Breaking barriers to emergency contraception

sad woman

Pharmacists and women alike need more education about the supply of Emergency Contraception, also known as the Morning After Pill, in order to improve access to the medicine.

So says Dr Safeera Hussainy, from Monash University’s Centre for Medicine Use and Safety, who with colleagues is conducting research exploring access to EC from community pharmacy, and how it could be improved. Her work was highlighted by Monash today as part of International Women’s Day.

In 2008-10, Dr Hussainy and her team implemented a national survey of pharmacists to find out what they knew about EC, and what their attitudes were.

“Their knowledge was good, however their attitudes and practices were sub-optimal,” she told the AJP.

“Some of them had quite paternalistic attitudes towards supplying it, they acted as gatekeepers and they had the belief that EC acts as an abortifacient, rather than emergency contraception, when it simply isn’t. This prompted a revision of the most commonly-used guidelines, the PSA guidelines, at the time.”

Three major changes in provision were warranted, Dr Hussainy says: regarding the time frame the medicine is supplied, supply to under-16s and advance supply.

“Emergency contraception can be used up to four days, effectively up to 96 hours after unprotected sex – the literature says 72, but later evidence says 96 and possibly we’re seeing now a little longer,” she says.

“We were finding a lot of pharmacists weren’t supplying it after 72 hours.

“We also included in the guidelines the fact that you can supply to women who are under the age of 16 as long as they meet certain criteria – we followed guidance from the UK around that.

“It’s also possible for women to have EC on hand for future use. If women come to the pharmacy and say, ‘I’m going on holiday, I’d like to have a packet on hand,’ or just wanting a packet on hand anyway, that’s legitimate.”

The evidence shows “no real medical reasons or contraindications” for not supplying EC, she says.

Attitudes and knowledge have improved in the years since, Dr Hussainy says, but could improve further.

She is now working on ACCESS: a qualitative study exploring barriers and facilitators to accessing the emergency contraceptive pill from community pharmacies in Australia.

The results, which include telephone interview data from a large sample of women and pharmacists, are not yet analysed but Dr Hussainy says that her observations so far point to a need for greater education for women, many of whom remain unaware that EC is available over the counter.

“The aim is to explore what barriers there are to accessing this important drug, because it’s a time-sensitive drug and not contraindicated, its supply should be relatively straightforward and yet women are still having difficulty getting it,” she says.

“Some are having to go to a doctor when a doctor’s visit is not usually necessary, unless the pharmacist suspects sexual abuse or something else untoward, or it’s outside the time frame.

“A major finding is that many women still don’t know it’s available OTC. That’s something we really need to work on, and advertising is a problem because it’s S3, so addressing that could take years. We could also look at how it’s promoted within pharmacies, which could work as it’s not really an advertised product, but you could advertise the professional service in pharmacy.

“We’re looking at strategies to make the entire process more woman-friendly and less judgemental. Our next steps are to take these ideas and propose a pilot for them this year.

“My hope is that women, not just in Australia but all around the world – because we know that in both developed and developing countries, there are issues with accessing this life-saving commodity – will be able to access emergency contraception with ease and without judgement, and that where referral is necessary, that it happens.”

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  1. Jarrod McMaugh

    It’s not accurate to say there are no contraindications, but they aren’t a major consideration, either.

    Clearly a patient who is sensitive/allergic to ingredients will have an issue.

    Secondly, diagnosis of existing ectopic pregnancy may be delayed when utilising EHC, although past history or abdominal discomfort would be the only signs to guide on this potential (history being easy to determine but uncommon, abdominal pain being a very diffuse symptom to base a decision on)

    Of greater concern is misunderstanding by pharmacists about the nature of this medication. As Dr Hussainy pointed out, there are still a minority of pharmacists who believe this medication causes an abortion – these pharmacists need to review the pharmacology of this medication.

    Also relevant are HCPs who have a consienscious objection to contraceptives (ie barrier methods, OCP, EHC, etc). These HCPs need to ensure they have a protocol in place to assist patients access treatment via an alternative source without disadvantaging the patient or causing undue distress or delay in treatment.

