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© 2005 American Public Health Association
DOI: 10.2105/AJPH.2004.046433
RESEARCH AND PRACTICE |
At the time of the study, Kenneth D. Rosenberg and Jihong Liu were with the Oregon Department of Human Services, Office of Family Health, Portland, Oregon. Kenneth D. Rosenberg and Jodi K. DeMunter are with Oregon Health & Sciences University, Portland.
Correspondence: Requests for reprints should be sent to Kenneth D. Rosenberg, Office of Family Health, 800 NE Oregon Street, Suite 850, Portland, OR 97212 (e-mail: ken.d.rosenberg{at}state.or.us).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We sought to learn about access to emergency contraception (EC) in Oregon emergency departments, both for women who are rape patients and for women who have had consensual unprotected sexual intercourse ("nonrape patients").
Methods. We interviewed emergency department staff in 54 of Oregon’s 57 licensed emergency departments in February–March 2003 (response rate = 94.7%).
Results. Only 61.1% of Oregon emergency departments routinely offered EC to rape patients. Catholic hospitals were as likely as non-Catholic hospitals to routinely offer EC to rape patients. The hospitals most likely to routinely offer EC to rape patients had a written protocol for the care of rape patients that included offering EC (P = .02) and access to staff with specialized sexual assault training (P=.002). For nonrape patients, 46.3% of emergency departments discouraged the prescribing of EC. Catholic hospitals were significantly less likely than non-Catholic hospitals to provide access to EC for nonrape patients (P=.05).
Conclusions. Oregon emergency departments do not routinely offer EC to women who have been raped or to women who have had consensual unprotected sexual intercourse.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Over 300 000 women are raped each year in the United States; about 25 000 of these rapes result in pregnancy. As many as 20 000 of these pregnancies could be prevented by timely administration of emergency contraception (EC).1 Emergency departments play an important role in the treatment of rape patients and may be the patient’s first and only site for medical care following a sexual assault. Hospital emergency departments do not consistently offer EC pills to rape patients: studies on data from 1994 to 2000 found that less than half of rape patients receive EC from a hospital emergency department at the time of treatment.2–4 Offering EC to all eligible rape patients for pregnancy prophylaxis has been endorsed by the American Public Health Association,5 the American Medical Association,6 and the American College of Obstetricians and Gynecologists.7
The EC pill is a short dose of progestin that prevents the production and fertilization of an egg and the implantation of a fertilized egg in the endometrium. It is most effective when taken within 12 hours of unprotected sexual intercourse,8 and treatment has some effectiveness at least through 120 hours after intercourse.9,10 However, the sooner it is administered, the more likely it is to prevent pregnancy.8,11 The main emergency contraceptive available in the United States is Plan B (levonorgestrol; Barr Laboratories, Pomona, NY). Another EC medication called Preven (Gynetics, Belle Mead, NJ) was available until Gynetics took it off the market in 2004.
It is estimated that if EC were widely available and widely used in the United States, 1.7 million unintended pregnancies could be avoided and the number of abortions each year could be cut by as much as half.12 Impediments to availability of EC include lack of information, misunderstanding of the mechanism of action, lack of access to pills, and political influence over Food and Drug Administration (FDA) rulemaking. Seven states (Washington, California, Alaska, Hawaii, New Mexico, Maine, and New Hampshire) have given authority to pharmacists to provide EC, thereby significantly increasing access. On December 16, 2003, an FDA advisory panel voted 23 to 4 to approve changing Plan B’s status from prescription to nonprescription (over-the-counter) status.13 Political pressure resulted in a May 6, 2004, rejection of the application.14
Previous work has found Catholic and rural emergency departments to be less likely to offer EC to rape patients than non-Catholic and urban emergency departments. Three studies found that Catholic hospital emergency departments were less likely to offer EC to rape patients than non-Catholic hospital emergency departments. The first, a national sample of large urban hospitals in 1998, found that Catholic hospitals were more likely to prohibit discussion of EC with rape patients than non-Catholic hospitals (P< .001) and that Catholic hospital pharmacies were less likely to dispense EC than non-Catholic hospital pharmacies (P< .001).15 The second study, a survey of Pennsylvania emergency departments in 2000, found that 32% of non-Catholic and 6% of Catholic hospitals routinely offered counseling and provision of EC to rape patients.4 The third study, a national survey of hospitals, found that Catholic hospital emergency departments were less likely than non-Catholic hospital emergency departments to dispense EC, even in the case of sexual assault.16 In addition, a 2002 national survey of Catholic hospitals found that 28% of Catholic emergency departments offered EC to rape patients (although a majority of these hospitals set up obstacles, such as pregnancy testing and police reports) and 5% offered EC to women who had consensual sexual intercourse.17 Another survey found that emergency physicians were less willing to prescribe EC after consensual sex than after sexual assault.18 The Pennsylvania survey also found that rural emergency departments were less likely to offer EC than were urban emergency departments.4
Obtaining EC quickly is crucial for both rape and nonrape patients: there is a short window of time in which to obtain EC to prevent unwanted pregnancy. There is little information about the number of women who currently request EC after consensual sexual intercourse from an emergency department, and there is no data on how much demand there might be after a marketing program that encouraged women to seek EC from emergency departments.
We assessed the availability of EC in emergency departments in Oregon for both rape victims and women who had consensual sexual intercourse. New studies of EC are needed to assess where public health efforts must be focused.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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A single interviewer ( J. K. D.) completed a telephone survey of emergency departments in Oregon hospitals from February to March 2003. A list of all hospital emergency departments was obtained from the Office of Health Care Licensure and Certification of the Oregon Department of Human Services. Psychiatric hospitals, children’s hospitals, and hospitals without emergency departments were removed from the list of hospitals we surveyed.
At least 2 attempts were made to reach the emergency department nurse manager or charge nurse. In the 15 occasions on which neither was available, staff nurses or emergency department physicians were interviewed. All phone surveys were made weekdays between 9:00 AM and 5:00 PM.
The questions posed in the survey provided data on the following: whether there was a written protocol for the care of rape victims who had been brought to the emergency department ("rape patients"); whether the rape protocol included offering EC to women who had been raped; how often physicians offered EC to rape patients ("routinely," "at their discretion," or "not at all"); whether any staff had received specialized sexual assault training; how EC pills were dispensed to rape patients ("in hospital," "prescription to community pharmacy," "none," and "referred to another hospital"); type of EC offered ("Plan B," "combination," "physician discretion," and "not applicable"); where women could fill EC prescriptions ("inhospital," "24-hour community pharmacy," or "other community pharmacy"); number of rape patients seen per year; and access to EC for women who had not been raped ("physician discretion," "discouraged by hospital," and "referred to outside provider"). Most of these questions had been used by previous researchers, and all were reviewed locally (the survey instrument is available from the corresponding author). All hospitals were later called to determine whether they were affiliated with the Roman Catholic Church. Population density, categorized by the Oregon Health & Science University’s Office of Rural Health, was used to determine whether a hospital was located in a rural county. Rural counties had less than 60 persons per square mile according to July 2001 estimates by the Population Research Center of Portland State University. Counties with 60 persons per square mile or more have been categorized here as nonrural.
We used different definitions of "access to EC" for rape and nonrape patients because we assumed that emergency departments were more likely to offer EC to rape patients than to nonrape patients. These definitions were embedded in the survey questions. In the question about access for rape patients, the highest level of access was emergency departments, where physicians routinely offered EC. In contrast, for nonrape patients, the highest level of access we explored was physicians being allowed to prescribe EC.
Due to small cell size, we used the Fisher exact test to assess the differences between groups in the sample. We considered differences at P
.05 to be statistically significant.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Fifty-seven hospitals with emergency departments were identified. Personnel at 54 of these 57 hospitals were interviewed (response rate = 94.7%).
Rape Patients
Among the 54 emergency departments, 46 (85.2%) reported ever prescribing EC pills to rape patients; the other 8 did not prescribe EC to rape patients at all. Only 33 of the 54 responding hospitals (61.1%) routinely offered EC to rape patients (numbers, but not percentages, shown in Table 1
). Of the responding emergency departments, 5 had no written rape protocol. A total of 28 of the remaining 49 emergency departments (57.1%) had written protocols for handling rape evaluations that included offering EC to rape patients. Four of the 5 emergency departments that had no protocol referred all rape patients to other facilities (data not shown). Only 8 of the 54 (14.8%) emergency departments routinely prescribed Plan B, and 20 (37.0%) reported that they did not offer EC pills directly to rape patients but gave them a prescription to be filled at a pharmacy outside the hospital. Table 1 also presents data on whether EC was routinely offered among the 46 emergency departments that ever offered EC. Overall, 33 (71.1%) reported that they routinely offered EC to rape patients. Hospitals with a written rape protocol that included offering EC were more likely to report routinely offering EC to rape patients than those that lacked such a protocol (P= .02), as was the case in those in which the staff had received specialized sexual assault training compared with those in which the staff had received no such training (P= .002). Catholic hospitals were as likely as non-Catholic hospitals to routinely offer EC to rape patients (P= .75). Rural hospitals were as likely as nonrural hospitals to routinely offer EC to rape patients (P= .53).
