Viewpoint - Access to contraception via community pharmacy

Mr Paul Bissell addresses concerns on access to emergency contraception via pharmacies.

In response to concerns about unwanted and teenage pregnancies, a series of developments aimed at enhancing access to emergency contraception (EC) have been put forward.

Access to EC via commu-nity pharmacies has been a key element in this. From 1999 onwards, accredited pharmacies in Greater Manchester began to supply free EC to requesting users, using patient group directions protocols. Similar schemes now operate in other parts of the UK.

Given the perceived success of these schemes, the manufacturers of EC sought a licence to deregulate (Levonelle-2) from prescription-only to pharmacy (P) status. It is now available OTC, although at a cost of approximately £24.99.

Use of pharmacy-based EC services has been described in controversial terms by some media.

Positive outcomes
Interestingly, most recent evidence from both the US and the UK indicates that pharmacy supply of EC has not impacted on conceptive behaviours and STIs rates in a negative way.

For example, a recent US study randomly assigned 2,117 young women (aged 15-24) to either pharmacy access to EC without a prescription, advanced provision of EC or usual care (requiring a visit to a clinic).

Over the six-month follow-up period, while there was greater use of EC in the advance provision group, pregnancy rates and rates of new STIs were comparable across all groups. Furthermore, the authors argue that eased access to EC did not appear to impact on regular contraceptive use or risky sexual behaviours.

In the UK, the authors of a recent study which used repeated cross-sectional surveys to explore the impact of pharmacy supply on contraceptive behaviours also argue that pharmacy supply had no impact.

We should also consider whether EC users 'miss out' on the opportunity to discuss their contraceptive needs. Research I have been involved in has shown that most pharmacists complied with the protocols governing the supply of EC and were providing contraceptive advice. This might have been due to the training and accreditation elements which were built into this service.

Wider issues
It is open to question, however, whether pharmacists (or their counter staff) routinely provide such counselling when users request EC; there is less research on this issue.

The provision of contraceptive advice at the point of supply is not always be viewed positively. Work I conducted in Manchester showed that women were focused on obtaining EC (thereby avoiding pregnancy) and were thus less amenable to receiving advice about contraception when requesting EC in the pharmacy. There is evidence that younger women have particular concerns about having to ask for EC, and this in itself can act as a deterrent to obtaining it.

It is therefore questionable whether the pharmacy-based services are currently being accessed by those who might be most in need of EC.

Research conducted in Greater Manchester suggests that free supplies of EC distributed through community pharmacies were being sought mainly by women over 20, and that use was mainly confined to higher socio-economic groups. Other researchers involved in advance provision also concluded that their project 'deepened rather than widened' access to EC.

The irony is that in concentrating on the putative links between easier access to EC and contraceptive behaviours and STIs rates, researchers might have overlooked the need to address whether the current configuration of EC services is appropriate for all women - particularly those women who experience social inequality, disadvantage or social exclusion. We need to make sure that contraceptive services can be easily and readily accessed by such women.

- Mr Bissell is lecturer in social pharmacy and pharmacy practice at the school of pharmacy, University of Nottingham

KEY POINTS

  • Emergency contraception (EC) is safe and cheap.
  • It is available OTC.
  • Women who experience social inequality, disadvantage or social exclusion are less likely to take EC.
  • Easy access is effective.
  • Pharmacists provide contraceptive advice and comply with the protocols.

REFERENCES

- Stammers T. Emergency contraception from pharmacists misses opportunity (letter). BMJ 2001; 322: 1,245.

- Raine T R, Harper C C, Rocca C H et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomised controlled trial. JAMA 2005; 293: 54-62.

- Marston C, Meltzer H, Majeed A. Impact on contraceptive practice of making emergency contraception available over the counter: repeated cross-sectional surveys. BMJ 2005; 331: 271-3.

- Bissell P, Anderson C. Supplying emergency contraception via community pharmacies in the UK: reflections on the experiences of users and providers. Soc Sci Med. 2003; 57: 428-33.

- Free C, Lee R, Ogden J. Young women's accounts of factors influencing their use and non use of emergency contraception. BMJ 2002; 325; 1,303-8.

- Ziebland S, Wyke S, Seaman P et al. What happened when Scottish women were given advance supplies of emergency contraception? Soc Sci Med 2005; 60: 1,767-9.

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