Pharmacists Are Needed to Provide Birth Control

In the United States, almost half of pregnancies are unintended.¹ Globally, maternal mortality has declined steadily over the past 3 decades,¹ but tragically, the number of American women dying during childbirth continues to climb.¹ Accessible, affordable birth control could decrease unintended pregnancies and maternal mortality by 30%.1 Family planning allows women to obtain college educations, pursue advanced professional degrees, and join the nation’s workforce.1 The American Gynecological and Obstetrical Society advocates for full unrestricted access to contraception,² and pharmacists are poised to help.

Current Situation

Forty-nine states have awarded some form of prescriptive authority to pharmacists with variable prescriber oversight and restrictions.³ Pharmacists address antimicrobial stewardship, chronic conditions, immunization, and the opioid crisis (eg, naloxone) every day.⁴

Oral contraception’s safety is well established.⁵ Although combined oral contraception creates a venous thromboembolism risk, it is small com- pared with the risk during pregnancy and post partum.² Studies show that women can self-screen and nonphysicians can safely assess contraindications to using oral contraception.⁵ Pharmacists can refer patients who need to use other methods.⁶

Fifteen states already allow pharmacists to prescribe birth control without collaborative practice agreements, and that number is increasing (Table 1).⁷ Successful pharmacist prescribing initiatives demonstrate its potential. Already, 46% of Oregon’s pharmacies prescribe contraception.⁸

All states require training and patient visit documentation.⁹ Typically, training involves certification or continuing education (CE) modules. Most locations use statewide protocols that identify when physician referral is required.^5,9 Patient questionnaires address health history and pregnancy status, identify patient preferences, require blood pressure measurement, and screen for eligibility and interacting medications.^2,10

Tools

The CDC has great contraception-prescribing resources. The evidence-based US Medical Eligibility Criteria (US MEC) for Contraceptive Use and the Selected Practice Recommendations for Contraceptive Use guide contraception choice based on medical conditions and help with managing challenges. The US MEC is updated at least every 5 years, and its components are available as mobile apps and include an easy-to-use summary chart.¹¹ The CDC offers CE on the US MEC’s clinical application (https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/training.htm ).¹²

Women hesitant to start birth control are most concerned with potential adverse effects. Pharmacists can guide patient decisions and discuss alternatives that may alleviate undesired effects.¹³ Birth control is a journey for women, and Table 2 lists factors that influence their selection of methods.¹⁴

Breaking Down Barriers

Barriers affecting all health care curb access to contraception. Limited appointment availability and having to miss work cause patients to avoid office visits.¹⁵ Expanding pharmacy services is the very definition of health care convenience.⁸ Patients may also prefer pharmacies because of the availability of multilingual staff, pharmacy hours, and the facility’s proximity to their home.⁸

Might access at the pharmacy decrease regular physician visits? On the contrary, pharmacist-patient interaction could encourage regular physician visits. Contraindications to prescription birth control require physician referral, and states often require pharmacists to inform the patient about the importance of regular exams.¹⁶

Cost remains a barrier for 11.7% of women of reproductive age who are uninsured or underinsured.¹⁴ Without insurance, contraception’s average out-of-pocket cost is $240 to $900 yearly including secondary expenses (eg, lost wages and transportation).¹⁴

Reimbursement

Pharmacist participation varies across states, and reimbursement influences participation.⁸ Paying pharmacists reasonable fees for patient assessment and prescribing or referral is critical.⁴

States often delay developing payment policies for contraception prescribing, so pharmacists may consider temporarily increasing dispensing fees for the additional services.¹⁷ For example, in 2014, Illinois established a $35 dispensing fee.¹⁷

Conclusion

Pharmacists ready to exercise prescriptive authority have the education and tools to successfully provide birth control to women.

Ashley Walsh, PharmD, is a pharmacist at Mohegan Pharmacy in Uncasville, Connecticut.

REFERENCES

1. Rice LW, Espey E, Fenner DE, Gregory KD, Askins J, Lockwood CJ. Universal access to contraception: women, families, and communities benefit. Am J Obstet Gynecol. 2020;222(2):150.e1-150.e5. doi:10.1016/j.ajog.2019.09.014
2. Over-the-counter access to hormonal contraception: ACOG committee opinion, number 788. Obstet Gynecol. 2019;134(4):e96-e105. doi:10.1097/AOG.0000000000003473
3. Adams AJ, Weaver KK. The continuum of pharmacist prescriptive authority. Ann Pharmacother. 2016;50(9):778-784. doi:10.1177/1060028016653608
4. Maternal Health Service Set For Pharmacists. National Alliance of State Pharmacy Associations. May 2020. Accessed May 10, 2021. https://naspa.us/wp-content/uploads/2020/06/Maternal-Health-Service-Set-Final.pdf
5. Rodriguez MI, Anderson L, Edelman AB. Prescription of hormonal contraception by pharmacists in Oregon: implementation of House Bill 2879. Obstet Gynecol. 2016;128(1):168-170. doi:10.1097/AOG.0000000000001474
6. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep. 2016;65(3):1-103. doi:10.15585/mmwr.rr6503a1
7. Pharmacist prescribing of hormonal contraception. Birth Control Pharmacist. Accessed May 10, 2021. https://birthcontrolpharmacist.com/policies/
8. Pharmacist prescribing of hormonal contraceptives. Power to Decide. January 1, 2021. Accessed May 11, 2021. https://powertodecide.org/sites/default/files/2021-01/Pharmacist%20Prescribing.pdf
9. Pharmacist prescribing: hormonal contraceptives. National Alliance of State Pharmacy Associations. April 22, 2021. Accessed May 10, 2021. https://naspa.us/resource/contraceptives/
10. Landau S, Besinque K, Chung F, et al. Pharmacist interest in and attitudes toward direct pharmacy access to hormonal contraception in the United States. J Am Pharm Assoc (2003). 2009;49(1):43-50. doi:10.1331/JAPhA.2009.07154
11. Summary chart of U.S. medical eligibility criteria for contraceptive use. CDC. Accessed May 10, 2021. https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf
12. CDC contraceptive method guidance: slide sets for health care providers. CDC. Updated September 25, 2020. Accessed May 10, 2021. https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/training.htm
13. Nelson AL, Cohen S, Galitsky A, et al. Women's perceptions and treatment patterns related to contraception: results of a survey of US women. Contraception. 2018;97(3):256-273. doi:10.1016/j.contraception.2017.09.010
14. Birth control 101. Power to Decide. Accessed May 10, 2021. https://powertodecide.org/what-we-do/information/resource-library/birth-control-101
15. A visual representation of pharmacist prescribing. Power to Decide. November 30, 2020. Accessed May 11, 2021. https://powertodecide.org/what-we-do/information/resource-library/visual-representation-pharmacist-prescribing
16. Joslin CM. Lessons for legislators: a guide to allowing pharmacist-prescribed birth control. R Street. September 2020. Accessed May 11, 2021. https://www.rstreet.org/wp-content/uploads/2020/09/Final-No-207-pharmacy-access-model-updated.pdf
17. Orris A, Mauser G, Bachrach D, Craven M. Implementing pharmacist contraceptive prescribing: a playbook for states and stakeholders. Manatt Health. January 2021. Accessed May 11, 2021. https://www.manatt.com/Manatt/media/Documents/Articles/Implementing-Pharmacist-Contraceptive-Prescribing_v3.pdf