^§, Amy Suss, MD, Rachel Bergeson, MD^¶, Michele Seitz, MD^#, and Deborah Saunders, MD^§

From ^* Schneider Children's Hospital, Albert Einstein College of Medicine, New Hyde Park, New York;  Coney Island Hospital, State University of New York Health Science Center at Brooklyn, Brooklyn, New York; ^§ North Shore University Hospital, Cornell University Medical College, Manhasset, New York;  Children's Medical Center at Brooklyn, State University of New York, Downstate, Downstate, New York; ^¶ State University of New York at Stony Brook, Stony Brook, New York; and ^# Nassau County Medical Center, East Meadow, New York.

	ABSTRACT

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Emergency contraception (EC) is the use of a method of contraception after unprotected intercourse to prevent unintended pregnancy. Although first described over 20 years ago, physician awareness of EC has been limited and many feel uncomfortable prescribing it.

Objective.  To assess the knowledge, attitudes, and opinions of practicing pediatricians regarding the use of EC in adolescents.

Methods.  An anonymous questionnaire was mailed to all 954 active members of New York Chapter 2, District II of the American Academy of Pediatrics. The questionnaire assessed basic knowledge, attitudes, and opinions regarding EC in adolescents. Data were analyzed by physician age, gender, year completed residency, and practice type.

Results.  Two hundred thirty-three practicing pediatricians (24.4%) completed the survey. Of the respondents, 23.7% had been asked to prescribe EC to an adolescent and 49% of these cases involved a rape victim. Only 16.7% of pediatricians routinely counsel adolescent patients about the availability of EC, with female pediatricians more likely to do so. Most respondents (72.9%) were unable to identify any of the Food and Drug Administration-approved methods of EC. Only 27.9% correctly identified the timing for its initiation and only 31.6% of respondents felt comfortable prescribing EC. Inexperience with use was cited as the primary reason for not prescribing EC by 70% of respondents. Twelve percent cited moral or religious reasons and 17% were concerned about teratogenic effects. There were no differences in comfort level based on age, gender, or practice type. Twenty-two percent of respondents believed that providing EC encourages adolescent risk-taking behavior and 52.4% would restrict the number of times they would dispense EC to an individual patient. A minority of respondents (17%) believed that adolescents should have EC available at home to use if necessary and only 19.6% believed that EC should be available without a prescription. The vast majority (87.5%) were interested in learning more about EC.

Conclusions.  Despite the safety and efficacy of EC, the low rate of use is of concern. Pediatricians are being confronted with the decision to prescribe EC but do not feel comfortable prescribing it because of inadequate training in its use. Practicing pediatricians are aware of their lack of experience and are interested in improving their knowledge base.

Although the rate of adolescent pregnancy in the United States is declining,¹ it is still more than twice that of other industrialized countries.² Many adolescents do not use any contraceptive method during the first year after initiation of sexual intercourse.^3,4 Others are exposed to the risk of pregnancy as a result of rape or sexual assault.

Emergency contraception (EC), the use of a method of contraception after unprotected intercourse, is one option open to adolescents. Different methods of EC are available including: the use of combination estrogen and progestin; estrogen alone; progestin alone; antiprogestins; danazol; and postcoital insertion of an intrauterine device.⁵ The best studied and most frequently used method is that described by Yuzpe et al,^6,7 which involves administration of 2 oral contraceptive pills, each containing 0.05 mg of ethinyl estradiol and 0.5 mg of norgestrel, taken 12 hours apart for a total of 4 tablets. The first dose of this regimen should be administered within 72 hours of unprotected intercourse. Although this method was first described over 20 years ago, awareness by physicians has been limited and many feel uncomfortable prescribing EC.

