Attitudes toward over-the-counter access to oral contraceptives among a sample of abortion clients in the United States

North Carolina Pharmacists' Support for Hormonal Contraception Prescription Status Change

BACKGROUND

Pharmacist-prescribed hormonal contraception (HC) may offer additional avenues of access for patients; however, it is unknown whether pharmacists would support over-the-counter access to contraception over pharmacist-prescribed models.

OBJECTIVE

The objective of this study was to understand how North Carolina (NC) pharmacists believed HC should be classified and how pharmacist and pharmacy characteristics were associated with those beliefs.

METHODS

This study was a secondary analysis of a cross-sectional, anonymous, online survey completed by 587 licensed NC pharmacists. The primary outcome of interest was how pharmacists believed HC should be classified: prescription-only, pharmacist-prescribed, behind-the-counter, or over-the-counter. Multinomial bivariate and multivariable regression analyses were conducted to describe the association between pharmacist and pharmacy characteristics with the outcomes of interest through odds ratios and adjusted odds ratios, respectively. Chi-square tests were used to examine the association of geographic location with distribution of attitudes toward HC classification.

RESULTS

Fifty-one percent of NC pharmacists supported classification of HC as pharmacist-prescribed, while 23% supported non-prescription (behind- or over-the-counter) classification. Controlling for pharmacist demographics and pharmacy characteristics, completing residency training was significantly associated with supporting pharmacist-prescribed vs prescription-only classification (adjusted odds ratio (aOR) = 2.55, P = .02). Pharmacists had higher odds of supporting pharmacist-prescribed vs prescription-only HC if they agreed that they were well trained to do so (aOR = 3.14, P < .01). Distribution of attitudes about classification of HC did not significantly differ by geographic location (P = .14).

CONCLUSIONS

Most NC pharmacists support deviating from the current prescription-only classification of HC, with more support for pharmacist-prescribed classification. Continuing education programs should focus on training pharmacists to feel more confident prescribing HC.

Association of pharmacist prescription and 12-month contraceptive continuation rates

BACKGROUND

States have passed legislation to expand the scope of pharmacists to directly prescribe contraception. It is thought that pharmacist prescription of contraception may promote correct and consistent use of contraception by reducing barriers to access. However, it is not known how this may impact ongoing contraceptive use.

OBJECTIVE

This study aimed to determine whether 12-month rates of continuation of an effective form of contraception or perfect use of contraception differ by prescribing provider (pharmacist or clinician).

STUDY DESIGN

We conducted a 1-year prospective cohort study of 388 women seeking contraception in 139 pharmacies across 4 states (California, Colorado, Hawaii, and Oregon). Our study was powered to detect a 10% difference in 12-month continuation of an effective form of contraception. We clarified women's pregnancy intention at baseline and subsequent follow-ups. Women received a prescription directly from a pharmacist (n=149) or were filling a prescription from a clinician, our comparison group (n=239). We used multivariable logistic regression to measure the association between pharmacist prescriber and use of any effective contraceptive method or perfect use at 12 months. Model covariates included age, race, education, side effects experienced, payor, and contraceptive supply dispensed at baseline.

RESULTS

Of the study cohort, 88% (n=340) completed 12 months of follow-up. Among women not planning to become pregnant, 7 women in the clinic-prescribed group vs 1 woman in the pharmacy-prescribed group (3.4% vs 0.8%; P>.05) reported a positive pregnancy test during the study period. The majority of the cohort was continuing to use an effective method of contraception at 12 months (clinician 89.3% vs pharmacist 90.4%; P=.86). Among women receiving a prescription from a clinician, 53.9% reported perfect use (no missed days) at 12 months, compared with 47% of the pharmacist-prescribed group (P=.69). Pharmacist prescriber type was not associated with continuation of an effective contraceptive method at 12 months (adjusted odds ratio, 0.70; confidence interval, 0.28-1.71) or with perfect use of contraception (adjusted odds ratio, 0.87; confidence interval, 0.51-1.48), controlling for other woman-level characteristics.

CONCLUSION

We found no difference in use of any effective contraception, perfect use, or switching at 12 months among those who received their baseline prescription from a pharmacist vs a clinician. This study is limited by not examining information on safety outcomes.

Over-the-counter oral contraceptive use among women in Mexico: results from a national survey

AIM

In Mexico, many pharmacies sell oral contraceptives (OCs) over the counter (OTC); however, little is known about the background characteristics of OTC pill users. The primary objective of this study was to understand the characteristics of OTC OC users in Mexico, including whether there were differences by age, urbanicity, and insurance status. This information is instructive as other countries explore allowing OTC access to OCs.

METHODS

We analysed the nationally representative 2014 Mexican National Survey of Demographic Dynamics (ENADID) among a sample of OC users aged 15-54 years (n=1970). We performed multivariable logistic models to understand the characteristics associated with OTC access, with age, urbanicity, and insurance status as our primary predictors of interest. Additionally, we descriptively explored knowledge of how frequently to take OCs by pill source and age.

RESULTS

Some 54% of pill users, including 66% of those aged 15-17 years, obtained their OCs OTC. In multivariable regression we found no differences in OTC access by age. However, being uninsured (adjusted odds ratio (AOR) 1.86, 95% CI 1.23 to 2.82) (compared with employer-based public insurance) and living in an urban area (AOR 4.73, 95% CI 3.37 to 6.66) (compared with rural area) were associated with a higher odds of OTC access among pill users. Women's knowledge of how frequently to take OCs was similar between OTC and prescription users within age groups.

CONCLUSIONS

These findings point to the importance of OTC availability of OCs for pill users of all ages and uninsured and urban women in Mexico in particular.

Patient and pharmacist perspectives on pharmacist-prescribed contraception: A systematic review

OBJECTIVE

Increasingly, states authorize pharmacists to prescribe hormonal contraception to patients without a prescription from another healthcare provider. The purpose of this review is to investigate pharmacist and patient perspectives on pharmacist-prescribed contraception in the United States.

STUDY DESIGN

We searched Medline, Embase, PsycInfo, CINAHL, Scopus, and the Cochrane Library from inception through July 10, 2019. We included qualitative and mixed-methods studies, quantitative surveys, observational studies, and randomized trials in the United States. Risk of bias was assessed using tools for quantitative and qualitative studies.

RESULTS

Fifteen studies met inclusion criteria, including studies on pharmacists and student pharmacists (n = 9), patients (n = 5), and both (n = 1). Study samples ranged from local to national. Studies had moderate to high risk of bias, primarily due to low response rates and lack of validated instruments. Most pharmacists (57-96%) across four studies were interested in participating in pharmacist-prescribed contraception services. Among patients, 63-97% across three studies supported pharmacist-prescribed contraception, and 38-68% across four studies intended to participate in these services. At least half of pharmacists across four studies felt comfortable prescribing contraception, though pharmacists identified additional training needs. Pharmacists and patients identified several reasons for interest in pharmacist-prescribed contraception services, including increasing patient access, reducing unintended pregnancies, and offering professional development for pharmacists. They also identified barriers, including payment, time and resource constraints, liability, and patient health concerns.

CONCLUSIONS

Most pharmacists and patients across 15 studies were interested in expanded access to contraception through pharmacist-prescribed contraception. Findings on facilitators and barriers may inform implementation efforts.

IMPLICATIONS

Pharmacist-prescribed contraception is a strategy to expand patient access to contraception. Reducing barriers to implementation could improve participation among pharmacists and patients.

Moving Oral Contraceptives over the Counter: Theory-based Formative Research to Design Communication Strategy

The American College of Obstetricians and Gynecologists (ACOG) recommends that oral contraceptives (OC) should be available over the counter (OTC). This study explored women's attitudes toward OC OTC in rural South Carolina. In-depth, individual interviews were conducted with 52 women ages 18-44 years old. Data analysis was informed by a reproductive justice theoretical framework and included an inductive, constant-comparative approach using HyperRESEARCH 3.7.5. Participants self-identified as either Black (62%) or White (28%). Participants believed that OC OTC would prevent unintended pregnancy by improving anonymity, convenience, and access to contraception. Many participants faced barriers to receiving a prescription, including time, transportation, cost, stigma, embarrassment, and clinician refusal based on religious reasons. Participants believed OC OTC would improve women's control over their fertility and emphasized the importance of health insurance coverage for OC OTC. Some participants expressed concerns about the risk of side effects, contraindications, and the potential for abuse. Some participants believed women, especially adolescents, required physician guidance and an annual exam to use OC. Findings suggest that a lack of knowledge and misinformation about the risks of OC serve as a barrier among some women in rural areas. Widespread acceptance of OC OTC will require messaging strategies to dispel safety concerns about OC OTC and empower women.

Should oral contraceptive pills be available without a prescription? A systematic review of over-the-counter and pharmacy access availability

Introduction

Making oral contraceptives (OC) available over the counter (OTC) could reduce barriers to use. To inform WHO guidelines on self-care interventions, we conducted a systematic review of OTC availability of OCs.

Methods

We reviewed data on both effectiveness and values and preferences surrounding OTC availability of OCs. For the effectiveness review, peer-reviewed articles were included if they compared either full OTC availability or pharmacist-prescribing (behind-the-counter availability) to prescription-only availability of OCs and measured an outcome of interest. For the values and preferences review, we included peer-reviewed articles that presented primary data (qualitative or quantitative) examining people's preferences regarding OTC access to OCs. We searched PubMed, CINAHL, LILACS and EMBASE through November 2018 and extracted data in duplicate.

Results

The effectiveness review included four studies with 5197 total participants. Two studies from the 2000s compared women who obtained OCs OTC in Mexico to women who obtained OCs from providers in either Mexico or the USA. OTC users had higher OC continuation rates over 9 months of follow-up (adjusted HR: 1.58, 95 % CI 1.11 to 2.26). One study found OTC users were more likely to report at least one WHO category 3 contraindication (13.4% vs 8.6%, p=0.006), but not category 4 contraindications; the other study found no differences in contraindicated use. One study found lower side effects among OTC users and high patient satisfaction with both OTC and prescription access. Two cross-sectional studies from the 1970s in Colombia and Mexico found no major differences in OC continuation, but some indication of slightly higher side effects with OTC access. In 23 values and preference studies, women generally favoured OTC availability. Providers showed more modest support, with pharmacists expressing greater support than physicians. Support was generally higher for progestogen-only pills compared with combination OCs.

Conclusion

A small evidence base suggests women who obtain OCs OTC may have higher continuation rates and limited contraindicated use. Patients and providers generally support OTC availability. OTC availability may increase access to this effective contraceptive option and reduce unintended pregnancies.

Systematic review PROSPERO registration number

CRD42019119406.

Hormonal contraception without a prescription: opinions of pharmacists, general practitioners and gynaecologists in Flanders, Belgium

OBJECTIVE

The accessibility of contraceptives varies greatly from country to country. Because unintended pregnancies have a considerable impact, programmes have been initiated in some countries to make certain contraceptives available without a prescription. We therefore investigated whether or not Flanders, the Dutch-speaking part of Belgium, is ready for such an initiative.

METHOD

We used a mixed-methods approach with a mainly qualitative methodology. The opinions of pharmacists, general practitioners (GPs) and gynaecologists, the three types of health care provider most closely involved in the prescription and delivery of contraception, were examined.

RESULTS

A majority of pharmacists supported the idea. Moreover, a large majority occasionally dispensed hormonal contraception without a prescription. Pharmacists expected negative responses from physicians. Among GPs and gynaecologists, a small majority supported the idea conditionally. A minority either fully supported the idea or found it completely unacceptable.

CONCLUSION

Economic aspects were clearly important in forming an opinion on the topic, although medical arguments were often used when they happened to point in the same direction. Flemish pharmacists were willing to train for and implement a new service that would provide contraceptives without a prescription. The majority of GPs and gynaecologists expressed reservations about such a service and doubted that it would reduce unintended pregnancies. If this service were to be implemented, caution would be needed to avoid giving contraceptive users conflicting information.

Medicines reclassification from a pharmaceutical industry perspective: An international qualitative study

BACKGROUND

Widening access to medicines through reclassification ('switching') of medicines from prescription to non-prescription is an international trend generally welcomed by community pharmacists. Research has focused on scheduling and committee deliberations affecting reclassification, rather than industry aspects, despite industry's role in driving reclassifications. The research aimed to identify how pharmaceutical industry and product-related factors influence reclassification, and to explore stakeholder acceptability of government or third-party driven reclassifications.

METHODS

Sixty-five in-depth, semi-structured interviews were conducted with 80 key informants (including representatives from regulatory bodies, industry, pharmacy and medicine) in developed countries including the United States, the United Kingdom, Japan, Australia, and New Zealand. The questions explored barriers and enablers to reclassification at the local (micro-), regional (meso-) and global (macro-) levels. Analysis of transcribed interviews entailed descriptive and thematic approaches.

RESULTS

Pharmaceutical industry decisions to drive medicine reclassification reflect characteristics of the company, product, and external environment at all levels. For the company, financial factors, company focus (e.g. on prescription business versus non-prescription business), and capability in non-prescription medicines and reclassification were common influences. Products with significant non-prescription market potential and a well-known prescription medicine brand name most suited reclassification, usually near patent expiry. Barriers included immediate generic entry post-reclassification, and a short-term profitability and/or prescription business focus. Some countries allow government or a third-party (including pharmacy) to drive reclassifications, with examples of successful reclassifications ensuing. Some industry and other participants held concerns about this practice, particularly in the United States. Concerns included insufficient resourcing, and the pharmaceutical company's business, potentially encouraging product withdrawal or legal challenge.

CONCLUSIONS

This study is the first to explore both pharmaceutical industry factors affecting reclassification and acceptability of alternate drivers of reclassification. Factors beyond clinical safety and efficacy and the local reclassification environment can influence reclassification. Pharmacy-driven reclassification might be one alternative.

Public perception of pharmacist-prescribed self-administered non-emergency hormonal contraception: An analysis of online social discourse

BACKGROUND

Increasing access to hormonal contraception reduces unintended pregnancies. One strategy gaining momentum is allowing patients to access hormonal contraception directly from pharmacists. Commentary on online news articles provides a naturalistic and real-time data source to assess public perceptions on timely and often controversial issues.

OBJECTIVE

Characterize public perceptions of pharmacist-prescribed self-administered non-emergency hormonal contraception using comments posted in response to online news articles.

METHODS

Retrospective, cross-sectional, mixed methods analysis of public comments posted in response to articles published by major media outlets between January 1 to December 31, 2015 on pharmacist-prescribed hormonal contraception. Comments were then extracted and reviewed through a two-step process to identify emerging themes using a thematic analysis.

RESULTS

A total of 1060 public online comments were collected from eight articles. Of these, 757 comments (71.4%) were not related to pharmacist-prescribed hormonal contraception. Thematic analysis of the 303 relevant comments (28.6%) identified three overarching messages. First, a wide variety of reasons for how pharmacist-prescribed hormonal contraception improves healthcare and/or supports patient preferences were cited, but there was no consensus on the primary vantage. Second, individuals have varying opinions about the role of the pharmacist which creates both opportunities and challenges for pharmacist-prescribed hormonal contraception. Third, practical and logistical considerations will need to be addressed by healthcare systems, pharmacies, and payers prior to and alongside implementation.

CONCLUSION

Commenters were generally positive and cited several benefits, such as increasing access to healthcare, reducing unintended pregnancies, and supporting individual autonomy. However, it was acknowledged that these benefits would need to be balanced with potential safety concerns and logistical issues associated with delivering clinical services in a community pharmacy setting. Study results can help understand public concerns and may be useful in addressing barriers hindering public acceptance of expanded pharmacist roles.

