CorrectCare

Juvenile Voice

Emergency Contraception in Maryland

In this column, Judith Robbins, LCSW, JD, CCHP-A, talks with a team of health professionals from the Maryland Department of Juvenile Services about an emergency contraception program in DJS facilities.

JR: What is emergency contraception?

     DJS: EC is a safe, effective method to prevent unintended pregnancy after sexual intercourse. The most common type of EC is oral hormonal medication, often called the “morning after pill.” The most widely used product of this type is Plan B, which consists of 1.5 mg of levonorgestrel (available either as two 0.75 mg tablets taken together or a single pill) taken up to 120 hours (five days) after intercourse. Plan B works to prevent pregnancy by thickening cervical mucus, preventing ovulation and affecting sperm or ova movement through the uterus. Plan B does not harm an existing pregnancy nor cause an abortion.
     Women may choose Plan B in many situations, such as sex without a condom, condom breakage, rape, unprotected sex with inconsistent use of hormonal birth control (or during the first month of hormonal birth control) and unprotected sex while impaired by drugs or alcohol.
     Plan B is approved by the FDA for over-the-counter sales to those age 17 and older. For those younger than 17, it is available by prescription.

JR: Why did you start an EC program at your secure juvenile justice facilities?

     DJS: In the United States, nearly 1 million teenagers become pregnant each year and approximately four out of five of those pregnancies are unwanted. Girls in the juvenile justice system are at an even greater risk due to inconsistent condom use, early sexual activity, prostitution, substance abuse, gang involvement, mental illness and histories of sexual or physical abuse.
     Secure juvenile justice facilities have a prime opportunity to link youth to reproductive health services, including EC. The Maryland DJS recognized an opportunity to prevent unintended pregnancies and also wanted DJS girls to have access to the same services available in the community. The EC screening process also starts an important conversation about family planning options and sexual health in general.

JR: How does your EC program work?

     DJS: The program is nurse directed and integrated into the nursing intake assessment. Upon admission, all girls are offered testing for pregnancy, HIV, syphilis, gonorrhea and chlamydia. We also obtain a reproductive health history that includes questions about the date of last sexual intercourse, contraception use and pregnancy concerns. If a youth has had possibly unprotected sexual intercourse in the past 120 hours and doesn’t want to become pregnant from that encounter, the EC protocol is initiated.
     Among the forms we developed to facilitate EC administration are a fact sheet, consent form and protocol flow sheet. When youth qualify for EC, the nurse initiates discussion guided by the fact sheet. If the youth wants EC, the nurse proceeds to the protocol flow sheet, which outlines the process for determining eligibility, obtaining consent, getting a physician’s verbal order, administering EC and scheduling follow-up.

JR: How did you introduce the program and train the staff? Were there any challenges?

     DJS: During the planning phase, we sought feedback from stakeholders including health care staff, facility superintendents and DJS legal counsel. We developed a comprehensive nurse training module that discussed background on EC, the protocol and documentation, potential ethical concerns and strategies for communicating with youth. The trainings included a PowerPoint lecture, interactive scenarios and case studies.
     Initially, some nurses had misconceptions about EC, confusing it with “the abortion pill” or thinking it could harm existing pregnancies. Others felt that DJS youth would not be interested in EC. The training addressed these concerns. We assessed knowledge through pre- and post-training tests. Test scores improved dramatically from an average 62.9% before training to an average 98.6% after training.

JR: What have you learned through program evaluation?

     DJS: Program evaluation strategies include chart reviews, observation of intake assessments, and nurse and youth surveys. Our goals are to ensure that EC materials are youth-friendly, that nurses feel comfortable counseling youth on these issues and that girls who receive EC get appropriate follow-up. Nurses have reported high efficacy in using the EC protocol. Our greatest challenge has been ensuring consistent screening within the 120-hour window.

— About the contributors: Judith Robbins, LCSW, JD, CCHP-A, directs the Juvenile Detention Mental Health Program of Yale Behavioral Health, Department of Psychiatry, Yale Medical School, New Haven, CT. She represents the National Association of Social Workers on NCCHC’s board of directors and chairs the juvenile health committee.
     At the Maryland DJS, Jennifer Maehr, MD, is the medical director and a board-certified pediatrician and adolescent medicine specialist. Jessica Burns, RN, MSN/MPH, is a nursing program consultant. Alison Smith, RN, BSN, is a Johns Hopkins University graduate student intern.

[This article first appeared in the Fall 2009 issue of CorrectCare.]