Emergency Contraception Considerations and Use Among College Women

Abstract

Background:

Emergency contraception (EC) has been available behind the counter without a prescription since 2006. Evidence has shown increased use of EC among young women, but no recent findings have been published to date of current use.

Methods:

This cross-sectional study surveyed 482 college heterosexually active college women attending a large public university who either visited the college-based health clinic or were enrolled in selected undergraduate classes. Prediction models were created for each outcome, EC consideration and use, using Poisson regression with robust variance estimates.

Results:

Just over 58% of college women sampled reported ever considering EC, and just under 47% reported actual use. Consideration and actual EC use were highest for students who were nonwhite and who reported more sexual partners. Although female students who did not use condoms were more likely to use EC, there was no difference in EC relative to hormonal contraception use.

Conclusions:

As EC becomes both better known and more readily available, use is expected to grow. Moving forward, greater attention is needed to the efficacy of EC use on preventing unwanted pregnancies.

Introduction

In July 1999, the Food and Drug Administration (FDA) approved a two-dose progestin only emergency contraception (EC) regimen called Plan B and, in June 2009, a replacement one-dose version called Plan B One Step. Since 2006, the Plan B regimen has been available behind the counter without a prescription to women and men aged ≥18 years. In 2009, Plan B One Step was approved for behind the counter access to women and men aged ≥17 years. Although access is still dependent on the availability of a licensed pharmacist, a clinic, or a student health service provider willing to dispense the pills as well as overcoming other barriers, EC has been available without a prescription for >5 years.¹

In other countries, where EC has been available over the counter for a longer period of time, increased use has been noted. For example, in Australia, where EC has been available without a prescription since 2003, it was found that approximately 29% of college students reported use.² In Norway, there has been an estimated 30-fold increased use of EC since it was made available without a prescription in 2000.³

The college female student embodies the prime potential user of EC, as she tends to be sexually active⁴ and willing to consider new means of contraception.^5,6 Most research examining EC use in the United States was conducted either before 2006, when EC became available from pharmacies without a prescription, or just after this change. Over the last decade, researchers have measured both the awareness and use of EC among U.S. college populations, finding that most of the female college students were aware of EC,^7
–9 but many were confused about how to obtain it. Several studies examined the association between access to EC and the use of other means of contraception, finding no association between increased access to EC and decreased condom use frequency.^10

–16 All these studies, however, were conducted before EC became available behind the counter, and none were focused on college students specifically.

We know that there appears to be an increase in EC use over time in the general population of U.S. women aged 18–24, with approximately 9.4% reporting ever using EC before 2006,¹⁷ compared with a 2006–2008 national sample finding that 18.4% of women in this age group reported EC use.¹⁸ Among female college students specifically, a study conducted 2 years after EC was approved for behind the counter sale identified a usage rate of approximately 17%.⁹ This study provides a more contemporary snapshot of EC use and acceptability following the 2009 availability of Plan B One Step. This study examines current EC use among a sample of female college students from a single large public university, seeking to answer for this population three questions. (1) What is the prevalence of EC consideration and use? (2) What factors are associated with students' EC consideration and use? (3) What is the relationship between ever using EC and the use of other means of contraception?

Materials and Methods

Design

This study is part of a larger cross-sectional self-administered anonymous written survey that looked at use of the human papillomavirus (HPV) vaccine and behavioral risk factors published elsewhere,¹⁹ conducted from January through March 2010 at a single large public university. The study was approved by the University's Institutional Review Board; a waiver of signed informed consent was obtained to maintain anonymity.