Pharmacist Intentions to Prescribe Hormonal Contraception Following New Legislative Authority in California

OBJECTIVE:

Following a California law expanding pharmacists' scope of practice to include directly providing self-administered hormonal contraception to patients pursuant to a statewide protocol, this study aimed to assess California pharmacists' intentions to provide this new service prior to the protocol development and implementation.

DESIGN:

Descriptive, nonexperimental, cross-sectional study.

SETTING:

California between August and September 2014.

PARTICIPANTS:

California pharmacists working in community pharmacies.

INTERVENTION:

Invitations to participate in the online survey were sent to 1774 pharmacists.

MAIN OUTCOME MEASURES:

Main outcomes included pharmacists' current practices, intentions to prescribe hormonal contraception, comfort performing various activities, knowledge about contraceptive methods, training needs, and barriers to prescribing.

RESULTS:

A total of 257 responses (14.5% response rate) were received. Of those, 121 respondents met inclusion criteria and were included in the analysis. About half of the respondents (49.6%) reported working in a community chain pharmacy, 46.3% in an independent pharmacy, and 4.1% in other community pharmacy settings. The majority (72.7%) of pharmacists reported that they would likely provide this new service. Respondents reported being comfortable educating patients on short-acting (94.2%) and long-acting reversible contraception (81.7%), as well as identifying drug interactions with hormonal contraception (96.7%). Respondents indicated time constraints (74.4%), lack of reimbursement (63.6%), and liability concerns (62.0%) as barriers to prescribing hormonal contraception.

CONCLUSIONS:

California pharmacists expressed strong intentions and comfort in prescribing hormonal contraception. Pharmacists' additional training needs and barriers should be addressed for successful implementation. This new service has great potential to increase access to contraception, potentially fostering increased use and adherence.

A trauma-informed examination of the hardships experienced by abortion fund patients in the United States

Researchers describe hardships experienced by abortion patients, examining administrative health cases from 2010 to 2015 in the United States. All patients received financial assistance from an abortion fund to help pay for abortion. Case data were analyzed to assess types and numbers of hardships experienced by age, race, and geographic origin. Hardships ranged from homelessness to parenting multiple children. Patients from the geographic South experienced the most hardships, followed by those from the Midwest. Hardships experienced by abortion fund patients are like those reported in other samples of abortion patients; hardships potentially cause or exacerbate trauma. Results are discussed in the context of a trauma-informed perspective.

Over-the-Counter Access to Oral Contraceptives

Making oral contraceptives (OCs) available over the counter (OTC) could help to reduce the high rate of unintended pregnancy in the United States. Surveys show widespread support for OTC access to OCs among US women. Studies indicate that women can accurately use checklists to identify contraindications to OCs. Continuation is as good or better among OTC users compared with women using OCs obtained by prescription. Women and clinicians have expressed concerns related to making OCs available OTC. These concerns can be addressed by existing data or through research required by the Food and Drug Administration as part of the application to make OCs available OTC.

A Survey of Teenagers' Attitudes Toward Moving Oral Contraceptives Over the Counter

CONTEXT

Evidence suggests that over-the-counter access to oral contraceptives may help expand use among adult women. Teenagers may particularly benefit from this approach, as they experience disproportionately high rates of unintended pregnancy and face unique challenges accessing contraceptives. However, limited research has explored teenagers' attitudes toward over-the-counter access.

METHODS

In 2014, a sample of 348 females aged 14-17, recruited via Facebook advertisements, participated in an online survey assessing teenagers' attitudes toward over-the-counter access and their understanding of how to use oral contraceptives after reading a prototype over-the-counter product label. Differences by participants' characteristics were assessed in bivariate analyses (Pearson chi-square and Fisher's exact tests for categorical measures, and independent t tests and one-way analyses of variance for continuous measures).

