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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Health Sciences Center, University of New Mexico, Albuquerque, New Mexico.
Address reprint requests to: Eve Espey, MD, MPH, Department of Obstetrics and Gynecology, Health Sciences Center, 2211 Lomas Boulevard NE, ACC-4 1 UNM, University of New Mexico, Albuquerque, NM 87131; E-mail: eespey{at}salud.unm.edu.
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ABSTRACT |
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METHODS: Two research assistants posed as women needing emergency contraception. They visited 89 pharmacies in Albuquerque, New Mexico, presenting a prescription for either Plan B or Preven. The assistants recorded the availability of the products in the pharmacies. When the product was not in stock, the research assistants asked pharmacy providers why the products were not carried. Fisher exact test was performed to compare categoric data.
RESULTS: Plan B and Preven were in stock at only 19 visits (11%). Of the pharmacies that did not stock the products, 53% reported they could obtain Plan B or Preven within 24 hours. The most common reason cited by pharmacy providers for not stocking Plan B or Preven was the lack of prescriptions received for them (65%).
CONCLUSION: Plan B and Preven were not in stock at the majority of pharmacies in a moderately sized metropolitan area. Lack of availability at the pharmacy constitutes a major barrier to emergency contraception access.
Emergency contraception has the potential to prevent a sizable portion of the 3 million unintended pregnancies yearly in the United States.1 Previous studies have focused on some determinants of emergency contraception usage: women’s knowledge of the method,2–4 providers’ knowledge about emergency contraception,5,6 prescribing and dispensing patterns of physicians and clinics,3,7 and barriers to access for women requiring a prescription for emergency contraception on short notice.8
This study examined one further crucial determinant of emergency contraception usage: its availability at local pharmacies. A previous study used the method of calling the 1-888-NOT-2-LATE hotline to determine how many calls would result in a timely prescription for emergency contraception.8 The current study was designed to determine whether a patient with a prescription in hand could have it filled in a timely fashion. We investigated whether women who had secured a prescription for Plan B or Preven within the recommended time frame encountered obstacles to usage—either unavailability of the prescription at pharmacies or unwillingness on the part of pharmacists to dispense the method. This study was conducted to examine and compare the availability of Plan B and Preven for women in Albuquerque, New Mexico. We also aimed to identify differences between availability on weekends versus weekdays, reasons provided for not carrying the products, and the helpfulness of pharmacy providers to the research assistants when the product was unavailable.
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METHODS |
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Prescriptions for Plan B and for Preven were written for each of two research assistants, one woman in her 20s and one woman in her 40s. Each research assistant was instructed to role play a woman presenting to a pharmacy with a prescription for emergency contraception. The assistants were provided a script beginning with the question, "I would like to know if I can get this prescription filled today?" If the product was unavailable, the research assistant asked further questions, including the ability and time frame for ordering the prescription. Availability was categorized as "in stock," "able to be ordered," or "never available." If the pharmacy provider could order the product, he or she was asked whether it would be available within 24 hours or in more than 24 hours. The product was considered "never available" when the pharmacy provider indicated that the medication either could not be ordered (eg, unavailable through the wholesaler) or would not be ordered (eg, as a result of moral objections).
If the medication was not in stock, the research assistant asked questions about whether substitutions were available and why the item was not carried by the pharmacy. Typically, the research assistants spoke with a pharmacy technician at the counter. If the technician was unable to provide answers to questions, the assistants asked to speak to a pharmacist. In addition to coding categoric answers, the assistants recorded pertinent comments made by pharmacy personnel, including assistance provided to obtain the product when it was not available in the pharmacy.
We considered emergency contraception to be available in a timely fashion when it was in stock or able to be obtained within 24 hours. Although women have up to 4 to 5 days during which emergency contraception may be effective,9 we assumed that obtaining the prescription may take several days. In visits where the medication was not in stock or was not available within 24 hours, the authors reviewed the comments on the code sheets to determine whether the pharmacy provider had been helpful to the research assistant in obtaining a substitution or in having the prescription filled elsewhere. Three categories were established: helpful, somewhat helpful, and unhelpful. If the pharmacists or technicians were helpful, they spontaneously called or offered to call the prescribing physician to substitute another form of emergency contraception (eg, combined pills) or called another pharmacy to determine availability elsewhere. If they were somewhat helpful, they spontaneously or with prompting suggested an alternative form of emergency contraception or suggested another pharmacy. If they were unhelpful, they provided no further information, despite prompting.
Pharmacy visits were made on all days of the week at the convenience of the research assistant between the hours of 8 AM and 7 PM. All pharmacy visits were made between March and June 2002. The research assistants completed the questionnaires immediately after leaving each pharmacy. Each research assistant visited all identified pharmacies but presented the Plan B prescription at half the pharmacies and the Preven prescription at the other half. The research assistants divided the list such that if one research assistant presented Preven to one pharmacy, the other research assistant presented the Plan B prescription to that pharmacy. In this way, each pharmacy was presented with a prescription for both Plan B and for Preven.
The responses to the questionnaires were entered into Epi Info 6.2. Statistical methods included Fisher exact tests of categoric data.
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RESULTS |
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). The overall availability of Plan B was not different from that of Preven (Fisher exact test, P = .30). However, the percentage of pharmacies with Plan B in stock was somewhat less than Preven, though not significantly different (6.8% versus 14.3%, Fisher exact test, P = .09). Although the specifically prescribed, dedicated product was available in only 11% of visits, 20% of pharmacies did stock one or the other dedicated product. Additionally, 53% of pharmacies could obtain either Plan B or Preven within 24 hours.
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Of the 159 visits in which Plan B and Preven were not in stock, 128 pharmacy providers answered the research assistant’s query about the reason the product was not carried. The most common reason for not carrying Plan B or Preven in the pharmacy was lack of perceived need, cited by 65% of pharmacists or technicians. Responses like "we never get this prescription" or "it sat in stock until it expired" were the most common comments accompanying the box checked "lack of perceived need." Corporate policy against stocking emergency contraception and local decisions not to carry or dispense emergency contraception were cited by only 6% and 7% of pharmacy providers, respectively. Seven percent of pharmacy providers reported that the requested dedicated product was not available because the pharmacy carried the other dedicated product.
In only 21% of visits was the pharmacy provider considered to be helpful to the research assistant who was not able to obtain her prescribed product immediately or within 24 hours. In 37% of visits, the pharmacy provider was considered to be somewhat helpful. The most common response of pharmacy providers in the somewhat helpful category was "try another pharmacy down the street." In 42% of pharmacy visits, the pharmacy provider was considered to be unhelpful. In addition, pharmacy providers where emergency contraception was never available were significantly less likely to be helpful than in pharmacies where a product was in stock or could be ordered (P = .02)
There was no difference in availability of Plan B or Preven obtained between the two research assistants (Fisher exact test, P = .24).
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DISCUSSION |
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The fundamental problem is likely one of awareness; women do not have the knowledge to ask about emergency contraception, and providers only offer prescriptions when the medication is requested. A recent survey of reproductive-aged men and women revealed that only 66% of women and 51% of men had heard of emergency contraception. Only 1% of women had used it, and only 11% of the women had adequate knowledge to use it effectively.10 Few physicians include emergency contraception in routine counseling about contraception.3,5 Surveys of physicians demonstrate that although the majority have written a prescription for emergency contraception in the last year, few have written more than five.4 In typical clinical practice, the provision of advance prescriptions for emergency contraception is rare. However, several recent studies demonstrate that when advance prescriptions are provided, women are more likely to use emergency contraception than when they must request a prescription from the provider.11–13
We had predicted that the primary reason for the lack of availability of Plan B and Preven would be moral objections to providing emergency contraception. Although no studies have specifically examined attitudes of pharmacists, surveys of knowledge and attitudes among different populations in the United States have shown that about a third of respondents have ethical concerns about emergency contraception.2,3,14
We found that few pharmacy providers expressed ethical concerns when visited by the research assistants. Of the minority of pharmacy providers who expressed ethical objections, few helped ensure that patients were able to secure the medication in a timely fashion. Additionally, the research assistants suspected that sometimes pharmacy providers reported an inability to order emergency contraception when, in fact, they were simply reluctant to do so, perhaps for moral reasons that they were unwilling to discuss.
Another important finding of this study is the increased difficulty in obtaining emergency contraception in a timely manner over the weekend. Decreased access to providers for emergency contraception prescriptions over the weekend is a well-recognized problem.15,16 Lack of availability at the pharmacy is an additional hurdle.
