By Rebecca Bowers

EXECUTIVE SUMMARY

Even though age limits for purchasing emergency contraception (EC) were removed five years ago, results of a recent survey of more than 700 Texas pharmacies found that 46.5% of drugstores still have an age restriction for buying the medication, and more than 50% require a consultation before medication purchase.
  • A 2017 national survey of retail pharmacies found that almost one-third (30%) of stores were continuing to impose age restrictions and identification requirements for EC sales, despite removal of such barriers.
  • Educate adolescent patients on the efficacy of various forms of emergency contraception. The copper intrauterine device represents the most effective option for EC.

Even though age limits for purchasing emergency contraception (EC) were removed five years ago, results of a recent survey of more than 700 Texas pharmacies found that 46.5% of drugstores still have an age restriction for buying the medication, and more than 50% require a consultation before medication purchase.1

Texas ranks fifth among states with the highest rates of teen pregnancy, and the state’s rate of repeat teen pregnancy is the highest in the United States, says paper co-author Maria Monge, MD, assistant professor at Dell Medical School and Texas A&M College of Medicine and director of adolescent medicine at Dell Children’s Medical Center of Central Texas. However, not all teenagers across Texas have easy access to comprehensive sex education and contraception services, leading many teens to substitute for more effective contraceptive methods, she notes.

“As Texas faces ongoing challenges in improving maternal health outcomes and decreasing teen pregnancy rates, removing barriers so that adolescents may more easily access over-the-counter emergency contraception is an important piece of this puzzle that deserves additional attention,” noted Monge in a press statement.

Understand Barriers to Access

Barriers to emergency contraception and disparities in access still exist for adolescents, according to the results of a 2017 study. The study involved female mystery callers who posed as 17-year-old teenagers who were seeking emergency contraception. Using standardized scripts, the callers contacted 979 pharmacies in Nashville, Philadelphia, Cleveland, Austin, and Portland.2 Data indicate that 8.3% of the pharmacies reported that emergency contraception could not be obtained under any circumstances. That figure is not significantly different from a similar survey performed in 2012.3

“Given the history of EC in the U.S. and all the changing regulations, the fact that misinformation exists isn’t shocking; however, it is disappointing because the point of removing all the restrictions (which occurred in 2013) was to help decrease this misinformation and improve access,” says Tracey Wilkinson, MD, MPH, assistant professor of pediatrics at Indiana University in Indianapolis, who conducted an initial investigation of pharmacy access published in 2012. “Our study shows that there are still persistent barriers for adolescents, and so there is still work to be done to assure that everyone (especially adolescents) can have guaranteed access to EC when it is needed.”

In 2017, members of the American Society for Emergency Contraception, a nonprofit advocacy group, visited retail pharmacies nationwide to determine whether EC was stocked on store shelves as allowed by Food and Drug Administration regulations. Members also checked prices, as well as whether outdated age restrictions were being imposed.

In 40% of stores, researchers found that EC was not stocked on the shelf. Independent pharmacies were more likely than chain stores (91% vs. 24%) to keep the medication behind the counter, rather than to stock it on the shelf. Almost one-third (30%) of stores were continuing to impose age restrictions and identification requirements for EC sales, despite removal of such barriers.

The time has come for all pharmacies to “do the right thing” and stock emergency contraception on the shelf, where it belongs, says Kelly Cleland, MPA, MPH, the society’s executive director. The society is calling on all pharmacies, whether independent or part of a chain, to stock the medication on the shelf and eliminate unnecessary identification checks, since there is no longer an age restriction on the sale of EC, Cleland stated in a press release.

Give Teens the Facts

Providers can help educate adolescent patients on the efficacy of various forms of emergency contraception. The copper intrauterine device (IUD) represents the most effective emergency contraception method, with a 0.09% failure rate after placement.4 Ulipristal acetate and mifepristone are oral forms of emergency contraception that are most effective, with failure rates that range from 0.9% to 2.1%.5

Although levonorgestrel EC pills are less effective than ulipristal acetate and mifepristone, they are available over the counter. Failure rates for levonorgestrel pills range from 0.6% to 3.1%. No matter what form of emergency contraception is preferred, all methods of emergency contraception should be used as soon as possible after unprotected intercourse.6

“There are two approaches to emergency contraception that are both much more effective than Plan B One Step: one is insertion of the Copper T380A IUD and the second is what is used in much of Europe, mifepristone,” observes Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta. “Today, any community has multiple sources of the Copper T 380A IUD.”

A 2017 Committee Opinion from the American College of Obstetricians and Gynecologists calls for the following practices when it comes to emergency contraception:

  • Counsel patients that the most effective type of emergency contraception is a copper IUD. Obstetrician-gynecologists and other healthcare providers should think about including the copper IUD emergency contraception in their practices and providing the IUDs on the same day.
  • When possible, prescribe ulipristal acetate for EC. Ulipristal acetate is more effective than levonorgestrel in preventing pregnancy after unprotected intercourse at all time points within 120 hours. It is also effective for women of all body sizes.
  • Provide prescriptions for emergency contraception, especially ulipristal acetate, in advance to help prevent barriers to immediate EC access.
  • Use a visit for emergency contraception as an opportunity to give patients information about various contraception methods and to start the patient with a regular method, when possible.7

REFERENCES

  1. Monge M, Loh M, Goff C, et al. Barriers to obtaining and effectively using emergency contraception in Texas adolescents. Presented at the Pediatric Adolescent Societies 2018 Meeting. Toronto; May 2018.
  2. Wilkinson TA, Clark P, Rafie S, et al. Access to emergency contraception after removal of age restrictions. Pediatrics 2017;140: doi: 10.1542/peds.2016-4262.
  3. Wilkinson TA, Fahey N, Suther E, et al. Access to emergency contraception for adolescents. JAMA 2012;307:362-363.
  4. Cleland K, Zhu H, Goldstuck N, et al. The efficacy of intrauterine devices for emergency contraception: A systematic review of 35 years of experience. Hum Reprod 2012;27:1994-2000.
  5. International Consortium for Emergency Contraception (ICEC). Emergency Contraceptive Pills: Medical and Service Delivery Guidelines. 3rd edition. New York; 2012.
  6. Society for Adolescent Health and Medicine. Emergency contraception for adolescents and young adults: Guidance for health care professionals. J Adolesc Health 2016;58:245-248.
  7. Committee on Health Care for Underserved Women. Committee Opinion No 707: Access to emergency contraception. Obstet Gynecol 2017;130:e48-e52.