RESULTS

Seventy-three percent of participants supported over-the-counter access, and 61% reported that they would likely use oral contraceptives available through this approach. Few subgroup differences were found. Notably, sexually experienced participants were significantly more likely than others both to support this approach (85% vs. 63%) and to be interested in obtaining oral contraceptives this way (77% vs. 48%). Participants understood an average of 7.1 of eight key concepts that the prototype product label was intended to convey; no significant differences were found among subgroups.

CONCLUSIONS

Over-the-counter access may be a promising approach for providing oral contraceptives to teenagers. Additional research is needed to evaluate whether teenagers can screen themselves for contraindications to oral contraceptive use and correctly use oral contraceptives obtained over the counter.

Views and attitudes of oral contraceptive users towards their availability without a prescription in the Republic of Ireland

Background:

Previous studies show that provision of oral contraceptive pill (OCs) without a prescription is safe, feasible and effective and that users are interested in obtaining contraception in this way, especially if a pharmacist screening is involved. A recent national survey conducted in the Republic of Ireland has highlighted that unintended pregnancy resulting from the failure of OCs could be linked to poor compliance due to costs and difficulty of access.

Objective:

To evaluate views and attitudes of OC users towards the availability of OCs without a prescription in the Republic of Ireland.

Methods:

A cross sectional survey was conducted using an opportunistic sample of OC users aged 18 to 50 years. Sixty community pharmacists were recruited nationwide. Data were collected using self-completed questionnaires. The questionnaires comprised information on: demographic data, need of the service, views on the availability of OCs without prescription, advantages and concerns around the service, role of pharmacists and cost implications for private and public patients.

Results:

A total of 488 eligible OC users completed the survey. The majority of the respondents (71.7%;n = 350/488) reported to have missed a pill for reasons connected to the OCs prescription status and 55.5% (n = 268/488) of the respondents reported to have felt distressed on at least one occasion because they could not renew their OC prescription. A total of 87.9% (n = 429/488) of the respondents said they were in favour of OCs being available without prescription and 92% (n = 448/488) said they were likely to obtain OCs without prescription if available. Convenience and ease of access were indicated as the main advantages of availing of OCs without prescription, while safety was the biggest concern reported. Over 88% (n = 430/488) of the respondents indicated that pharmacists would be able to safely supply OCs without prescription. Private patients expected to save an average of 27.3% on their OC if obtained without prescription.

Conclusions:

OC users in the Republic of Ireland are in favour of OCs being available without prescription and are willing to obtain it this way, providing that pharmacists supply them according to protocols that facilitate the safety and the efficacy of the supply. An easier and more convenient access to OCs could also reduce the likelihood of missed pills and bring considerable savings to users.

Women's perspectives on age restrictions for over-the-counter access to oral contraceptives

PURPOSE

There is a growing movement for an over-the-counter (OTC) oral contraceptive (OC) in the United States. This study aimed to explore women's views regarding an age restriction for an OTC OC.

METHODS

From November to December 2011, we administered a nationally representative survey of U.S. women aged 18-44 years who were at risk of unintended pregnancy to explore their opinions of an age restriction for an OTC OC. A total of 2,046 women completed the survey. Weighted proportions were calculated, and logistic regression was used to identify covariates associated with supporting an age restriction. Chi-square tests of potential advantages and disadvantages of OTC access to OCs by support for an age restriction were also performed.

RESULTS

Overall, 26% of respondents supported an age restriction for an OTC OC; 28% were against an age restriction, and 46% were unsure. In multivariable analysis controlling for overall support for OTC access to OCs and for other covariates, women were more likely to support an age restriction for an OTC OC if they had less than a high school degree (odds ratio [OR], 2.5), a high school degree (OR, 1.6), or some college (OR, 1.6) compared with a college degree; if they were married compared with never married (OR, 2.1); and if they lived in the Midwest (OR, 2.1) or South (OR, 2.1) compared with the West.

CONCLUSIONS

A minority of women support an age restriction. Women's concerns about a potential OTC OC should be addressed through education and ongoing research.