Regardless of the reason for not carrying emergency contraception, few pharmacy providers were helpful to the women who sought to prevent pregnancy. The majority of pharmacy providers lacked a positive approach to helping women with a need for a medication with time-limited effectiveness. This lack of guidance could seriously limit the ability of emergency contraception to decrease unintended pregnancy. Guidelines for referring such women could address this shortcoming.
We speculate that lack of knowledge on the part of both patients and providers has contributed to the lack of demand for Plan B and Preven. Educational interventions show some promise in increasing prescriptions for emergency contraception. Beckman et al6 found a 20% increase in the number of providers who wrote prescriptions for emergency contraception a year after an educational in-service. Legislation has been proposed locally and nationally to fund media campaigns to get the word out to the general public and to providers about the "well-kept secret" of emergency contraception.
A number of strategies may be required to improve the availability and use of emergency contraception. We echo the recommendations of Trussell et al,8 who call for the routine discussion of emergency contraception during visits with providers, liberal use of advance prescriptions, and abandonment of requirements for physical examinations or pregnancy tests for women seeking emergency contraception. We agree with legislative strategies to improve access to emergency contraception, such as making emergency contraception available without a prescription. Our findings suggest an additional critical requirement: Education of patients and providers to increase requests for emergency contraception products might encourage more pharmacies to stock these products and allow emergency contraception to fulfill its potential in reducing unintended pregnancy.
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Footnotes |
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Received May 28, 2003. Received in revised form July 29, 2003. Accepted August 7, 2003.
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REFERENCES |
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2. Van Royen AR, Calvin CK, Lightner CR. Knowledge and attitudes about emergency contraception in a military population. Obstet Gynecol 2000;96:921–5.
3. Delbanco SF, Mauldon J, Smith MD. Little knowledge and limited practice: Emergency contraceptive pills, the public and the obstetrician-gynecologist. Obstet Gynecol 1997; 89:1006–11.[Abstract]
4. Harper C, Ellertson C. Knowledge and perceptions of emergency contraceptive pills among a college-age population: A qualitative approach. Fam Plann Perspect 1995; 27:149–54.[Medline]
5. Grossman RA, Grossman BD. How frequently is emergency contraception prescribed? Fam Plann Perspect 1994;26:270–1.[Medline]
6. Beckman LJ, Harvey M, Sherman CA, Petitti DA. Changes in providers’ views and practices about emergency contraception education. Obstet Gynecol 2001;97: 942–6.
7. Brown JW, Boulton ML. Dispensation of emergency contraceptive pills in Michigan Title X clinics. Am J Public Health 1998;88:1380–3.
8. Trussell J, Duran V, Schochet T, Moore K. Access to emergency contraception. Obstet Gynecol 2000;95: 267–70.
9. Ellertson C, Evans M, Ferden S, Leadbetter C, Spears A, Johnstone K, et al. Extending the time limit for starting the Yuzpe regimen of emergency contraception. Obstet Gynecol 2003;101:1168–71.
10. Delbanco SF, Stewart FH, Koenig JD, Parker ML, Hoff T, McIntosh M. Are we making progress with emergency contraception? Recent findings on American adults and health professionals. J Am Med Womens Assoc 1998;53: 242–6.[Medline]
11. Grimes DA, Raymond EG, Jones BS. Emergency contraception over-the-counter: The medical and legal imperatives. Obstet Gynecol 2001;98151–5.
12. Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med 1998;339:1–4.
13. 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.
14. Ellertson C, Ambardekar S, Hedley A, Coyaji K, Trussell J, Blanchard K. Emergency contraception: Randomized comparison of advance provision and information only. Obstet Gynecol 2001;98:570–5.
15. Golade BA, Kirkman RJE, Elstein M. Emergency contraception, weekends and bank holidays: Improving access through cooperation between hospital and community based services. Br J Fam Plann 1996;22:120–2.
16. Priddy A, Reed B. A survey of hospital based out-of-hours emergency contraception service. Br J Fam Plann 1996;21: 139–41.
This article has been cited by other articles:
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  S. Dunn MD, T. E.R. Brown PharmD, and J. Alldred BSc Pharm Availability of emergency contraception after its deregulation from prescription-only status: a survey of Ontario pharmacies Can. Med. Assoc. J., February 12, 2008; 178(4): 423 - 424. [Abstract] [Full Text] [PDF]
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 Committee on Adolescence Emergency Contraception Pediatrics, October 1, 2005; 116(4): 1026 - 1035. [Abstract] [Full Text] [PDF]
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