Original research articlePharmacists' knowledge and the difficulty of obtaining emergency contraception1
Introduction
Emergency contraception (EC) to prevent pregnancy after unprotected intercourse has great potential to reduce unintended pregnancy, a public health problem of tremendous significance. Unintended pregnancy is an all too common experience—half of all US pregnancies are unintended and half of these result in abortion [1]. There is convincing evidence of the impact of EC. In 2000, an estimated 51,000 pregnancies were prevented by EC, accounting for 43% of the decline in the abortion rate since 1994 [2], [3].
Unfortunately, substantial barriers to more widespread use of EC persist. The Kaiser Family Foundation commissioned several national surveys of physicians and the public about EC [4]. The 2000 survey found that only 20% of obstetrician-gynecologists and 23% of family practice physicians routinely discuss EC with their patients [5], and that 24% of women age 18–44 do not even know of its existence [6]. Among health professionals, pharmacists have been receiving recent attention because five states (Alaska [7], California [8], Hawaii [9], New Mexico [10] and Washington [11]) have granted pharmacists authority to dispense EC directly to women through “collaborative agreements” with physicians. However, no other states currently allow these arrangements, so most women need prescriptions to obtain EC.
Still, pharmacists have an important role in increasing access to EC products. They can advise medical colleagues, answer women's questions, dispel any misconceptions (because EC is often confused with the abortion pill, mifepristone, previously called RU-486) as well as stock and dispense EC. However, there are no published studies that assess pharmacists' knowledge about EC or that examine the availability of EC at community pharmacies in the 45 states without collaborative agreements.
Currently there are two forms of hormonal ECs. The Yuzpe method consists of taking a specified dose of combined oral contraceptive pills (100 μg of ethinyl estradiol plus 0.5 mg levonorgestrel or 1.0 mg dl-norgestrel) with the first dose within 72 h after unprotected intercourse and a second identical dose 12 h later [12]. When used in this manner, EC is >74% effective in preventing pregnancy [13]. This method had been used in the United States and Europe for many years, and in 1997 the US Food and Drug Administration (FDA) declared 6 (now updated to 13) brands of combined oral contraceptives as safe and effective for use as ECs [14]. Preven™, the first designated product, was FDA-approved in 1998 [15]. Plan B®, FDA-approved in 1999 [16], is a progestin-only (0.75 mg levonorgestrel) preparation, shown to be more effective and have fewer side effects than the combined pill [17].
This study is unique because it employs a “mystery shopper” method, in which investigators, posing as female community members, contact pharmacists with requests for more information about EC. The method provides a window into the actual interaction that might occur between a woman in need of an EC and her community pharmacist.
The specific objectives of this study are: (a) to evaluate the accuracy of information pharmacists provide about EC, (b) to determine the proportion of pharmacies able to provide EC to the caller and to assess any regional differences in provision and (c) to determine which responses to the callers' questions and pharmacy characteristics best predict pharmacist provision of EC
Section snippets
Study design and sample
This cross-sectional study portrays a “snapshot” of pharmacists' knowledge and opinions within a short period of time, avoiding any secular, time-dependent changes.
A list of all licensed pharmacies in the state was obtained from the Pennsylvania Department of State, Bureau of Professional and Occupational Affairs. Using a random systematic sampling method, 10% (320/3194) of Pennsylvania pharmacies were selected. Prior to sampling, the complete pharmacy list was sorted by zip code within county
Baseline characteristics of sample
Of the 320 pharmacists in the sample, 315 (98%) were contacted by telephone and participated in the survey. Characteristics of the pharmacies and pharmacists are reported in Table 1. Sixty-four of 67 counties had one or more participating pharmacies sampled, while no pharmacies were sampled in 3 of the most sparsely populated counties. Only one pharmacy was selected in 21 out of 64 counties (33%). The six regions each had equivalent proportions of sampled pharmacies compared to the total number
Discussion
Our most important finding from this investigation is that among the 315 randomly sampled pharmacists in Pennsylvania, only 35% were able and willing to provide an option for EC. An affirmative response to the question, “Can you fill a prescription today?”, required both that the pharmacist understand what EC is (and that birth control pills could be used for this purpose), as well as stock a product that the caller would be able to pick up the day of the call.
In our study, only 12% of
Acknowledgements
This research was supported (in part) by an Alpha Omega Alpha Student Research Fellowship.
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Wendy Bennett is now a medical resident at Johns Hopkins-Bayview Medical Center, Baltimore, MD.