Abstract
SummaryBackgroundUnless women start effective contraception after oral emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies. We hypothesised that pharmacist provision of the progestogen-only pill as a bridging interim method of contraception with emergency contraception plus an invitation to a sexual and reproductive health clinic, in which all methods of contraception are available, would result in increased subsequent use of effective contraception.MethodsWe did a pragmatic cluster-randomised crossover trial in 29 UK pharmacies among women receiving levonorgestrel emergency contraception. Women aged 16 years or older, not already using hormonal contraception, not on medication that could interfere with the progestogen-only pill, and willing to give contact details for follow-up were invited to participate. In the intervention group, women received a 3-month supply of the progestogen-only pill (75 μg desogestrel) plus a rapid access card to a participating sexual and reproductive health clinic. In the control group, pharmacists advised women to attend their usual contraceptive provider. The order in which each pharmacy provided the intervention or control was randomly assigned using a computer software algorithm. The primary outcome was the use of effective contraception (hormonal or intrauterine) at 4 months. This study is registered, ISRCTN70616901 (complete).FindingsBetween Dec 19, 2017, and June 26, 2019, 636 women were recruited to the intervention group (316 [49·6%], mean age 22·7 years [SD 5·7]) or the control group (320 [50·3%], 22·6 years [5·1]). Three women (one in the intervention group and two in the control group) were excluded after randomisation. 4-month follow-up data were available for 406 (64%) participants, 25 were lost to follow-up, and two participants no longer wanted to participate in the study. The proportion of women using effective contraception was 20·1% greater (95% CI 5·2–35·0) in the intervention group (mean 58·4%, 48·6–68·2), than in the control group (mean 40·5%, 29·7–51·3 [adjusted for recruitment period, treatment group, and centre]; p=0·011).The difference remained significant after adjusting for age, current sexual relationship, and history of effective contraception use, and was robust to the effect of missing data (assuming missingness at random). No serious adverse events occurred.InterpretationProvision of a supply of the progestogen-only pill with emergency contraception from a community pharmacist, along with an invitation to a sexual and reproductive health clinic, results in a clinically meaningful increase in subsequent use of effective contraception. Widely implemented, this practice could prevent unintended pregnancies after use of emergency contraception.FundingNational Institute for Health Research (Health Technology Assessment Programme project 15/113/01).
Highlights
Emergency contraception prevents unintended pregnancy after unprotected sex or contraceptive failure,[1] but unless women start an effective method of ongoing contraception after oral emergency contraception, they remain at risk of unintended pregnancy
Women who have unprotected sex after receiving emergency contraception are up to three-times more likely to conceive than women who do not,[1,2,3] and without contraception these women remain at risk of pregnancy in subsequent cycles
The Bridge-It study showed that this simple pharmacistdelivered intervention, in which a bridging supply of the progestogen-only pill was given to women requesting emergency contraception along with the offer of rapid access to a sexual and reproductive health clinic, resulted in a significantly higher proportion of women using an effective method of contraception 4 months later compared with when emergency contraception was supplied alone
Summary
Emergency contraception prevents unintended pregnancy after unprotected sex or contraceptive failure,[1] but unless women start an effective method of ongoing contraception after oral emergency contraception, they remain at risk of unintended pregnancy. Women who have unprotected sex after receiving emergency contraception (in the same cycle) are up to three-times more likely to conceive than women who do not,[1,2,3] and without contraception these women remain at risk of pregnancy in subsequent cycles. Current UK and US guidelines recommend initiating regular hormonal contraception immediately after emer gency contraception (known as quick-starting).[4,5]. With the exception of a few areas in the UK in which local arrangements have been made for a finite supply of oral
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