Women are facing access barriers to first line EC in pharmacies

New research revealed that almost one third of pharmacies don’t stock the first-line oral emergency contraceptive.

In an Australian study, only 70% of the 233 pharmacies surveyed, kept ulipristal acetate emergency contraceptive (EC) pills on hand, with most (98%) opting to stock levonorgestrel.

The researchers decided to delve into EC access in community pharmacy after colleagues in reproductive health reported that patients were experiencing difficulties, said study co-author Associate Professor Luke Grzeskowiak, who leads the Reproductive and Perinatal Pharmacoepidemiology Research Group at Flinders University.

‘It came to light that not many people were being offered ulipristal acetate, even though it is more effective,’ he said.

‘So we looked at a random sample of pharmacies across all the different states and territories, including rural and remote areas and major cities, to try to get a proper estimate.’

Where is it more difficult to access the first line EC?

Key differences in the EC medicines stocked were observed between rural and metro areas.

‘In major cities, ulipristal was stocked by 76% of pharmacies,’ said A/Prof Grzeskowiak. ‘In regional, rural, remote areas it was only stocked by 59% of pharmacies.’

Not only is ulipristal less accessible outside metropolitan areas, it’s also more expensive –  despite unintended pregnancies being more common among those living in rural and remote areas, he said.

As legislation and guidelines don’t extend to the stocking of individual products, access is based on a ‘postcode lottery’.

‘There are clear differences in equity in availability and cost,’ he added.

Why aren’t all pharmacies stocking the first line treatment?

Most pharmacies stock at least one form of emergency contraception. But the reason ulipristal is not supplied by all pharmacies is likely financial.

While the cost of levonorgestrel ranges from $13 to $40, ulipristal is pricier – ranging from $26 to $80. In rural and remote areas, prices can peak due to the cost of transportation, said A/Prof Grzeskowiak.

‘If the pharmacist has made a decision that it’s not in their interests to stock both products because of the difference in price, they’ve made an assumption that people don’t want to pay more,’ he said.

‘By trying to keep it simple, they are no longer supporting reproductive choice or decision making.’

The two products are not the same. ‘One pharmacist explained that they don’t want to be the pharmacy that charges more,’ adds A/Prof Grzeskowiak. ‘But what gets lost in that is that they’re actually providing a different service.’

Informed choice is an important part of pharmacists’ prescribing of EC, said PSA National President Associate Professor Fei Sim FPS, who is also the only pharmacist on the Government’s Women’s Health Advisory Council, led by Assistant Minister Ged Kearney.

‘This includes providing a clear recommendation to women regarding the efficacy, suitability of ulipristal and levonorgestrel and the associated costs, so patients can make an informed decision,’ she said.

It is important individuals are given the choice of both EC options, provided both are therapeutically suitable, and that health providers don’t withhold the option on the assumption that the price will not be acceptable to them, said A/Prof Sim.

‘This also means that both options should be routinely kept in stock,’ she added.

What are the potential outcomes of not offering the recommended EC?

Failure to stock the recommended EC can place patients at greater risk of an ongoing pregnancy, with the average pregnancy rate after EC use in clinical trials being approximately 1% with ulipristal and 2% with levonorgestrel, said A/Prof Grzeskowiak.

The risk is greater depending on where a patient is in their menstrual cycle, which is often unknown. Ulipristal (unlike levonorgestrel) can prevent ovulation even after the luteinising hormone surge (which triggers ovulation) has started.

‘If the person presenting for EC is going to be ovulating in 12 hours or the next day, then it is unlikely that levonorgestrel will work’ he said. ‘If they are sold ulipristal, there’s still a chance it could work.’

There are a number of other factors to consider when selecting the most appropriate EC product for each patient, including use of other oral contraceptives, body mass index or contraindications.

Ulipristal and levonorgestrel both have precautions and contraindications. The APF guidance document has preferential recommendations for a range of factors such as drug-drug interactions, body weight and recent administration of emergency contraception.

What needs to change?

There are several measures that could help to boost the number of pharmacies stocking the first line EC.

‘It starts with education and awareness among pharmacists so they know how to use it and where to recommend it,’ A/Prof Grzeskowiak.

Pharmacists should refer to the APF’s ‘Emergency contraception treatment guideline’ available in APF 26 or APF Digital, which states that when a patient presents within 96 hours, the first line recommendation is ulipristal, and the second line treatment option is levonorgestrel.

However it is important to note that there may be patient factors, precautions and/or contraindications which will help determine which is first-line for an individual’s specific circumstances. Pharmacists should refer to the APF guideline for more information.

‘You should always have the APF close-at-hand during consultations about emergency contraception,’ said A/Prof Sim.

‘I’ve had pharmacists reflect to me how valuable it has been to be able to refer to these clinical considerations during consultations with patients.

‘It is also a non-negotiable that this conversation occurs in an area where patients’ privacy and confidentiality can be maintained.’

In nearly all cases, a consultation room is the most appropriate and preferred location for this to occur. There are also a number of systemic issues that must be addressed.

‘Strategies to address price are really important,’ said A/Prof Grzeskowiak. ‘There have been pushes for government to consider making EC free or subsidising access.’

Once this barrier is removed, care can be guided by what’s most effective, safe and appropriate for individual patients.

‘Cost shouldn’t be a driver of essential reproductive healthcare,’ he said.

The PSA and A/Prof Grzeskowiak are also collaborating to drive some of these changes.

‘Initial discussions are around standard approaches of education,’ he said. ‘This includes raising awareness in pharmacy, media, and education all the way from practising pharmacists through to training programmes for undergraduate pharmacists and intern training settings.’

Other work includes improved awareness and visibility in the general community around access to EC.

‘If people know what pharmacies provide what core reproductive health services, such as EC or abortion care, it may create demand for pharmacists to be part of that and for their pharmacies to be recognised as specialist providers,’ said A/Prof Grzeskowiak.

‘What I and other pharmacists hear from women, is that they want to be provided all the options available, and that when provided the choice of both options, women tend to prioritise efficacy over price when it comes to emergency contraception,’ A/Prof Sim added.

For more information, pharmacists can refer to: