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储; Rachel Bergeson, MD¶; Michele Seitz, MD#; and
Deborah Saunders, MD§
ABSTRACT. Emergency contraception (EC) is the use of a method of contraception after unprotected inter-course to prevent unintended pregnancy. Although first described over 20 years ago, physician awareness of EC has been limited and many feel uncomfortable prescrib-ing 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 question-naire assessed basic knowledge, attitudes, and opinions regarding EC in adolescents. Data were analyzed by phy-sician age, gender, year completed residency, and prac-tice type.
Results. Two hundred thirty-three practicing pedia-tricians (24.4%) completed the survey. Of the respon-dents, 23.7% had been asked to prescribe EC to an ado-lescent 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 pedia-tricians more likely to do so. Most respondents (72.9%) were unable to identify any of the Food and Drug Ad-ministration-approved methods of EC. Only 27.9% cor-rectly 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 per-cent cited moral or religious reasons and 17% were con-cerned about teratogenic effects. There were no differ-ences in comfort level based on age, gender, or practice type. Twenty-two percent of respondents believed that providing EC encourages adolescent risk-taking behav-ior 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.Pediatrics2001;107:287–292; emer-gency contraception, adolescents.
ABBREVIATIONS. EC, emergency contraception; FDA, Food and Drug Administration.
A
lthough the rate of adolescent pregnancy in the United States is declining,1it is still more than twice that of other industrialized coun-tries.2 Many adolescents do not use any contracep-tive method during the first year after initiation of sexual intercourse.3,4Others 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 inter-course, 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 postco-ital insertion of an intrauterine device.5 The best studied and most frequently used method is that described by Yuzpe et al,6,7which involves adminis-tration 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, aware-ness 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 con-traceptives 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
avail-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;储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.
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@lij.edu
ability of EC will encourage sexual promiscuity and will not protect against acquisition of sexually trans-mitted 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 knowl-edge, attitudes, and opinions of practicing pediatri-cians regarding the use of EC in teenagers. A second-ary aim was to increase awareness of the use of EC and to assess interest in learning more about the subject.
METHODS
An anonymous 5-page questionnaire was mailed by the Amer-ican Academy of Pediatrics (Elk Grove Village, IL) with a self-addressed envelope to all 954 active members of New York Chap-ter 2, District II in January 1999. This ChapChap-ter 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?” Pos-sible choices included: 1)ⱕ24 hours after unprotected intercourse; 2) ⱕ48 hours after unprotected intercourse; 3)ⱕ72 hours after unprotected intercourse; 4) ⱕ96 hours after unprotected inter-course; 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 usingSPSS, Ver-sion 9.0(SPSS, Inc, Chicago, IL). For purposes of analysis, partic-ipants were divided by age into 3 groups (ⱕ40 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 using2analysis for categorical variables.
RESULTS
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 con-fronted 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 re-quests for EC or in prescribing patterns by gender or practice type. Compared with older physicians, phy-sicians under 40 years of age were more likely to have been confronted with the decision to prescribe EC (P ⬍ .01). Although 79% of pediatricians coun-seled adolescents about methods of contraception
TABLE 1. Oral Contraceptive Equivalents for the Yuzpe Method of EC
Trade Name Formulation No. Pills Taken
With Each Dose*
Preven† 0.05 mg ethinyl estradiol 2 0.25 mg levonorgestrel
Ovral 0.05 mg ethinyl estradiol 2
0.50 mg norgestrel
Lo-Ovral 0.03 mg ethinyl estradiol 4 0.30 mg norgestrel
Nordette 0.03 mg ethinyl estradiol 4 0.15 mg levonorgestrel
Levlen 0.03 mg ethinyl estradiol 4
0.15 mg levonorgestrel
Triphasil (Yellow pills only) 4
0.03 mg ethinyl estradiol 0.125 mg levonorgestrel
Trilevlen (Yellow pills only) 4
0.03 mg ethinyl estradiol 0.125 mg levonorgestrel
* Treatment consists of 2 doses taken 12 hours apart. † Approved by the FDA in September 1998.
(Adapted from the American College of Obstetricians and Gyne-cologists Practice Patterns on Emergency Oral Contraception, De-cember 1996).9
TABLE 2. Characteristics of Respondents*
(%)
Mean age, y 47.1⫾9.7
Gender
Male 106 (46.3)
Female 123 (53.7)
Year completed residency
ⱕ1960 5 (2.3)
1961–1970 28 (12.7)
1971–1980 57 (25.9)
1981–1990 77 (35.0)
⬎1990 53 (24.1)
Type of practice
Group private practice 78 (35.6)
Solo private practice 60 (27.4)
Academic practice 34 (15.5)
Hospital-based clinic 23 (10.5)
Health maintenance organization 12 (5.5)
Other 12 (5.5)
during health maintenance visits, only 16.7% coun-seled adolescents about the availability of EC. Com-pared 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 com-fortable in prescribing EC with 68.4% feeling some-what or very uncomfortable (Table 5). There were no differences in comfort level based on age, gender, or whether they classified themselves as general pedi-atricians 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 phy-sicians who responded to this question felt comfort-able (35.0%), compared with 28 of 102 male physi-cians (27.5%;2⫽1.22;P⫽.27). Similarly, 38.5% of
TABLE 3. Experience With EC (n⫽233 Pediatricians in Prac-tice)
n %
Experience in practice (n⫽233)
Has had opportunity to learn about EC 99 (42.5) Has been confronted with decision to
prescribe
55 (23.7)
Has not had the opportunity to learn about or to prescribe EC
79 (33.8)
Reasons asked to prescribe EC (n⫽55)*
Unprotected intercourse 36 (65.5)
Rape 27 (49.1)
Condom broke 25 (45.5)
Other 1 (1.8)
During past 12 mo (n⫽55)
Asked to prescribe 51 (92.7)
Prescribed 41 (74.5)
During routine adolescent health maintenance visits, counsels about (n⫽233)†
Methods of contraception 171 (79)
EC 36 (16.7)
* More than 1 option possible.
† Not all respondents replied to each question.
TABLE 4. Knowledge of EC (n⫽233 Pediatricians in Prac-tice)*
n %
Knowledge
Unable to identify any FDA-approved regimen 164 (72.9) Knows maximum time of prescribing 62 (27.9) General physical examination
Necessary before prescribing 103 (46.8)
Not necessary but advisable 80 (36.4)
Not necessary 37 (16.8)
Pelvic examination
Necessary before prescribing 79 (35.7)
Not necessary but advisable 82 (37.1)
Not necessary 60 (27.1)
Pregnancy test
Necessary before prescribing 141 (63.8)
Not necessary but advisable 37 (16.7)
Not necessary 43 (19.5)
Informed consent by parent or guardian
Necessary before prescribing 22 (10.0)
Not necessary but advisable 55 (25.1)
Not necessary 142 (64.8)
* Not all respondents replied to each question.
TABLE 5. Attitudes Toward EC (n ⫽ 233 Pediatricians in Practice)*
n %
Comfort in prescribing EC
Very/somewhat comfortable 51 (22.7)
Comfortable 20 (8.9)
Very/somewhat uncomfortable 154 (68.4) Do not prescribe EC because of †
Inexperience with use 156 (70)
Fear of tetatogenic effects if patient already pregnant
40 (17.1)
Lack of trust in patient’s report of no other episodes of unprotected intercourse
34 (14.6)
Believe that patients would not use other contraceptive methods effectively
29 (12.4)
Patients having never requested within appropriate time frame
29 (12.4)
Reservations on moral or religious grounds 28 (12.0) Not FDA-approved or not effective 13 (5.6) Do not prescribe but would refer to†
A local gynecologist 117 (42.0)
Planned Parenthood 61 (21.9)
Emergency room of nearby hospital 50 (18.0)
EC hotline 25 (9.0)
Other location 19 (6.8)
Would not refer 6 (2.2)
Satisfaction with current knowledge of EC
Very/somewhat satisfied 34 (15.2)
Satisfied 24 (10.8)
Very/somewhat unsatisfied 165 (74.0)
Interest in learning more about EC
Very/somewhat interested 137 (61.2)
Interested 59 (26.3)
Not very/not at all interested 28 (12.5)
those in academic practice felt comfortable prescrib-ing EC, compared with 28.8% of those practicprescrib-ing in the community (2⫽ 1.59;P⫽ .21).
Seventy percent of respondents cited inexperience with use as being the major reason for not prescrib-ing EC. Twenty-eight respondents (12%) did not pre-scribe EC on moral or religious grounds. Fear of teratogenic effects if the patient was already preg-nant 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 emer-gency 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 contracep-tive 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 inter-course.
Approximately one half of the pediatricians sur-veyed were unsure about potential health risks from repeated use of EC and an equal number had con-cerns 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 con-traceptive methods effectively if EC were easily available (P ⫽ .02), to fear teratogenic effects if the adolescent were already pregnant (P ⫽ .01), to
re-strict 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
EC is safe, effective, and has the potential to dra-matically reduce the number of unintended pregnan-cies 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 adminis-tering 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 sug-gested that a discussion of the availability of EC should be part of the anticipatory guidance provided to teenagers, even before they become sexually ac-tive.1
The pediatricians in our study are being con-fronted 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 knowl-edge 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 pro-fessionals. 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 al10who found that male physicians were more likely to be-lieve that the availability of EC would discourage use of other methods of contraception. Gold surveyed physicians with expertise in adolescent health, in-cluding 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 pre-scribe 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
repeat-TABLE 6. Opinions Regarding EC (n⫽233 Pediatricians in Practice)*
Yes
n%
No
n%
Unsure
n%
Providing EC encourages adolescent contraceptive risk-taking behavior
50 (22.1) 114 (50.4) 62 (27.4)
Would prescribe EC for patient to have on hand before an episode of unprotected intercourse
39 (17.1) 157 (69.2) 31 (13.7)
Would restrict the number of times EC prescribed to an individual patient
118 (52.4) 36 (16) 71 (31.6)
Think that repeated use of EC poses health risks
81 (36.1) 38 (17.0) 105 (46.9)
Think providing EC discourages compliance with other contraceptive methods
100 (44.8) 59 (26.5) 64 (28.7)
Think that EC should be available over the counter, without a prescription
44 (19.6) 149 (67) 31 (13.4)
edly to replace more reliable contraceptive methods. Whether these findings are applicable to adolescents remains to be determined.
Awareness of EC among adolescents and physi-cians 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.14In contrast, in the United States, a nationally representative telephone survey con-ducted on 1510 adolescents in 1996 found that only 23% of the teenagers were aware that something could be used after an episode of unprotected inter-course to prevent pregnancy and only 28% had heard of EC.15 EC has been available in the Nether-lands 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 incor-rect information about side effects. Students with more accurate information were more receptive to using EC. Some students confused EC with the abor-tifacient RU 486. Although the precise mechanism of action of EC is not known, it is thought to act pri-marily by inhibiting or delaying ovulation but may also alter the endometrial lining to prevent implan-tation. 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 differ-ences in the prescribing practices of British and Eu-ropean physicians compared with physicians prac-ticing 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 practitio-ners with expertise in adolescent health who pre-scribed oral contraceptives, have prepre-scribed 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 pedia-tricians 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 recom-mended time limit for intervention is within 72 hours of unprotected intercourse. EC can safely be
pre-scribed by pediatricians. A pregnancy test is advis-able to exclude the possibility of pregnancy, but there are many instances where requiring a preg-nancy test before prescribing EC may place an added barrier to an adolescent receiving a timely prescrip-tion. Because EC is not teratogenic if taken acciden-tally during early pregnancy, in such situations, a pregnancy test should not be considered mandatory. A pelvic examination is not required before prescrib-ing 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 pediatri-cians 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.21For 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 bias—that those who responded were more interested in learning about EC. The respondents to our survey, however, did not differ from the nonre-spondents with regard to age, gender, and time since completion of residency, as determined from a pre-vious survey conducted on the same group of pedi-atricians. In addition, our findings may not be gen-eralizable to pediatricians practicing in other parts of the country.
CONCLUSION
ACKNOWLEDGMENTS
We thank Leah Kafenbaum for data entry and Kim Galleli, PhD, for help with data analysis.