Sample

The original study from which these data are drawn examined both men and women, drawing from introductory general education undergraduate classes and the college health clinic. Students were informed that the main focus of the study was sexual health, focused on HPV and HPV vaccine. For this study, only female participants were examined. Women were recruited from both the university's health clinic and classroom settings. For clinic recruitment, research assistants approached individual women keeping medical appointments who met the eligibility criteria (≥18 years, current undergraduate student at the university, and not sent to infection isolation area or administratively lost, that is, sent directly into an examination room) during the study period. Surveys were completed and returned while women were in the clinic. For in-class recruitment, a convenience sample of instructors was contacted for permission to conduct the survey during their class session. The study was presented to the entire class of male and female students. Eligible and interested students were provided survey packets containing an informed consent document and survey. Surveys were completed in class and returned to research assistants upon completion.

In the clinic, 551 women were present during the recruiting periods, 207 of whom were not approached (122 were in the respiratory disease isolation area; 85 were sent immediately to the physical examination area for their appointment before they could be approached). The reason for the visit was not asked as a part of recruitment. Sixty-nine women were not eligible to participate (e.g., <18 years old, not a current student). Thirty women refused to speak with the research assistant, and thus eligibility could not be assessed. Of the remaining 275 potentially eligible women, 207 (75.3%) completed the survey. In-class recruitment was performed in 20 class sections, and response proportion was calculated for female and male students combined, as sex-specific attendance could not be measured. Of the 1241 students in attendance, 735 surveys (381 female, 354 male) were completed (59.2% response proportion).

The two samples combined to include 942 students. For this study, the sample was restricted to the 482 surveys completed by female students from both the clinic and classroom setting who reported any history of vaginal sexual intercourse. The two subsamples were compared, and the results are reported elsewhere.¹⁹ It was found that the classroom sample was younger, as introductory classes were targeted; no other significant demographic differences were noted, and the overall sample was found to have mirrored the university's population well. Likely because of the age difference, the clinic sample showed a significantly greater proportion of women who reported ever having vaginal intercourse. However, this study was limited to only those women who replied that they had a history of vaginal intercourse, making this difference no longer relevant.

Measures

EC consideration and use were each measured, asking: Have you considered using emergency contraception? Have you ever used emergency contraception? This measure of ever use of EC reflects the operationalization used in previous studies,^7
–9,17,18 allowing for easier comparison across findings. Descriptive and predictive measures included age, race (white, black, Asian, other, or multiple), Hispanic or Latin ethnicity (yes, no), class (freshman, sophomore, junior, senior), worry about sexually transmitted infection (STI) (higher worry/ low/no worry), ever having binge drunk (yes, no), age at first intercourse, total number of partners, having ever hooked up (yes, no), worried about getting pregnant (very worried, moderately worried, somewhat worried, not worried), currently using hormonal contraception (pill, patch, ring, other), and condom use (never, <50% of the time, about 50% of the time, almost always, always). Having ever hooked up serves as nomenclature for engaging in noncommittal sexual relations; this does not necessarily include intercourse. For the regression analysis, age, race, age at first intercourse, total number of partners, worry about pregnancy, hormonal contraception use, and condom use were recoded into dichotomous categories.

Statistical analysis

Data were entered into Epi-Info, version 3.5 (Centers for Disease Control and Prevention [CDC]); all statistical analyses were performed using SAS v9.1.3 (SAS Institute, Cary, NC). Approximately 40% of surveys were double-entered into Epi-Info, and data quality was verified using SAS PROC COMPARE. Descriptive statistics, including frequencies and percentages, were computed. Categorical chi-square tests were conducted to test for statistical significance between measured factors and EC consideration and use. Prediction models were created for each outcome, consideration and use, to identify the individual effect of each factor using Poisson regression with robust variance estimates. Poisson regression was conducted because the outcome is common and log-binomial regression did not converge. Furthermore, logistic regression computes adjusted odds ratios (OR) that overestimate adjusted prevalence ratios because of the large proportion of EC use.²⁰

Results

Sample descriptives

Eligible respondents were predominantly non-Hispanic white, mostly within a traditional college age range (18–22 years), with a relatively equal distribution across class levels (Table 1). Most of the female students surveyed (70.1%) reported binge drinking, and most (63.3%) had their first sexual intercourse between the ages of 15 and 17. The majority of female students (70.3%) reported having five or fewer partners in their lifetime, with most of these having only one or two partners. Approximately 21% reported having ever hooked up, and about 65% reported being moderately to very worried about getting pregnant. Just over 60% reported using hormonal contraception (primarily the birth control pill), and 53.6% reported almost always or always using a condom during intercourse.