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Nonrape Patients
As shown in Table 2
, 29 (53.7%) of the 54 emergency departments reported that the decision to prescribe EC was left to the discretion of the treating physician (access we have labeled "possible access to EC"). The remaining 25 emergency departments stated that they either discouraged the prescribing of EC or that they referred patients to a provider outside the emergency department. Catholic hospitals were significantly less likely than non-Catholic hospitals to allow physicians to prescribe EC for nonrape patients (P= .05). Rural hospitals were not significantly more likely than nonrural hospitals to allow physicians to prescribe EC for nonrape patients (P= .42).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Rape Patients
Hospital emergency departments are responsible for most of the initial care of rape victims. All appropriate care, including access to EC, should take place in the emergency department. We found that almost 40% of Oregon emergency departments did not routinely offer EC to rape patients. Although 91% of Oregon emergency departments had written protocols for handling rape evaluations, 43% (21/49) of the protocols did not include offering EC. We found that having a written protocol for the care of rape patients that includes access to EC was associated with increased access to EC.
Among emergency departments that did offer EC to rape patients, 43% (20/46) gave them a prescription to be filled at a pharmacy outside the hospital. This approach is fraught with problems, as not all women would be able to buy the pills shortly after having been raped (e.g., no cash or credit cards, or lack of insurance information), many community pharmacies do not stock EC pills, and most are not open 24 hours a day. This lack of access will not be alleviated by the new knowledge that both required doses of EC can be taken at the same time
Plan B is more effective than combination EC and has fewer side effects.11 However, at the time of this study, most emergency departments were not prescribing Plan B. Only 8 of 54 (14.8%) emergency departments prescribed Plan B. Emergency departments should routinely prescribe the most effective EC.
Interestingly, Catholic hospitals provided equal access to EC to rape patients compared to non-Catholic hospitals. These results notably differ from those of previous studies.4,15 This difference may be attributable to regional variation, or it may represent recent changes in how Catholic hospitals train staff (in rape treatment) and treat rape patients. Another possible reason for our finding is that we did not ask emergency departments whether they required rape patients to have a negative pregnancy test or file a police report before they could receive EC. According to the Ibis Reproductive Health Study,17 almost half of the Catholic hospital emergency departments that did offer EC to rape patients reported such requirements. We may therefore have overestimated the availability of EC in Catholic hospital emergency departments.
We found a statistically significant association between any staff receiving specialized sexual assault training and routine access to EC (P= .002). These programs are designed to teach nurses how to complete the initial evaluation for a patient who has been sexually assaulted. Among emergency departments with trained staff, 89.3% offered routine access to EC; in contrast, only 44.4% of those without trained staff offered routine access. Our findings are higher than those of the Pennsylvania study: in 2000 researchers found that 56% of emergency departments with specialized training routinely offered EC compared to 21% for emergency departments whose staff did not have such training.4
Nonrape Patients
We found that 46% of Oregon emergency departments did not offer any access to EC for women who had consensual unprotected sexual intercourse. Catholic hospitals were less likely than non-Catholic hospitals to provide EC access for nonrape patients. None of the Oregon emergency departments had protocols describing how to handle EC for women following unprotected consensual sexual intercourse. Almost half of all emergency departments either referred patients to resources outside the emergency department or actively discouraged the prescribing of EC in this situation. Emergency departments should improve access to EC for nonrape patients, make EC available in the emergency department, and improve physician and patient education. Emergency department registrars or triage staff should facilitate expedited access to EC for women who only wish to obtain EC.
Study Limitations
One limitation of this study is that we interviewed only 1 person per hospital. Interviewing several persons simultaneously might have provoked group discussions about hospital practice and may have led to more accurate answers. A second limitation is that we have reported on the responses of the interviewees and not the content of the actual protocols. We obtained protocols from 24 of the hospitals and, in some cases, these protocols differed from the reports of those we interviewed. We have reported on the interview information because it was complete and because it might better reflect real practice than do the protocols.