Since the approval of EC by the Food and Drug Administration (FDA) in February 1997,⁸ interest among physicians caring for adolescents has been increasing. A number of different types of oral contraceptives have equivalent doses of hormone to the original regimen of Yuzpe et al and can be used for EC (Table 1).^8,9

Multiple barriers to widespread use of EC still remain. These include lack of knowledge about EC among patients and physicians, lack of physician comfort in prescribing EC, concerns that the availability of EC will encourage sexual promiscuity and will not protect against acquisition of sexually transmitted diseases, and concern that the widespread use of EC will lead to less consistent use of other more effective forms of contraception.

The aim of this study was to survey the knowledge, attitudes, and opinions of practicing pediatricians regarding the use of EC in teenagers. A secondary aim was to increase awareness of the use of EC and to assess interest in learning more about the subject.

	METHODS

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An anonymous 5-page questionnaire was mailed by the American Academy of Pediatrics (Elk Grove Village, IL) with a self-addressed envelope to all 954 active members of New York Chapter 2, District II in January 1999. This Chapter includes 4 counties, 2 of which are boroughs of New York City (Brooklyn and Queens) and 2 of which are on suburban Long Island (Nassau and Suffolk). Pediatricians in training were excluded.

The questionnaire was adapted from that used by Gold et al¹⁰ and included 30 forced choice questions assessing demographic data, type of practice, frequency of prescribing EC, comfort in doing so, and reasons for not doing so, where applicable. A 5-point Likert scale was used for questions on frequency, comfort, and satisfaction with knowledge. The questionnaire also assessed basic knowledge including indications for prescribing EC, period of time after unprotected intercourse that it could be prescribed, and methods of EC that were FDA-approved. Preven and plan B were not included as choices because these regimens were not FDA-approved at the time that the questionnaire was developed.

Forced choice questions were used to assess knowledge. For example, pediatricians were asked, "What is your understanding of the maximum time within which you can prescribe EC?" Possible choices included: 1) 24 hours after unprotected intercourse; 2) 48 hours after unprotected intercourse; 3) 72 hours after unprotected intercourse; 4) 96 hours after unprotected intercourse; and 5) don't know. Respondents were asked whether informed consent, a pelvic examination, and/or a pregnancy test are necessary before prescribing EC. Possible choices were: 1) necessary, 2) not necessary, and 3) not necessary but advisable. Pediatricians were asked whether they believed that providing EC encouraged adolescent risk-taking behaviors, whether they would restrict the number of times they prescribed EC, and whether they would prescribe EC for the patient to have on hand before an episode of unprotected intercourse. The questionnaire took ~10 minutes to complete.

Data were computer-tabulated and analyzed using SPSS, Version 9.0 (SPSS, Inc, Chicago, IL). For purposes of analysis, participants were divided by age into 3 groups ( 40 years, 41-50 years, and >50 years of age). Responses to questionnaires were analyzed by age of physician, gender, year completed residency, and type of practice using ² analysis for categorical variables.

	RESULTS

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Two hundred thirty-three pediatricians replied to the survey, representing a response rate of 24.4%, similar to the response rate on a previous survey of this group of pediatricians.¹¹ The characteristics of the respondents are shown in Table 2. Mean age was 47.1 ± 9.7 years and slightly over half were female. The majority (63%) were in solo or group private practice. Twenty-six percent worked in an academic practice or hospital-based clinic. Seventy-six percent of respondents spent >50% of their time practicing general pediatrics, with only 16.7% spending >50% of their time in subspecialty pediatrics. Respondents did not differ from nonrespondents with respect to age, gender, or nature of practice as determined from the previous survey.¹¹

Twenty-four percent of respondents had been confronted with the decision to prescribe EC, usually for unprotected intercourse (36 of 55 = 65.5% of those who replied in the affirmative). Twenty-seven of the 55 pediatricians who had been asked to prescribe EC (49.1%) had been asked to do so for a patient who was the victim of rape (Table 3).

