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OB/GYN Editorial September 2001
Access to Emergency Contraception in the United
States
Vivian M. Dickerson, MD
 Emergency
contraception using standard birth control pills—the well-known
"Yuzpe" method—has been prescribed off-label for years. In
1997, the US Food and Drug Administration (FDA) approved Preven,
a pill containing levonorgestrel 0.25 mg and ethinyl estradiol 0.05
mg. As with the Yuzpe regimen, the first dose (two pills) is taken
within 72 hours of intercourse, and the second dose (two pills)
is taken 12 hours after the first dose. In 1999, the FDA ap-proved
Plan B, a levonor-gestrel-only method (0.75 mg) with even greater
efficacy and fewer side effects.1
Since that time, the use of postcoital methods of contraception
has increased somewhat, but not to the extent anticipated. Multiple
reasons for this low usage rate exist. First of all, few clinicians
provide or prescribe emergency contraceptive pills (ECPs) for women
to have on hand "just in case," even though this has been shown
to be effective, even in high-risk young women.2 Second,
only a small proportion of females are aware that such a contraceptive
method is available.3 Third, even if more women were familiar with
ECPs, very few, especially those who have low incomes and/or who
are at high risk for unintended pregnancy, have access to prescribing
physicians.3 And fourth, some women with knowledge and
access may not have time to see their physician in the 72-hour window
of opportunity or they may fear reprimand if they do.4
It is high time that, at the very least, we address the issue of
access. In most states in this country, ECPs may be obtained only
by prescription from a licensed physician/clinician. In general,
this entails a telephone call or an office visit. Currently, approximately
3.2 million pregnancies per year in the United States are unintended;
in 50% of these cases, the couple did not use a contraceptive method,
and in the remaining 50%, the couple experienced method failure.5
It is estimated that widespread use of ECPs could lower the unintended
pregnancy rate by up to 50%.6
Many strategies for improving women's access to emergency contraception
have been described. These include information campaigns, advance
provision of ECPs at routine office visits, standing prescriptions,
and expansion of the range of prescribers to include pharmacists.
This last option continues to disturb some physicians. A few states
(including WA, OR, CA, KS, and IA) allow physicians to delegate
prescriptive authority to pharmacists under strict protocols. A
1997 study concluded that in at least 13 additional states, it would
be possible for pharmacists to prescribe these agents without major
revisions in existing law.7 Most pharmacists favor such
plans because they would increase women's access to ECPs, and be-cause
they would enhance pharmacists' involvement in patient care and
their opportunity to collaborate with physicians.4 The
primary concern of pharmacists has to do with reimbursement, as
payment mechanisms for this service in the absence of a prescription
have not been elaborated to date. In contrast, physicians have cited
concerns about safety, and about lost opportunities to counsel women
about ongoing contraception and to screen for sexually transmitted
diseases (STDs). Both pharmacists and physicians have concerns about
liability.8
It is my opinion that, after years of making ECPs available only
by prescription from a physician/clinician, it is time to remedy
the access problem. Despite my concerns about the degree of freedom
that some pharmacists have taken with the prescriptions that I write—not
to mention the freedom we would grant them to prescribe ECPs themselves—I
am unwilling to hold women hostage in a turf war. Al-though it is
beyond the scope of this editorial to address the issue of over-the-counter
access to ECPs, it is clear that these agents are safe and effective,
and probably do not have the same exclusionary criteria and contraindications
for use that pertain to daily birth control pills. The American
College of Ob-stetricians and Gynecologists has stated that data
regarding safety are limited.9 However, Grimes et al
re-cently published very convincing arguments regarding the safety
of ECPs, as well as the public health imperative that these agents
be readily available.10 I recommend that we work with
pharmacists to create a collaborative program enabling ECPs to be
available from pharmacists on a "demand" basis. In re-turn, pharmacists
will provide ECP users with written referrals to collaborating physician-partners
for counseling, STD screening, and pregnancy testing, with documentation
of the patient-pharmacist encounter available to the physician.
Pharmacists would also need to apprise physician-partners of the
patients whom they have referred for follow-up (to ensure that patients
do, in fact, see their physician afterward). Of course, we must
create policies and procedures that are consistent with good medical
practice, such as written authorization for treatment, contact numbers
for adverse drug reactions, assessment of appropriateness of ECP
administration, and detailed patient instructions for both use and
follow-up. In addition, pharmacies must provide information in a
manner that respects privacy. Further, this program will require
that patients who qualify for state Medicaid or other insurance
programs that cover contraception be apprised of their qualification
and/or enrolled.
Such a program is already ongoing in the state of Washington, and
has been very successful; more than 30,000 women have received ECPs
directly from local pharmacists. This has occurred in an environment
where practitioners and pharmacists have worked in cooperation for
some time. In those states where this has not been the case, such
collaborations would undoubtedly serve patients' best interest.
And where better to begin than with ECPs? In a country plagued by
ongoing sociopolitical turmoil over abortion, it behooves everyone
to explore all possible ways to in-crease access to contraception.
No longer can provision of ECPs be considered the sole purview of
physicians.
Vivian M. Dickerson, MD
Associate Editor
References
- Task Force on Postovulatory Methods of Fertility Regulation.
Randomised controlled trial of levonorgestrel versus the Yuzpe
regimen of combined oral contraceptives for emergency contraception.
Lancet. 1998;352:428-433.
- Raine T, Harper C, Leon K, Darney P. Emergency contraception:
advance provision in a young, high-risk clinic population. Obstet
Gynecol. 2000;96: 1-7.
- Trussell J, Duran V, Shochet T, Moore K. Access to emergency
contraception. Obstet Gynecol. 2000;95:267-270.
- Ellertson C, Shocet T, Blanchard K, Trussell J. Emergency contraception:
a review of the programmatic and social literature. Contraception.
2000;61: 145-186.
- Henshow SK. Unintended pregnancy in the United States. Fam
Plann Perspect. 1998;30:24-29,46.
- Glasier A, Baird D. The effects of self-administering emergency
contraception. N Engl J Med. 1998;339:1-4.
- Wells E, Fuller T, Beck G. Investi-gation of Use of Pharmacist
Pre-scriptive Protocols for Emergency Contraceptive Pills. Seattle,
WA: Program for Appropriate Technology in Health; 1997.
- Blanchard K. Improving women's access to emergency contraception:
innovative information and service delivery strategies. J Am
Med Wom Assoc. 1998;53:238-241.
- American College of Obstetricians and Gynecologists. Emergency
oral contraception. ACOG Practice Patterns #3. Washington, DC:
American College of Obstetricians and Gynecologists; 1996.
- Grimes DA, Raymond EG, Jones BS. Emergency contraception: the
medical and legal imperatives. Am J Obstet Gynecol. 2001;98:151-155.
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