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Claire Anderson is professor of social pharmacy
at the Centre for Pharmacy, Health and Society, University of Nottingham
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Supplying emergency hormonal contraception (EHC) through community pharmacies is one pharmacy public health role that has long been campaigned for. By 2005 around 50 per cent of all EHC was supplied through community pharmacies in England — nearly double the proportion in the previous year.
The first scheme whereby pharmacists supplied EHC using collaborative
prescribing agreements (similar to supplementary prescribing) started
in 1997 in Washington State, US. Pharmacists in the UK, and in a number
of other European countries, have been supplying EHC since 1999. UK research
indicates that pharmacy supply enables most women to receive EHC within
24 hours of unprotected sexual intercourse. A recent review of international
studies exploring pharmacy supply of EHC found evidence to suggest that
it did not negatively impact on contraceptive use or sexual behaviour,
did not increase the risk of sexually transmitted infections and was
highly regarded by women who used the service. However, some women, particularly
younger ones, would prefer more privacy during the EHC consultation.
Before deregulation of EHC in the UK, attitudes about potential future
supply were often negative. Following the introduction of patient group
directions (PGDs) and deregulation of EHC to a pharmacy medicine, most
pharmacists appear to be satisfied with delivering EHC services and see
them as a way to improve their role in patient-focused care. What is
more they are using skills in diagnoses and prescribing. Pharmacists
say that other service providers, such as family planning advisers, say
that pharmacists had received better training than them. Furthermore
as PGD schemes have usually been developed along with local collaborations
with family planning, local GPs and organisations such as the Brook Advisory
Service, this is a good example of where pharmacists have been enabled
to become a valuable part of the wider health care team and are referring
women to a greater range of other services.
A resounding theme of many of the studies about EHC is a fear among both
pharmacists and women about the possibility of repeated use of EHC as
opposed to using a regular method of contraception. Although pharmacists
in the Manchester scheme had more nuanced attitudes in comparison to
those uncovered by some other researchers, this may be a reflection of
the multidisciplinary training received by the pharmacists. Studies indicate
that women tend to overrate the health risks of emergency contraception
in general and of repeated use in particular. It has also been shown
that providers also tend to overestimate the potential for misuse, especially
since no studies have been published that have found any empirical basis
for the fear that women abuse EHC. A study tracking EHC use in 95,007
women over four years in the UK showed that 16 per cent had received
EHC in the study period, and only 4 per cent had used EHC more than twice
in any year. Indeed a recent European study indicates that women’s
EHC experience was actually a motivating factor leading to a more consistent
use of regular contraception. Moreover, abuse was not considered to be
a problem for the respondents to a questionnaire in Sweden.
Part of the problem, research suggests, is undoubtedly the medical barriers
imposed in many settings, such as requests for pregnancy tests and pelvic
examinations. Indeed some PGD schemes in the UK have further medicalised
the supply of EHC by requiring women to take their EHC tablet under supervision
before leaving the pharmacy.
Another major theme of many studies about EHC is women’s and pharmacists’ concern
about the effect of the availability of EHC on the incidence of STIs.
A randomised controlled trial was conducted in the US comparing access
to EHC through clinics (usual care), through community pharmacies and
through advance supply, in which the woman received three packs of EHC.
This study provides important new evidence: 2,117 women aged between
15 and 24 participated and they were followed up for six months. Pregnancy
rates were similar in the three groups, as was the incidence of new STIs.
There were no differences in the use of other contraceptives and no increase
in risky sexual behaviour. EHC was used on more than one occasion by
a small proportion of women: 6.8 per cent of women used it twice and
4.1 per cent used it three times.
The amount of information given to women during the pharmacy consultation
appears to vary considerably. There is reluctance by some women to receive
information about STIs and ongoing contraceptive needs as part of the
EHC consultation, perhaps because they are in stable relationships and
may feel that they are being judged. Some women consider their situation
to be an emergency and just wish to obtain their EHC as quickly as possible.
Furthermore, they might not be in the right state of mind to be receptive
to receiving additional information. Other women say they did not get
enough information. In considering how much information or advice to
give to a woman, pharmacists are encouraged to assess each case individually.
EHC works better the quicker it is started after unprotected sexual intercourse.
The success of EHC depends upon women’s ability to obtain it and
pharmacy availability has been shown greatly to improve access.
It is clear from research that women with EHC on hand start therapy sooner
and are more likely to use it. Randomised controlled trials in different
countries have shown increased use when EHC is provided in advance. In
addition a recent Scottish study shows that advance supply ensures earlier
usage of EHC. Advance provision is controversial because some commentators
believe it will lead to overuse, decreased use of routine contraception
and sexual risk taking, as discussed above. Others have made the point
that women interviewed in their study of advanced provision viewed not
having to undergo the embarrassment of seeking EHC from a health professional
as a positive development. However, women clearly have to access a health
professional initially in order to obtain advance supplies. A commentary
in The Lancet (2005;365:1668–70) asked to what extent, then, does
having to contact a health professional deter younger women and those
from lower socioeconomic groups from seeking EHC. It has been suggested
that perhaps the easiest way of achieving continual access to EHC is
for women to keep it on hand in their medicines cabinet. The Faculty
of Family Planning and Reproductive Health supports the advance provision
of EHC. Additionally the World Health Organization recognises that in
certain circumstances it is appropriate and acceptable. The FPA has also
supported it, so long as women know when and how to use it. The number
of women obtaining EHC from pharmacies for future use, despite restrictions
on sale and supply, is unknown. However, it would be naive to assume
that, with at least 50 per cent of all EHC being supplied through pharmacies,
this is not a widespread occurrence. It is time to think seriously about
making emergency hormonal contraception available for advance supply
from community pharmacies. |
The
Pharmaceutical Journal