When asked how frequently they had been asked to prescribe EC, 174 of 226 respondents (77.0%) had not been confronted with that situation within the past 12 months. Fifty-one pediatricians (22.6%) had been asked to prescribe EC in the previous year, but infrequently (26 were asked once and 25 were asked "a few times," but less frequently than once per month). There were no significant differences in requests for EC or in prescribing patterns by gender or practice type. Compared with older physicians, physicians under 40 years of age were more likely to have been confronted with the decision to prescribe EC (P < .01). Although 79% of pediatricians counseled adolescents about methods of contraception during health maintenance visits, only 16.7% counseled adolescents about the availability of EC. Compared with male pediatricians, female pediatricians were more likely than were their male counterparts to counsel their adolescents about both contraception (P = .03) and EC (P = .02).

Knowledge

Only 27.9% of respondents answered correctly that the maximum time within which to prescribe EC is 72 hours after unprotected intercourse. Younger physicians (P = .001) and female physicians (P = .02) were more likely to answer this question correctly. Thirty-two percent of respondents underestimated the time limit and 40.1% answered that they did not know the time limit. Almost 73% of respondents were unable to identify any of the FDA-approved methods of EC (Table 4). Younger physicians (P = .02), more recent graduates (P = .02), and those in academic or hospital-based practice (P = .004) were more likely to respond that they could identify at least one of the FDA-approved regimens.

Over 50% of respondents answered correctly that in a mature adolescent known to the physician, a physical examination or a pelvic examination are not necessary before prescribing EC. The majority (63.8%) answered correctly that a pregnancy test was necessary before prescribing EC and that informed consent was not necessary (64.8%). One quarter of the pediatricians surveyed believed that informed consent was not necessary, but advisable. There were no differences in knowledge about the need for a pelvic examination, need for a pregnancy test, or need for informed consent by age, gender, or practice type.

Attitudes

Only 31.6% of respondents stated that they felt comfortable, somewhat comfortable, or very comfortable in prescribing EC with 68.4% feeling somewhat or very uncomfortable (Table 5). There were no differences in comfort level based on age, gender, or whether they classified themselves as general pediatricians or subspecialists. The mean age of those who felt comfortable was 45.1 ± 8.8 years, compared with 47.9 ± 10.0 years (P = .10) for those who did not feel comfortable. Forty-three of the 122 female physicians who responded to this question felt comfortable (35.0%), compared with 28 of 102 male physicians (27.5%; ² = 1.22; P = .27). Similarly, 38.5% of those in academic practice felt comfortable prescribing EC, compared with 28.8% of those practicing in the community (² = 1.59; P = .21).

Seventy percent of respondents cited inexperience with use as being the major reason for not prescribing EC. Twenty-eight respondents (12%) did not prescribe EC on moral or religious grounds. Fear of teratogenic effects if the patient was already pregnant was cited as a major concern of 17% of those who replied. Only one pediatrician believed that EC was not effective. The majority of pediatricians who did not prescribe EC refer to a local gynecologist (42%), Planned Parenthood (21.9%), or the emergency department of a local hospital (18.0%).

A minority of the pediatricians surveyed (26%) were satisfied with their current knowledge and the vast majority (87.5%) were either interested or very interested in learning more about this topic.

Opinions

As noted in Table 6, ~22% of respondents believed that providing EC encouraged adolescent contraceptive risk-taking behavior, and 118 of 225 respondents (52.4%) would restrict the number of times they would dispense EC to an individual patient. Only 17% would prescribe EC for the patient to have on hand before an episode of unprotected sexual intercourse.

Approximately one half of the pediatricians surveyed were unsure about potential health risks from repeated use of EC and an equal number had concerns that providing EC discourages compliance with other contraceptive methods. A minority (19.6%) believed that EC should be available over the counter without a prescription. Compared with male pediatricians, female pediatricians were more likely to believe that adolescents would not use other contraceptive methods effectively if EC were easily available (P = .02), to fear teratogenic effects if the adolescent were already pregnant (P = .01), to restrict the number of times EC was dispensed to an individual patient (P = .02), and to think that EC should not be available over the counter (P = .005).