Table 1.

Sample Descriptives Overall and by Emergency Contraception Consideration and Use

Factor	n	Considered EC (%)	p	Used EC (%)	p
Total	482	58.4		46.5
Age
18–19	206	60.5	0.00	45.6	0.17
20–21	190	61.7		51.1
22+	37	32.4		35.1
Race
White	332	54.8	0.03	43.4	0.10
Black	56	63.6		57.1
Asian	27	74.1		55.6
Other or multiple	20	80.0		60.0
Class
Freshman	121	63.6	0.32	38.8	0.06
Sophomore	109	58.9		56.9
Junior	150	57.0		46.7
Senior	91	54.9		47.3
Where do you currently live?
On campus	313	59.4	0.75	46.6	0.88
Off campus, no parents	117	58.1		48.7
Off campus with parents	36	52.8		44.4
Ever binge drink?
Yes	331	61.7	0.05	49.8	0.08
No	141	52.1		41.1
Age at first intercourse
Under 15	37	62.2	0.24	56.8	0.04
15–17	299	60.9		49.8
18 or older	136	52.6		38.2
Total number of partners
1–2	177	53.4	0.32	37.3	0.01
3–5	142	61.7		50.0
6–10	86	64.0		51.2
11 or more	49	59.2		61.2
Have you ever hooked up?
Yes	97	53.6	0.28	46.4	0.89
No	377	59.6		47.2
Are you worried about getting an STI?
Yes	419	58.4	0.41	48.0	0.78
No	48	64.6		45.8
Are you worried about getting pregnant?
Very worried	202	59.7	0.11	46.0	0.79
Moderately worried	105	65.4		51.4
Somewhat worried	63	61.9		49.2
Not worried	99	49.0		45.5
Current hormonal contraception use
Pill	258	55.1	0.15	45.7	0.37
Patch	1	100.0		0.0
Ring	22	83.3		59.1
Other	12	59.1		66.7
How often do you use condoms?
Never	69	52.2	0.11	50.7	0.01
<50% of the time	89	58.0		52.8
About 50% of the time	61	59.0		60.7
Almost always	123	68.0		47.2
Always	130	52.7		35.4

Consideration of EC use

When asked if they had ever considered using EC, about 58% of the female college students surveyed reported they had. Those students <age 20 were statistically more likely to consider EC use (p<0.01) compared with those ≥20. Although consideration of use showed a dose decline from freshmen to seniors, this was not statistically significant. White students were statistically less likely to consider EC use compared with the other racial groups (p=0.03). Those who reported ever binge drinking were more likely to consider EC use than those who did not (p=0.05). Of those who ever considered using EC, approximately 77% reported actual EC use. In addition, among those who never used EC, 42% reported that they have considered using it.

Table 2 provides a predictive model for consideration of EC use by female college students. Adjusting for other factors, EC consideration increased by approximately 30% among those who were worried about pregnancy. Nonwhite students were 50% more likely to consider EC use compared with white students, after adjusting for other measured factors. In terms of sexual risk behaviors, those women who ever hooked up and those who reported binge drinking were nearly 40% more likely to consider EC use compared with their counterparts. The use of condoms and hormonal contraception showed no individual effect on EC consideration.

Table 2.

