During my three years of didactic learning, advocacy for and the advancement of the pharmacy profession, MY profession, admittedly fell by the wayside. Instead, my focus was solely on my present – exams, organizational activities, internships, etc. Looking at the current state of the profession and patients’ health disparities didn’t seem as imperative as the thought of passing the next exam. Now that I am in my final year of pharmacy school and getting experience with the real world on my Advanced Pharmacy Practice Experiences, I’ve come to realize that this is the stuff that matters.
In the Oath of a Pharmacist, one of the vows that a pharmacist makes is to “embrace and advocate changes that improve patient care.” One avenue in which we can do this is by supporting reproductive justice, which is a one’s right to “control [their] sexuality, gender, work, and reproduction.” One of the barriers that reproductive justice seeks to address is access. “There is no choice where there is no access.” Advocating for services such as pharmacist-prescribed contraception can be one avenue to support patients’ reproductive justice.
Contraception and Relation to Health and Poverty
Currently, there are 61 million persons in the US that are of reproductive age, which is considered ages 15-44. Of these, about 70% are at risk of unintended pregnancy. An unintended pregnancy occurs when a person who can become pregnant is sexually active and does not want to become pregnant, but becomes pregnant due to failure to use a contraceptive method correctly and/or consistently. Unintended pregnancy is linked to adverse health outcomes, such as preterm birth and postpartum depression. The US Department of Health and Human Services included in their Healthy People 2030 objectives a reduction in the proportion of unintended pregnancies and an increase in effective birth control usage.
A recent study concluded that changes in contraceptive use are associated with pregnancy scares and can increase the risk of unintended pregnancy. These changes included discontinuing the use of contraception, changing from consistent to inconsistent use of contraception, and changing from a more effective to a less effective method of contraception. These results further exemplify the need for contraception education and family planning services and the role that pharmacists can play in meeting these needs. Sexual health knowledge has been shown to be suboptimal among medical students, and PharmD curricula likely will need to enhance their training to prepare pharmacists for their emerging roles in reproductive health.
Additionally, not only can pharmacists help to reduce the rates of unintended pregnancy and the associated consequences by prescribing contraception, but pharmacists can also address preconception care which is often overlooked. Chronic diseases such as diabetes, hypertension, and asthma have been increasing in patients of reproductive ages, and people who have these chronic diseases are more likely to report their pregnancies as unintended. Pharmacists can aid in providing necessary preconception care such as identifying potentially teratogenic medications and development of a reproductive life plan, lack of folic acid supplementation, and immunization needs. Each encounter would also serve as an opportunity to link patients back into primary care, as there have been decreases over time in patients of reproductive age (with or without comorbidities) who receive primary care.
Contraception Deserts and Pharmacist-Prescribed Contraception
Nearly half of all pregnancies in the United States are unintended, with low-income persons having some of the highest rates of unintended pregnancy due to many factors, including inconsistent contraceptive use. One in four of these patients report difficulties in obtaining contraception from a prescriber’s office due to reasons such as difficulty scheduling appointments (long waits, high copays, inconvenient clinic hours) and concerns about receiving pelvic exams. Oftentimes, contraception prescriptions have been tied to a required pelvic exam, despite the American College of Obstetrics and Gynecologists (ACOG) stating that pelvic exams are not required to receive most contraceptives. Routine pelvic exams are not recommended in asymptomatic patients by the United States Preventative Services Task Force (USPSTF) and cervical cancer screenings are generally only recommended every three years. In North Carolina alone, approximately one in four counties do not have an OB/GYN, and although most of these counties have a primary care provider, 87 counties are health care provider shortage designation areas, meaning patients experience many challenges in overcoming barriers to contraception access. Pharmacist-prescribed contraception can help to fill this gap in service since 91% of patients live within 5 miles of a pharmacy.
According to Power to Decide, 19 million patients live in contraception deserts. Those who live in contraception deserts “lack reasonable access in their county to a health center that offers the full range of contraceptive methods.” This means that for these patients, accessing contraception means more than just keeping an appointment. They may have to find child care, take time off from school or work, and/or travel longer distances to access their preferred birth control method. For more on contraception deserts, head to this link.
As of June 2021, there are 17 states and jurisdictions that authorize pharmacists to prescribe contraceptives via a standing order or protocol. This authorization allows for broader implementation and utility to address public health needs whereas collaborative practice agreements are typically limited to mutual patients of both the prescriber and the pharmacist. Policies differ depending on the state, but most authorize pharmacists to prescribe oral contraceptives, vaginal rings, and contraceptive patches. Six states also include prescribing of depot medroxyprogesterone in their protocols. Many of these protocols (64%) also include age restrictions to patients 18 and older. Read more about existing authorities at Birth Control Pharmacist.
One of the first states to authorize pharmacist-prescribed contraception was Oregon. In the first two years of policy implementation, pharmacists wrote 10% of all new oral or transdermal contraceptive prescriptions for Medicaid beneficiaries. An analysis of the data from Oregon shows that an estimated 51 unintended pregnancies were averted saving the state $1.6 million dollars.