	DISCUSSION

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EC is safe, effective, and has the potential to dramatically reduce the number of unintended pregnancies in adolescents. Low failure rates of EC, ranging from .2% to 2.8%, result in a 75% reduction in the risk of unintended pregnancy.¹² The major side effects are nausea (30%-66%) and less frequently, vomiting (12%-22%). Side effects can be reduced by administering an antiemetic 1 hour before each dose of pills.⁹ There have been no documented teratogenic effects in the 48 known patients in whom treatment failed and who went on to term after receiving EC.⁹

Despite the safety and efficacy of EC, the low rate of use is of concern. Most patients requesting EC are adolescents or young women and it is important that their health care providers are adequately trained and feel comfortable prescribing EC. Some have suggested that a discussion of the availability of EC should be part of the anticipatory guidance provided to teenagers, even before they become sexually active.¹

The pediatricians in our study are being confronted with the decision to prescribe EC, but most indicated that because of inadequate training and inexperience, they feel uncomfortable providing EC. Moral or religious reasons were not major barriers to the prescribing of EC. What is clear is that many of the pediatricians surveyed lack the required knowledge to ensure appropriate prescribing practices and that many of the concerns about potential dangers are unfounded. The pediatricians were, however, aware of their lack of knowledge and many indicated that they referred such patients to appropriate professionals. It was encouraging to see that most of the pediatricians who we surveyed were interested in learning more about EC.

Our results reveal interesting gender differences among pediatricians regarding EC. Although female pediatricians were more likely to counsel adolescents about EC at health maintenance visits, they had more concerns than male pediatricians about safety and compliance with other contraceptive regimens and were more reticent to make EC easily available. These findings differ from those of Gold et al¹⁰ who found that male physicians were more likely to believe that the availability of EC would discourage use of other methods of contraception. Gold surveyed physicians with expertise in adolescent health, including obstetrician-gynecologists, internists, and family physicians along with pediatricians.

Similar to the findings of Gold et al, we found that the vast majority of our respondents would not prescribe EC for the adolescent to have on hand before an episode of unprotected intercourse.

In our survey, only 17% of pediatricians would do so. Glazier⁵ recently showed that in adults, those women who had a replaceable supply of EC pills at home had lower rates of unintended pregnancy.¹³ These women used EC correctly and, compared with a control group, were no more likely to use it repeatedly to replace more reliable contraceptive methods. Whether these findings are applicable to adolescents remains to be determined.

Awareness of EC among adolescents and physicians is greater in Europe and the United Kingdom than in the United States. In Scotland, a survey of 1206 pupils aged 14 to 15 found that 93% had heard of EC and one third of the girls who were sexually active had used it.¹⁴ In contrast, in the United States, a nationally representative telephone survey conducted on 1510 adolescents in 1996 found that only 23% of the teenagers were aware that something could be used after an episode of unprotected intercourse to prevent pregnancy and only 28% had heard of EC.¹⁵ EC has been available in the Netherlands since 1964 and a combined oral contraceptive has been packaged and specifically marketed for EC in the United Kingdom since 1984.¹⁶ In the United States such a product was only approved by the FDA in September 1998 (Preven, Gynetics, Inc, Somerville, NJ).

Even in those populations where awareness of EC is high, knowledge of the details of EC is limited.^14,17 Many of the women were unaware that EC could be administered as large doses of oral contraceptive pills, many had misinformation about the correct time limits for taking the pills, and others had incorrect information about side effects. Students with more accurate information were more receptive to using EC. Some students confused EC with the abortifacient RU 486. Although the precise mechanism of action of EC is not known, it is thought to act primarily by inhibiting or delaying ovulation but may also alter the endometrial lining to prevent implantation. This regimen is not an abortifacient and will not disrupt an established pregnancy.¹⁸

Similar to the differences in awareness of EC among British and American youth, there are differences in the prescribing practices of British and European physicians compared with physicians practicing in the United States. In a national survey of British health authorities, 26% of respondents said that they prescribe EC 3 to 5 times a week, 57% did so 1 to 10 times a week, and only 19% reported that they prescribe EC less than once a week.¹⁹ In the United States, Gold et al found that 80% of practitioners with expertise in adolescent health who prescribed oral contraceptives, have prescribed EC, but only a few times a year. Obstetrician-gynecologists were more likely to prescribe EC than pediatricians and those who considered themselves to be working in an academic setting were more likely to prescribe EC than those who are working in the community.¹⁰

Most adolescents in the United States are cared for by community pediatricians and not by experts in adolescent health working out of academic centers. Our data demonstrate that many community pediatricians lack the knowledge to ensure appropriate prescribing practices but are interested in improving their fund of knowledge. Referring a patient to an obstetrician-gynecologist may result in unnecessary delay, which may be critical because the recommended time limit for intervention is within 72 hours of unprotected intercourse. EC can safely be prescribed by pediatricians. A pregnancy test is advisable to exclude the possibility of pregnancy, but there are many instances where requiring a pregnancy test before prescribing EC may place an added barrier to an adolescent receiving a timely prescription. Because EC is not teratogenic if taken accidentally during early pregnancy, in such situations, a pregnancy test should not be considered mandatory. A pelvic examination is not required before prescribing EC.

Pediatricians need to be kept informed of recent developments in the field. For example, a few months after our survey was completed, the FDA approved a progestin-only regimen for use in EC (Plan B, Women's Capital Corp, Kirkland, WA). This regimen involves taking only 2 pills, each containing 0.75 mg of levonorgestrel, taken 12 hours apart. This regimen is even more effective and has less side effects than the Yuzpe regimen.²⁰

It is striking that almost one half of the pediatricians who indicated that they had been requested to prescribe EC were asked to do so because of a rape. Data indicate that the rates of rape and sexual assault are highest in the adolescent age group. Yearly rates are 6.7 per 1000 in 12- to 14-year-old females; 12.0 per 1000 for 15- to 17-year-old females; and 13.8 per 1000 for 18- to 21-year-old females.²¹ For this reason alone, it is important that physicians who treat adolescents be aware of the use of EC for teenagers who have been the victim of rape.

There are a number of limitations to our study. The most obvious is the poor response rate. This response rate is similar to the 27% response rate to a different questionnaire distributed 6 years earlier to the same group of pediatricians.¹¹ There is the possibility of selection biasthat those who responded were more interested in learning about EC. The respondents to our survey, however, did not differ from the nonrespondents with regard to age, gender, and time since completion of residency, as determined from a previous survey conducted on the same group of pediatricians. In addition, our findings may not be generalizable to pediatricians practicing in other parts of the country.

	CONCLUSION

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We found that in a sample of pediatricians from the New York metropolitan area almost one third of pediatricians surveyed had been confronted with the decision to prescribe EC in the previous year. Most pediatricians did not feel comfortable prescribing EC and cited lack of knowledge as the main reason for lack of comfort. Concern on religious grounds was not a major factor. Most pediatricians were aware of their lack of knowledge and were interested in improving their knowledge base. Pediatricians can play an important role in promoting awareness of EC among their adolescents. Therefore, they need to be knowledgeable about the subject, so that they can discuss it with their patients and prescribe it when indicated.

	ACKNOWLEDGMENTS

We thank Leah Kafenbaum for data entry and Kim Galleli, PhD, for help with data analysis.

	FOOTNOTES

Received for publication Jan 31, 2000; accepted Jun 9, 2000.

Reprint requests to (N.H.G.) Division of Adolescent Medicine, Schneider Children's Hospital, 410 Lakeville Rd, New Hyde Park, NY 10040. E-mail: golden{at}lij.edu

	ABBREVIATIONS

EC, emergency contraception; FDA, Food and Drug Administration.

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