Predictive Model for Ever Considered Emergency Contraception Among Female College Students (n=482)

Factor	PR ^a	CI	p
Number of partners
3+	1.23	(1.00–1.51)	0.06
1–2 (referent)
Age at first intercourse
Under 18	1.01	(0.81–1.26)	0.91
18 or older (referent)
Age
18–19	0.98	(0.82–1.17)	0.83
20 or older (referent)
How worried are you about becoming pregnant?
More worried	1.29^a	(1.06–1.58)	0.01
Less worried (referent)
Worry about STI
Yes	0.90	(0.69–1.17)	0.43
No (referent)
How often do you use a condom?
Often/always	1.02	(0.85–1.23)	0.83
Never/less often (referent)
Are you currently using hormonal contraception
Yes	1.08	(0.90–1.30)	0.39
No (referent)
Race
Nonwhite	1.48^a	(1.22–1.79)	0.00
White (referent)
Ethnicity
Hispanic	1.25	(0.88–1.78)	0.22
Non-Hispanic (referent)
Do you ever hook up?
Yes	0.78^a	(0.61–0.99)	0.05
No (referent)
Do you currently have a main partner?
Yes	0.87	(0.72–1.04)	0.13
No (referent)
Do you ever binge drink?
Yes	1.37^a	(1.11–1.69)	0.00
No (referent)

Statistically significant at p=0.05.

CI, confidence interval; PR, prevalence ratio; STI, sexually transmitted infection.

EC use

Of the women sampled, 46.5% reported ever using EC. As with consideration of EC, actual EC use was found to be more prevalent among nonwhite students; however, this difference only approached statistical significance. Also only approaching statistical significance of 0.05, sophomores showed the highest prevalence of EC use compared with the other classes (p=0.06), as did students who ever binge drank compared with those who did not (p=0.08). Students who had sexual intercourse before age 17 showed a significantly higher prevalence of EC use compared with those who had their first sexual intercourse encounters at a later age (p=0.04). As the total number of sex partners increased, so did reported EC use (p=0.01). Whether or not the woman ever hooked-up and a woman's fear of pregnancy each had no apparent impact on EC use; however, those who always or almost always used a condom were statistically less likely to ever use EC (p=0.01).

Table 3 provides a predictive model for EC use among the female college students sampled. When adjusting for other factors, the higher use among nonwhite students persisted; these students were found to be 52% more likely to use EC than white students. Sexual risk behaviors showed some impact on EC use, as those women who have had three or more sexual partners were 36% more likely to use EC compared with females who have had one or two partners; those who binge drink were about 30% more likely to use EC than those who do not, after adjusting for other factors. However, hooking up behavior showed no individual effect on EC use. It was found that women who often or always use a condom were 30% less likely to use EC than those who use it less often or never; use of hormonal contraception showed no individual relationship after adjusting for other factors.

Table 3.

Predictive Model for Ever Using Emergency Contraception Among Female College Students (n=482)

Factor	PR ^a	CI	p
Number of partners
3+	1.36^a	(1.03–1.78)	0.03
1–2 (referent)
Age at first intercourse
Under 18	1.21	(0.90–1.62)	0.21
18 or older (referent)
Age
18–19	0.90	(0.72–1.11)	0.33
20 or older (referent)
How worried are you about becoming pregnant?
More worried	1.14	(0.91–1.44)	0.26
Less worried (referent)
Worry about STI
Yes	1.25	(0.83–1.87)	0.29
No (referent)
How often do you use a condom?
Often/always	0.70^a	(0.55–0.88)	0.00
Never/less often (referent)
Are you currently using hormonal contraception?
Yes	0.97	(0.76–1.22)	0.77
No (referent)
Race
Nonwhite	1.52^a	(1.19–1.96)	0.00
White (referent)
Ethnicity
Hispanic	1.37	(0.93–2.03)	0.11
Non-Hispanic (referent)
Do you ever hook up?
Yes	0.98	(0.74–1.30)	0.90
No (referent)
Do you currently have a main partner?
Yes	1.02	(0.79–1.33)	0.87
No (referent)
Do you ever binge drink?
Yes	1.29^a	(1.01–1.66)	0.05
No (referent)

Statistically significant at p=0.05.