  2. Marc Grimer

    Not an abortifacient? My understanding is that this prevents the implantation of a fertilised ovum. Anything that arrests the development of the human life past the point of conception is an abortifacient. Certainly “contraceptives” by definition, arrest the process before this point, so it’s certainly incorrect to call it that.

    • Jarrod McMaugh

      Look to the medical definition of conception and this will clarify your concerns here

      EHC is a contraceptive, not an abortifacient.

  3. Marc Grimer

    do you mean this one?
    The precise moment of conception is that at which the male element, or spermatozoon, and the female element, or ovum, fuse together” [Blacks Medical Dictionary 2010]
    or this one?

    a. Formation of a viable zygote by the union of the male sperm and female ovum; fertilization.
    b. The entity formed by the union of the male sperm and female ovum; an embryo or zygote.
    I think what you are alluding to is that in recent years some have tried to change the definition to mean ‘implantation’ rather than ‘fusion’, precisely to muddy the waters in relation to this issue. That just doesn’t wash with any intelligent person. A new human being with its own genetic make up, is formed at the point of the fusion of the sperm and ovum. How else do you justify the term “ectopic pregnancy” for example?

    • Jarrod McMaugh

      Ectopic “pregnancy” is justified by the fact that many medical terms are based on a qualitative description, rather than technical description.

      Ectopic pregnancy also reinforces the point I was making, since it involves implantation.

      The key word you are looking for is “viable”

      By your definition, there are pregnant storage facilities in IVF clinics, and a woman who receives multiple IVF or ZIFT transfers has multiple pregnancies.

      Implantation is required to be viable.

      You should be capable of understanding the biological processes occurring in the use of EHC – the progesterone alters the capacity for implantation. It does nothing to an already implanted zygote.

  4. Marc Grimer

    I understand the processes completely. The point I am making is that human life begins at conception, not implantation. Conception is the point at which a new individual is made, with his/her own genetic makeup.

    That individual “zygote” then implants, grows and develops into an adult human over the next 18 years and 10 months. Implantation is a step in the process as arbitrary as the growth of organs, limbs, birth, growth of teeth, hair, then puberty etc. At no point can you say they are more or less human before of after these stages.

    Viability is relative to each stage of the process. A newborn baby is only viable if you feed it and shelter it. A newly fertilized human embryo is just as viable if you don’t interrupt the process with a dose or two of progesterone. If it becomes an ectopic pregnancy, then viability is lost and the mother is also in life threatening danger, so treatment of that is not something anybody would dispute.

    The definition of “pregnancy” may involve implantation, so if you are defining abortion purely as a “termination of pregnancy” progesterone is not abortifacient; But that’s a moot point. It does interrupt the development of a human life after it’s creation.

    So, the IVF storage facilities are not “pregnant” but yes, they do contain fertilised human embryos who’s destruction is morally questionable. This is why those who oppose abortion are also opposed to these IVF methods.

    • Jarrod McMaugh

      It’s interesting that you keep trying to muddy the waters by trying to bring in related, but off topic, points.

      By definition, these medications are not abortifacient.

      It’s ok to be morally opposed to them anyway – that’s your perogative. Is it safe to assume from the position you have taken that you oppose other forms of contraception?

      My point is this – if you find it morally unacceptable, that’s your right. It doesn’t mean you can apply a different clinical definition to this medication or treatment. I’m not sure why you would even do so….

  5. Marc Grimer

    I am equally baffled by your line of argument.

    The medical definition of what constitutes “abortiifacient” is irrelevant in the context of which this is being cited in the article. The points I am making are not off topic, they are actually explaining the point that the author, and yourself, seem to be missing.

    Why do you think anyone is concerned about it being “abortifacient” ? It’s because they don’t want to be involved in the termination (in its literal sense) of a human life, be it at 24 hours, 9 months or 18 years. To try and allay their concerns by assuming they don’t understand the pharmacology of the drug, is condescending to say the least. Changing the medical definition of contraceptive vs abortifacient won’t reassure anybody.

    • Jarrod McMaugh

      That’s fine Marc, then don’t be involved. Just ensure you have a protocol in place to refer patients to a pharmacist who is willing to supply the medication appropriately

  6. Louise

    What a stupidly pedantic and obfuscating line of discussion between these two posters. You are both getting lost in a moral argument which, by your male-sounding names, is NONE of your business.

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