Emergency contraception (EC) has been available in the United States for almost a decade. It is a safe and effective contraceptive choice when other methods have failed or have not been used and a pregnancy is not desired. Still, many barriers exist to the prompt and reliable provision of EC to appropriate patients. While the ethical battle concerning EC will likely never cease, these concerns do not represent the greatest barriers to appropriate EC access.

A new study published in the journal Pediatrics concluded that, among members of the American Academy of Pediatrics Section of Emergency Medicine who are attending emergency physicians, 85% had prescribed EC, and 71% had done so within the past year. Nearly three-quarters of physicians reported a concern about the lack of follow-up care as the primary barrier to providing EC. Other common barriers included time constraints (40%), lack of clinical resources (33%), concern about discouraging regular contraceptive use (29%), and concern about possible birth defects (27%). Only 14% of physicians reported ethical beliefs as a barrier to the provision of EC. In total, 39% of physicians reported 5 or more barriers to prescribing EC for their patients. Understandably, the more barriers reported, the less likely the physician was to have ever prescribed EC.

Interestingly, only 11% of the emergency department physicians in the recent survey cited lack of knowledge about EC as a barrier to providing EC to their patients. However, as part of the same survey, physicians answered knowledge-based questions about EC and only 57% were able to correctly answer more than half of the questions. For example, many physicians incorrectly answered that EC was effective within the first 24 hours after unprotected sexual intercourse; EC is actually effective within the first 72 hours after intercourse, with limited effectiveness up to five days after intercourse.

Several recent studies have examined barriers to effective provision of EC, in an effort to reduce the obstacles facing some women seeking EC. Not surprisingly, provision of EC by physicians depends on practice specialty, year of graduation, gender, religion, and location. As expected, physicians practicing in obstetrics and gynecology prescribe EC more than other practice specialties; women also prescribe EC more than male counterparts. Overall, however, a majority of physicians in many studies do not routinely prescribe EC, do not initiate conversations about EC with their patients, and do not offer advance prescriptions for EC.

Recently, EC was made available without a prescription for women over 18 years old. (Patients 17 years old and younger may obtain EC, but need a prescription to do so.) While this increased access may seemingly diminish some barriers to EC access, more barriers were discovered among pharmacists. Another recent survey in the journal Contraception reported that many pharmacists are providing inaccurate information about EC. Not all pharmacies maintain a supply of EC, and it is appropriate for these pharmacists to refer patients elsewhere. However, some pharmacies inappropriately reported that nothing could be done for patients requesting EC in these cases. Also, pharmacists often did not provide accurate and timely information to patients requesting EC, even if EC was available on the premises. These barriers from physicians and pharmacists all prevent many women from obtaining, or even understanding, EC.

Pharmacists reported other barriers to EC in yet another survey from early 2009 in the Journal of the American Pharmacists Association. In this survey, pharmacists reported a lack of time, lack of reimbursement, and resistance from physicians as barriers to efficient access to EC in the community pharmacy setting. This survey of more than 2700 pharmacists, in contrast to the Contraception study, reported a strong interest, comfort level, and knowledge base in increasing access to EC. Practice guidelines and up-to-date information would further increase pharmacist support for providing EC in the community setting.

Many healthcare providers report concerns about increasing sexually irresponsible behavior and decreasing use of regular contraceptive practices if access to EC is increased. To date, most studies have not supported this belief. Instead, education about the proper use of EC has not reduced the use of regular contraceptives or increased sexual behavior among groups at-risk for unintended pregnancies.

Even after 10 years, barriers exist in the appropriate provision of EC to patients in need. While some of the barriers are physician- or pharmacist-related, others are still patient-related. Unfortunately, socioeconomic status and geographic location are barriers to EC, as they are to the provision of other medical services. Patients in lower socioeconomic brackets are more likely to access EC if it is available in a community pharmacy without a prescription, but some rural pharmacies do not maintain a supply of EC.

Estimates suggest than more than half of the 3.5 million unintended pregnancies in the United States each year could be avoided with timely access to EC. Overall, however, there is still an under-utilization of EC, even with procedures in place to seemingly increase access to it. This under-utilization results from barriers from patients, as well as the health care community. While the moral and ethical debate concerning EC practices will continue, these barriers are not the most significant in most cases. By directing the appropriate time, clinical resources, and education to physicians and pharmacists, EC access could be increased to patients in a prudent and professional manner.

References

Chuang, C. (2004). Emergency contraception: prescribing practices of general internists compared with other primary care physicians Contraception, 69 (1), 43-45 DOI: 10.1016/j.contraception.2003.09.003

Costa NF, Ferraz EA, Souza CT, Silva CF, Almeida MG. [Access to emergency contraception: old barriers and new questions]. Rev Bras Ginecol Obstet. Feb 2008;30(2):55-60.

Goyal, M., Zhao, H., & Mollen, C. (2009). Exploring Emergency Contraception Knowledge, Prescription Practices, and Barriers to Prescription for Adolescents in the Emergency Department PEDIATRICS, 123 (3), 765-770 DOI: 10.1542/peds.2008-0193

Landau, S., Besinque, K., Chung, F., Dries-Daffner, I., Maderas, N., McGhee, B., & Foster, D. (2009). Pharmacist interest in and attitudes toward direct pharmacy access to hormonal contraception in the United States Journal of the American Pharmacists Association, 49 (1), 43-50 DOI: 10.1331/JAPhA.2009.07154

LANDAU, S., TAPIAS, M., & MCGHEE, B. (2006). Birth control within reach: a national survey on women’s attitudes toward and interest in pharmacy access to hormonal contraception? Contraception, 74 (6), 463-470 DOI: 10.1016/j.contraception.2006.07.006

NELSON, A., & JAIME, C. (2009). Accuracy of information given by Los Angeles County pharmacies about emergency contraceptives to sham patient in need??? Contraception, 79 (3), 206-210 DOI: 10.1016/j.contraception.2008.10.003

Raine, T. (2005). Direct Access to Emergency Contraception Through Pharmacies and Effect on Unintended Pregnancy and STIs: A Randomized Controlled Trial JAMA: The Journal of the American Medical Association, 293 (1), 54-62 DOI: 10.1001/jama.293.1.54

Sarkar, N. (2008). Barriers to emergency contraception (EC): does promoting EC increase risk for contacting sexually transmitted infections, HIV/AIDS? International Journal of Clinical Practice, 62 (11), 1769-1775 DOI: 10.1111/j.1742-1241.2008.01827.x

Xu, X., Vahratian, A., Patel, D., McRee, A., & Ransom, S. (2007). Emergency Contraception Provision: A Survey of Michigan Physicians from Five Medical Specialties Journal of Women’s Health, 16 (4), 489-498 DOI: 10.1089/jwh.2006.0196