We found that 61.1% of emergency departments "routinely offered" EC to rape patients, and 53.7% offered "possible access" for nonrape patients. These numbers are not comparable because they use different criteria for access. For rape patients, our definition of "access" was the emergency department routinely offering EC; "physician discretion" was considered lack of access. Because no emergency department routinely offered EC to nonrape patients, we defined "possible access" to EC for nonrape patients as "physician discretion" (in contrast to emergency departments that discouraged offering EC or referred women to another provider). We would have been better able to compare differential access if we had asked the same question for both groups of patients.
Conclusions
For rape patients, there is a need to improve EC access in emergency departments. Five states (California, New Mexico, New York, South Carolina, and Washington) already require emergency departments to dispense EC on request to women who have been sexually assaulted.19 All emergency departments need to have written protocols that include access to EC for the care of rape patients. Emergency departments should require staff members to receive training in proper care of sexual assault victims. The Oregon legislature recently created standards for the care of rape patients and a fund to reimburse hospitals for forensic examinations.
For women who have had consensual unprotected sexual intercourse, emergency departments should create protocols to dispense EC, and should publicize its availability. Emergency departments would be an excellent access point for dispensing EC, because they are open 24 hours a day and many already stock EC pills. Even if the FDA approves the request from Barr Laboratories to make Plan B available over the counter, it will still be important for emergency departments to offer EC, because many women will not be able to obtain EC pills at community pharmacies.
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Acknowledgments |
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J. Liu was supported by a postgraduate fellowship appointment from the Oak Ridge Institute for Science and Education through an interagency agreement between the US Department of Energy and the Centers for Disease Control and Prevention.
We are grateful for the contributions of Katrina Ramsey, Don Downing, Jane Hutchings, Jeanne Atkins, Julie McFarlane, Lisa Angus, and Jessica Duke.
Human Participant Protection
State review found this study to be public health practice, not research. Therefore, institutional review board review was not required. Voluntary consent was provided by all respondents.
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Footnotes |
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Peer Reviewed
Contributors
K. D. Rosenberg conceptualized and designed the study, supervised the survey and the data analysis, and wrote the final version of the article. J. K. DeMunter administered the survey, did initial data analysis, and wrote the first draft of the article. J. Liu conducted the final data and statistical analyses and edited the final article.
Accepted for publication September 24, 2004.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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4. Simons R. Emergency Contraception for Sexual Assault Survivors: A Survey of Hospital Emergency Rooms in Pennsylvania. Philadelphia, PA: The Clara Bell Duvall Education Fund; 2000.
5. American Public Health Association. Ensuring Access to Emergency Contraception for Survivors of Rape: Official Position Paper. Adopted November 18, 2003.
6. American Medical Association. Access to emergency contraception. Policy of the House of Delegates, H-75.985; 2002. Available at: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-75.985.HTM. Accessed March 30, 2004.
7. American College of Obstetricians and Gynecologists. ACOG Practice Pattern Number 3: Emergency Contraception. Washington, DC: American College of Obstetricians and Gynecologists; 1996.
8. Piaggio G, von Hertzen H, Grimes DA, Van Look PF. Timing of emergency contraception with levonorgestrel or the Yuzpe regimen. Task Force on Postovulatory Methods of Fertility Regulation. Lancet. 1999;353:721.[CrossRef][Web of Science][Medline]
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13. FDA’s Decision Regarding Plan B: Questions and Answers. US Food and Drug Administration. Available at: http://www.fda.gov/cder/drug/infopage/planB/planBQandA.htm. Accessed July 13, 2004.
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15. Smugar SS, Spina BJ, Merz JF. Informed consent for emergency contraception: Variability in hospital care of rape victims. Am J Public Health. 2000;90: 1372–1376.
16. Harrison T. Availability of emergency contraception: a survey of hospital emergency department staff. Ann Emerg Med. In press.
17. Ibis Reproductive Health, Catholics for a Free Choice. Second chance denied: emergency contraception in Catholic hospital emergency rooms. Washington, DC: Catholics for a Free Choice; 2002; pp. 1–24. Available at: http://www.ibisreproductivehealth.org/pub/downloads/ECcffcStudy.pdf. Accessed March 24, 2004.
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19. Alan Guttmacher Institute. State Policies in Brief: Access to Emergency Contraception. New York, NY: Alan Guttmacher Institute; March 1, 2004.
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