While the impact of pharmacist contraception services is only available from one state during a limited time frame and population, the results are encouraging. Even if the financial savings and unintended pregnancy rate impact is less than suggested in Oregon, patients have shown an interest in accessing their contraception from pharmacists. Results from the Direct Access Study showed that 98% of patients who received contraceptive services from a pharmacist were satisfied and would recommend the service, 70% continued their use of oral contraceptives after one year, 60% utilized pharmacist-prescribed contraception because of convenience, and 50% did not have a primary care provider prior to the time of service.
Resources for Contraception Advocates
There are several resources to help pharmacists be better contraception advocates. Birth Control Pharmacist provides education, training, assistance with implementing pharmacist-prescribed contraception practices, clinical updates, and state specific policies. They also maintain a pharmacy directory that helps patients find direct access to a pharmacist for their contraceptive needs.
Mitchell et al. discuss opposition to pharmacist-prescribed contraception and provide information to help rebut those arguments. One argument against pharmacist-prescribed contraception is that patients won’t utilize the service. Several studies show that patients are willing to utilize pharmacies for contraception needs due to convenience, greater time efficiency, and easier adherence. Additionally, this report also addresses patients’ desire for broader access to contraception and their willingness to utilize pharmacists for their contraceptive needs. Research has shown that 89% of patients who utilize pharmacist contraception services had a visit with their primary care provider in the previous year, suggesting that these services don’t fragment care, but ensure patients stay connected to primary care.
If you’re wanting to get back to the basics, Bedsider provides a great breakdown of birth control options that can serve as a refresher for you, and can also be shared as a resource for patients. Reproductive access also provides a contraception resource page that can be useful to both pharmacists and patients as well. The Center for Disease Control and Prevention (CDC) provides guidance for contraceptive use. There are two resources, the United States Medical Eligibility Criteria for Contraceptive Use, 2016 (US MEC) and the United Selected Practice Recommendations for Contraceptive Use, 2016 (US SPR), both of which can be accessed for free using the CDC’s Contraception App.
A Call to Action: Realize Your Role in Contraception Access and Reproductive Justice
In states where pharmacists cannot currently provide contraception, pharmacists can contact their state legislators to educate them about contraception deserts and encourage them to introduce bills that would enable pharmacists to help increase access. Birth Control Pharmacist has compiled a list of research and news articles that can help spark the conversation.
In states that authorize pharmacist prescribed contraception, increasing uptake is crucial. In California, after the first year of policy implementation, only 11% of pharmacies were offering pharmacist-prescribed contraception. Low-income communities have been particularly impacted with many not having pharmacies and low availability, showing opportunity to address equity in roll-out of pharmacist contraception services. In Oregon, uptake was greater, but less than half of pharmacists planned to prescribe contraception if allowed. Pay parity must be achieved to support scaling of pharmacist contraception services — patients need contraception to be equitable in cost regardless of the provider providing it and pharmacists need fair reimbursement for their clinical services. Oregon has been a leading state in pay parity for contraception services with Medicaid enrolling pharmacists as providers after completion of a continuing education program. Pharmacists submit claims through their provider web portal or using the CMS 1500 claim form.
As a healthcare provider, understanding the prevalence of provider bias in contraceptive care is necessary. Taking a patient-centered approach and understanding that “the best contraceptive method for an individual patient is the one that is safe and that the patient is most comfortable using” is critical to practice reproductive justice in supporting patients’ rights to make autonomous decisions. The National Council of Jewish Women has a quick primer to support pharmacists who want to increase contraception access while respecting their patients’ reproductive rights.
Realizing the importance of advocacy early on in our careers as student pharmacists can ease the transition as new practitioners and improve our ability to be advocates for our patients. Admittedly, I turned a blind eye during my didactic career. Looking back, I wish I had been more present, more aware. We can create positive change for our patients by utilizing our voices, and now that I’ve gotten a glimpse of just how significant our collective voices can be, I wish I had jumped on the advocacy wagon sooner. Pharmacists have the opportunity to not only improve patient care, but to also advance our profession with expanded clinical roles. Why can’t it be us?
Guest Writers Profiles
Lynda Nguyen is a 4th year pharmacy student at Wingate University School of Pharmacy (WUSOP). Her passion for serving in underserved communities, and seeing the value of pharmacists in improving health outcomes in these communities, is what prompted her to apply to pharmacy school. She is the immediate past president of the WUSOP chapter of Student National Pharmaceutical Association, and was recently awarded Organization President of the Year. She plans to pursue residency upon graduation, with an interest in ambulatory care or community pharmacy. She realizes the importance of advancing the pharmacy profession, and hopes to do that by increasing her presence in the advocacy realm.
Cortney Mospan is an Associate Professor of Pharmacy at Wingate University School of Pharmacy and a Clinical Pharmacist Practitioner at Novant Health Arboretum Family & Sports Medicine. She received her PharmD from Ohio Northern University and completed a Community Care Pharmacy Practice Residency at The Ohio State University with practice sites at Uptown Pharmacy and the Ohio Pharmacists Association. Cortney was recognized as the 2018 American Pharmacists Association Good Government Pharmacist of the Year. She is currently co-chairing the Hormonal Contraception Task Force within the North Carolina Association of Pharmacists and is working to advance legislation leveraging community pharmacists to address public health disparities in North Carolina. Cortney’s research focuses on community pharmacist roles and responsibilities in contraception health access and mental health screening.