Discussion

This study, conducted over 4 years after EC became available behind the pharmacy counter, identified an EC use prevalence of nearly 47% for college women. This prevalence is closer to 50% for students between 20 and 21 years of age as well as for nonwhite students, notably higher than the 20% prevalence of EC use found among female college students conducted in 2008.⁹ Interestingly, the 2008 college student study identified that only about 24% of all women surveyed were even aware of EC. Although our study of only sexually active students did not measure awareness specifically, it identified that just under 60% of the students ever considered EC, which would suggest, at a minimum, awareness of this option. At the health center at the university from which this sample was drawn, EC counseling is individualized to those who provide information consistent with a history of unprotected intercourse. At the pharmacy, only those students seeking specific information on EC are provided education.

This study found that those students who regularly used condoms had a significantly reduced likelihood of using EC. These findings differ from those of past studies in which no relationship was identified between condom use and EC use.^{10

–16,21} In addition to these past studies being conducted before the 2006 EC regulatory status change, they are also limited to medical settings or studies of nonstudent populations. This study further found no relationship between EC use and use of hormonal contraception, suggesting that EC use is not necessarily considered a replacement for other contraception by college women. Finally, EC was initially touted as an efficacious means of reducing unwanted pregnancies⁸; this study found that EC consideration increased among those who feared pregnancy, but actual EC use did not. Actual pregnancy rates were not measured, nor were perceptions about the likelihood of pregnancy.

The context of these findings must be considered in terms of several methodologic limitations. First, as a cross-sectional study, it is impossible to determine causation. For example, we could not determine if condom or hormonal contraception use was initiated before or after EC use. Similarly, we are prevented from understanding if the lack of association between pregnancy worry and EC use is because fear is reduced as a result of the availability of EC or if there is simply no relationship. Second, this study did not measure use of intrauterine devices (IUDs) and implants to allow a comparison with these forms of contraception and EC use. In addition, although we used the term Plan B as an example of EC, no description of abortion pill vs. EC was provided, and no definition of hooked up was provided, potentially yielding different interpretations by some students.

Our prevalence estimates are not directly comparable with national estimates, as the National College Health Assessment (NCHA) asks only about past-year EC use whereas this study measures lifetime use. The college student study conducted in 2008 also measured lifetime use, coming up with a prevalence less than half of ours.⁸ We used a convenient sample from two sources, first-year classes and health clinic visitors, in an effort to have a sample more representative of the university population. In terms of comparability, we explored each group separately before combining to ensure that no biases existed from sample selection. No significant differences were found other than age, which was expected and desired. This age difference resulted because only introductory general education (nonhealth) classes were used, yielding a younger cohort of students. In terms of external validity, however, self-selection in this way is prone to exclude those who do not attend classes regularly or do not seek healthcare on campus. Despite this, there is no reason to believe that the excluded female students would have significantly lower rates of EC use, thus nullifying findings. Lastly, this study relies on self-report for all measures, including EC use and condom regularity. There are likely some reporting errors to be expected in this population. There are likely recall issues, but there is no reason why these should be differential by EC use and, thus, should not impact our outcomes.

Conclusions

Based on these findings, female college students are reporting having used EC at a prevalence rate higher than that found in previous studies in the United States. Selected higher-risk sexual behaviors, namely binge drinking and having a greater number of sex partners, were associated with increased EC use. Conversely, condom use was associated with decreased EC use. The greater prevalence of EC use in this sample likely resulted both from the availability of EC (Plan B and Plan B One Step) behind the counter and from the growing awareness of what EC is, how it is used, and how one obtains it. As EC becomes more accepted among college students, we can look forward to identifying its efficacy in reducing unwanted pregnancies among this population. Given the high degree of EC use and consideration found, this study also encourages exploration into the acceptability and use of EC among a broader population base of college women as well as other populations to allow for an expanded understanding of EC use overall as well as an understanding of predictive factors found here. Further research should also explore EC awareness and accessibility.

Footnotes

Disclosure Statement

No competing financial interests exist for the authors of this article.

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