Nonpresciption Access Has Not Raised UK Women's Reliance on Emergency Pills
Making emergency hormonal contraception available over the counter is not associated with an increase in its use, according to surveys conducted in Great Britain before and after nonprescription sale of this drug was legalized.1 The proportion of women in the general population using emergency contraception at least once in a year was the same (7-8%) when it required a prescription and when it no longer did. The proportions of women using regular methods of contraception were likewise unaffected. Roughly a year after the change in availability took effect, one-third of women using emergency contraception were obtaining it from pharmacies.
In January 2001, emergency contraception became available over the counter, at a cost of £20-25 ($36-46), to British women aged 16 or older. After this time, women could still obtain the method by prescription at no cost from general practitioners, family planning clinics and hospitals. To assess contraceptive practices among women aged 16-49 before and after the change in availability, researchers obtained data from the Omnibus Survey, an annual cross-sectional survey of a representative sample of British adults living in private households. Data were analyzed for the years 2000, 2001 and 2002.
Analyses were based on about 2,000 women interviewed in each year. The proportion of women using emergency contraception at least once in the preceding year did not differ across the consecutive survey years, remaining at 7-8%. In addition, there was no difference in the proportion using it twice or more a year—2% of women in each survey.
Among women using emergency contraception, the proportion obtaining it from general practitioners was 62% in 2000 and 49% in 2002; the proportion getting it from family planning clinics was 33% in 2000 and 18% two years later. Twenty percent of users in 2001 and 33% in 2002 obtained the method from pharmacies.
In bivariate analyses, age, marital status and education level were significantly associated with using emergency contraception. Specifically, the proportion of women using it was highest among 20-24-year-olds in 2000 and 2002 (17-20%) and among 16-19-year-olds in 2001 (22%). In each survey year, the proportion was higher among single women (12-16%) than among married women (2-3%), cohabiting women (8-9%) and women reporting another marital status (8-11%). And in 2001, it was higher among women with a secondary education or less (9%) than among women with more education (7%).
Bivariate analyses restricted to women using emergency contraception in 2001 or 2002 suggested that age and annual income were significantly associated with obtaining it over the counter. Specifically, the proportion obtaining the method in this way was higher among 30-34-year-old users (48%) than among users of other ages in 2001, and higher among those with annual incomes of at least Â£15,600 (44-56%) than among those with lower incomes in both survey years.
In multivariate analyses combining data for the three survey years, women younger than 30 had significantly higher odds than older women of having used emergency contraception in the preceding year (odds ratios, 2.2-2.9). And women who were single, were cohabiting or reported some other marital status were more likely to have used this contraception than were their married counterparts (2.1-3.7). Income, education and survey year were not associated with use.
By contrast, of the factors studied, only income was significantly associated with obtaining emergency contraception over the counter in 2001 or 2002. Compared with women with annual incomes of less than £6,240, those with incomes of £15,600 or higher had sharply elevated odds of having obtained the method in this way (odds ratio, 5.4).
Across the three survey years, the proportion of women who used no contraceptive remained essentially the same (21-23%). Likewise, there were no significant changes in the proportions using oral contraceptives, IUDs, injectables or implants (32-34%); sterilization (24-25%); barrier methods (20-21%); withdrawal or rhythm (4-5%); or some other method (1%). Among women using condoms, the proportion using them at every act of intercourse was significantly lower in 2001 (52%) than in 2000 (59%) and 2002 (60%). But in a combined analysis of women using condoms every time or usually, the proportion was statistically indistinguishable across years (73-75%).
The investigators assert that the findings do not support contentions that making emergency contraception available without a prescription leads to its "abuse" or to higher levels of unprotected sex. But they also note that the lack of change in use of this method suggests that its over-the-counter availability has had little effect on unwanted pregnancies. Although many women seem to prefer obtaining the method over the counter instead of from physicians—thereby reducing use of health care resources—he cost is apparently a barrier, the investigators contend. Overall, they conclude that their study "supports the case for lifting the ban on over the counter sales of [emergency contraception] in the United States and other countries."—S. London
1. Marston C, Meltzer H and Majeed A, Impact on contraceptive practice of making emergency hor-monal contraception available over the counter in Great Britain: repeated cross sectional surveys, British Medical Journal, 2005, 331(7511):271 <http://bmj. bmjjournals.com/cgi/content/full/331/7511/271>, accessed July 15, 2005.