Knowledge and availability of the emergency contraceptive pills: an Italian women survey

A 12-question questionnaire was organized to investigate the knowledge about the emergency contraceptive pills in a sample of Italian women. The questions’ scheme was adapted according to the questionnaire already administered to women and pharma-Revised


Introduction
Emergency contraception refers to methods of contraception that can be used to prevent pregnancy after sexual intercourse at risk for fertilization.These are recommended for use within five days, but are more effective the sooner they are used after the act of intercourse.Both pills and intrauterine copper devices are recommended for emergency contraception, and it is not acknowledged these provoke abortion [1].
Emergency contraceptive pills (post coital pills) prevent pregnancy by preventing or delaying ovulation.There are no absolute contraindications for using emergency contraceptive pills at any age of a fertile woman aiming to prevent an unintended pregnancy [1].Two pills have been registered worldwide as emergency contraceptives.The first one is the levonorgestrel-based pill, while the second one is the ulipristal-acetate based pill (also called "five day-pill").Both are effective in preventing the fertilization with similar pregnancy rate [2,3].Side effects of emergency contraceptive pills are not common, mild, and do not need further medications [1].
In Italy, both levonorgestrel-based and ulipristal-acetate pills are bought at the pharmacy.From 2011 to 2015, the ulipristal-acetate pill was available with some restrictions: it was mandatory a medical prescription and a negative pregnancy blood sample test.After 2015, the medical prescription for ulipristal-acetate pill is only mandatory for less than 18-year-old women (without pregnancy test), and, since 2016, same kind of prescription to younger women is needed for the levonorgestrel pill.In summary, the Italian law has been organized with the aim to facilitate availability to emergency contraception for preventing unwanted pregnancy.However, in the past, the suspicious that both emergency pills could provoke abortion (by interfering with the implant processes) still causes many religious concerns among physicians and pharmacologists, leading to hamper the availability of the emergency contraception.
The aim of the following investigation is to assess to what extent do Italian women know about the emergency contraceptive pills and about their availability.

Materials and Methods
A 12-question questionnaire was organized to investigate the knowledge about the emergency contraceptive pills in a sample of Italian women.The questions' scheme was adapted according to the questionnaire already administered to women and pharma-  1 and were administered from the first to the last one.Responders did not known the succeeding question before answering the previous one, thereby avoiding conditioning.The answers are both closed and open, providing the chance to give comments or to answer with open statements to the questions.For questions 2 and 7, an additional question was queried in case of the answer "no" (Question 2) or "hardly" and "very hardly" (Question 7).The concepts expressed in the open answers were summarized and aggregated, when appropriate.The questionnaire was administered in Italian language between April 2018 and August 2018.
Women enrolled were between 18-and 40-years-old and they could not be neither physicians nor pharmacists.The sample was built by sending the questionnaire online, by using the Computer Assisted Web Interviewing (CAWI).The questionnaire was build by using "Google moduli".The link of the questionnaire form was sent by e-mails or by Facebook and WhatsApp contacts of one of the Author (Anna Clara Castigliego) of this paper.People contacted were invited to share the questionnaire by using the same social-network way.An additional way of administration of the questionnaire was through direct interview, in crowded places, drawn by Anna Clara Castigliego.Women were invited to communicate some information (age, education, place of Italy where they were from, parity, previous pregnancy interruption), along with the answers to the questionnaire.All data were treated anonymously according to Italian law.Incomplete questionnaires or information and questionnaires with nonsense open answers were rejected.The answers and the general information of women were crossed in order to find relationships in a univariate way.Chisquare test was used for comparisons, with a p-value set at ≤ 0.01 for significance.

Results
1,490 questionnaires were sent by the CAWI technique, while 182 were collected by direct interview.Among them, 1,580 eligible women fully answered to the questionnaire (1,419 online and 161 direct interview).Table 1 reports rates of each answer for each question, along with details of open answers.Tables 2 and 3 report crude numbers and rates of age, education, place of Italy where the women were from, parity and previous pregnancy interruption in the first lines.The Tables also report answering rate according to general information provided by women (age, education, place of Italy where the women were from, parity, and previous pregnancy interruption) along with univariate comparisons.Significant results indicated that age and/or education and/or place of Italy where the women were from and/or parity and/or previous pregnancy interruption conditioned the answers rates.
As it appears in Tables 2 and 3, the majority of interviewed were young (between 18-and 24-years old) and 79.7% were under 30 years.Therefore, the majority of interviewed were students, with middle or secondary school bachelor and they did have not had previous pregnancies (higher proportion of nulliparas and with no previous preg-nancy interruption).Concerning the place of Italy were the women were from, the sampling was overall homogeneous, with a higher prevalence of respondents from the center of Italy.A smallest quote of respondents were not Italian, but lived in Italy and participated to the Italian health system.It was chosen to provide data even for this small proportion of patients.
The wide majority of interviewed feel it is appropriate to plan a pregnancy (Question 1).Education and parity significantly condition the rates of answers.Additionally, the wide majority of interviewed are in favour of oral contraceptive use (Question 2).The wide majority of women know the "post-coital pill" (Question 3), despite many respondents do not know both pills (Question 4), and someone mistakes the abortive pill (RU486) or the common contraceptive pill with the emergency contraceptive pill (Table 1).Less than an half of women disclosed they have taken the emergency contraception pill (Question 5).Age, place of Italy, education, and previous pregnancy interruption condition the rates of answers.Assessing answers of Question 6, it appears that a consistent proportion of respondents (18.2%) think that the "post-coital pill" is useless, and 9.3% provided other answers, suggesting poor knowledge of the "post-coital pills" or own religious beliefs (Table 1).Place of Italy where women were from conditioned the rates of answers.A quite large proportion of women found it difficult to obtain the "post-coital pill" (Question 7).Reasons seems linked with the need of the prescription (Table 1).
More than an half of the interviewed did not know how the emergency contraceptive pills works (Question 8).Age, place of Italy where the women were from, and parity affected the rate of answers.The answers given to the Question 9 confirm that women poorly know how the emergency contraceptive pills work.The Questions from 10 to 12 investigate how difficult is to obtain the five-day pill and why.It seems that the need of prescription is sometimes advocated to create resistance to give the pill, while the resistance of the pharmacologists to provide the pill seems unspecific.Age, place of Italy where the women were from, and parity affected the rate of answers for Questions 10, 11, and 12.

Discussion
Information from the current questionnaire should be retained for improving the knowledge on the availability of the emergency contraceptive pills in Italy.As reported below, in 2015 [4], a similar online interview of Italian women and pharmacists had highlighted that the availability of ulipristal acetate pill and of the post-coital pills overall was difficult due to resistance of pharmacists to provide them.Results from the current questionnaire, drawn in 2018, confirm that the behavior of the Italian pharmacists remain unchanged from the women's point of view, despite    [5]; can the pharmacist pose resistance for the emergency contraception to be a "defensive pharmacology?"Recently, in United States, Lio et al. [6] have reported that the discomfort of pharmacists to provide contraception was linked to concern on liability, confirming similar behavior previously suggested by Hilverding et al. [7] and by Rodriguez et al. [8] in case of pharmacists' prescription of contraceptives.Moreover, since 2014, Italian pharmacists have also acknowledged that the prescription of some drugs is needed to avoid abuse, minimize risks, and educate patients on the correct use of medicines [9], thereby achievig their ethical goal of providing the best drugs administration.Therefore, it could be supposed that the current resistance of pharmacists to provide emergency contraception would involve at least ethic, religious, and liability issues in Italy.

Conclusion
The current study provides evidence that a proportion of women in Italy still have difficulties to obtain post-coital pills despite governmental dispositions for allowing an eas-ier emergency contraception.Poor knowledge of both the emergency contraception and of how to obtain the drugs have been proved.Additionally, a pharmacists' resistance to provide pills is involved in the phenomenon.Pharmacists' concerns to provide emergency contraception should be best investigated from a juridical point of view.

2019 CEOG Clinical and Experimental Obstetrics & Gynecology
Revised manuscript accepted for publication June 25,

Table 1 .
-List of questions and rates of answers.Do you know that, if the pregnancy is implanted on the uterine wall, the "post coital" pill could not work?The last available "post coital" pill name is "trade name" (ulipristal acetate).It is also called 5-days pill.From your knowledge, do you know if the medical doctor prescription is needed to buy it?The 2015 questionnaire aimed to assess the ulipristal-acetate pill availability in Italy after the Italian governmental change in the prescription of emergency contraceptive ulipristal-acetate pill.The questions of the current questionnaire are listed in Table

Table 2 .
-Descriptive and inferential statistics.Sub-groups analyses for each question.

Table 3 .
-Descriptive and inferential statistics.Sub-groups analyses for each question (following).thediffusion of the knowledge that the post-coital pills are safe and easily available.The resistance of Italian pharmacists does not seem linked only to religious concern, or, in case of religious concern, it cannot be excluded that it is advocated to avoid providing emergency contraception.It is unclear if such a kind of resistance of the pharmacists could favor the misunderstanding of emergency contraception for women, who feel that the pharmacists are aware that the pills are dangerous.Poor knowledge of emergency contraceptive pills seems in relation to age, education, and place of Italy where respondents were from (rates of answers for Question 6, 7, and 8).It could be supposed that, if women were not well informed about the emergency contraceptive pills, they referred to pharmacists for counseling on the post-coital pills, and, for avoiding liability, the pharmacists delegate the counseling to physicians by querying the prescription of emergency contraception.As in Italy, the jurisprudence orientation has acknowledged that the pharmacist has not liability if he carefully follows the prescription of the physicians