REFERENCES
1. Kaufmann RB, Spitz AM, Strauss LT, et al. The decline in US teen pregnancy rates, 1990 –1995.Pediatrics. 1998;102:1141–1147
2. Jones EF, Forrest JD, Goldman N, et al. Teenage pregnancy in industri-alized countries. New Haven, CT: Yale University Press; 1986 3. Allan Guttmacher Institute.Sex and America’s Teenagers. New York, NY:
Allan Guttmacher Institute; 1997
4. Zabin LS, Stark HA, Emerson MR. Reasons for delay in contraceptive clinic utilization: adolescent clinic and non-clinic population compared. J Adolesc Health. 1991;12:225–232
5. Glazier A. Emergency postcoital contraception.N Engl J Med. 1997;337: 1058 –1064
6. Yuzpe AA, Thurlow HJ, Ramzy, Leyshon JI. Post coital contracep-tion—a pilot study.J Reprod Med. 1974;13:53–58
7. Yuzpe AA, Smith RP, Rademaker AW. A multicenter clinical investi-gation employing ethinyl estradiol combined with d1-norgestrel as a postcoital contraceptive agent.Fertil Steril. 1982;37:508 –513
8. Food and Drug Administration. Prescription drug products: certain combined oral contraceptives for use as postcoital emergency contra-ception.Federal Register. 1997;62:8610 – 8612
9. American College of Obstetricians and Gynecologists.Emergency Oral Contraception: American College of Obstetricians and Gynecologists Practice Patterns on Emergency Oral Contraception. Washington, DC: American College of Obstetricians and Gynecologists; 1996
10. Gold MA, Schein A, Coupey SM. Emergency contraception: a national
survey of adolescent health experts.Fam Plann Perspect. 1997;29:15–19 11. Fisher M, Golden NH, Bergeson R, et al. Update on adolescent health
care in pediatric practice.J Adolesc Health. 1996;19:394 –399
12. Trussell J, Ellertson C, Stewart F. The effectiveness of the Yuzpe regi-men of emergency contraception.Fam Plann Perspect. 1996;28:58 – 64 13. Glasier A, Baird D. The effects of self-administering emergency
contra-ception.N Engl J Med. 1998;339:1– 42
14. Graham A, Green L, Glasier A. Teenagers’ knowledge of emergency contraception: questionnaire survey in South East Scotland.Br Med J. 1996;312:1567–1569
15. Delbanco SF, Parker ML, McIntosh M, Kannel S, Hoff T, Stewart FH. Missed opportunities—teenagers and emergency contraception. Arch Pediatr Adolesc Med. 1998;152:727–733
16. Glasier A, Ketting E, Ellertson C, Armstrong E. Emergency contracep-tion in the United Kingdom and the Netherlands.Fam Plann Perspect. 1996;28:49 –51
17. Harper CC, Ellertson CE. The emergency contraception pill: a survey of knowledge and attitudes among students at Princeton University.Am J Obstet Gynecol. 1995;173:1438 –1445
18. Grimes DA. Emergency contraception— expanding opportunities for primary prevention.N Engl J Med. 1997;337:1078 –1079
19. Webb A, Morris J. Practice of postcoital contraception—the results of a national survey.Br J Fam Plann. 1993;18:113–118
20. Task Force on Postovulatory Methods of Fertility Regulation. Random-ized controlled trial of levonorgestrel vs. the Yuzpe regimen of com-bined oral contraceptives for emergency contraception.Lancet. 1998;352: 428 – 433
21. Perkins C. Age patterns of victims of serious violent crime. Bureau of Justice Statistics. Available at: www:ncjrs.org. Accessed December 15, 2000
BIOLOGICAL COMPLEXITY
[In biology] . . . everything is caused by everything else in a way that is impos-sible to unscramble. As the old quotation had it, “We murder to dissect,” and any invention destroys the very phenomenon it is investigating. . .
In contrast to physics . . . biology is hampered by the fact that in organisms many weak causes interact and outcomes are crucially dependent on accidents of history and the initial state of the system.
Lewontin R, quoted inNew York Times Book Review.April 15, 2000
DOI: 10.1542/peds.107.2.287
2001;107;287
Pediatrics
Quijano, Amy Suss, Rachel Bergeson, Michele Seitz and Deborah Saunders
Neville H. Golden, Warren M. Seigel, Martin Fisher, Marcie Schneider, Emilyn
Emergency Contraception: Pediatricians' Knowledge, Attitudes, and Opinions
Services
Updated Information &
http://pediatrics.aappublications.org/content/107/2/287
including high resolution figures, can be found at:
References
http://pediatrics.aappublications.org/content/107/2/287#BIBL
This article cites 17 articles, 2 of which you can access for free at:
Subspecialty Collections
icine_sub
http://www.aappublications.org/cgi/collection/adolescent_health:med
Adolescent Health/Medicine
following collection(s):
This article, along with others on similar topics, appears in the
Permissions & Licensing
http://www.aappublications.org/site/misc/Permissions.xhtml
in its entirety can be found online at:
Information about reproducing this article in parts (figures, tables) or
Reprints
http://www.aappublications.org/site/misc/reprints.xhtml
DOI: 10.1542/peds.107.2.287
2001;107;287
Pediatrics
Quijano, Amy Suss, Rachel Bergeson, Michele Seitz and Deborah Saunders
Neville H. Golden, Warren M. Seigel, Martin Fisher, Marcie Schneider, Emilyn
Emergency Contraception: Pediatricians' Knowledge, Attitudes, and Opinions
http://pediatrics.aappublications.org/content/107/2/287
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
