Update on Emergency Contraception – Barriers

(Published March 2011)

Barriers to EC Access and Use

Timely access to emergency contraception (EC) is essential. Access has improved considerably since the Food and Drug Administration (FDA) approved over-the-counter (OTC) status for progestin-only emergency contraceptives for anyone aged 17 years or older. However, barriers to EC access and use continue to exist and are brought about by politics, lack of awareness, lack of clinician discussion of EC and its availability, and other issues.

Political barriers

The fact that many emergency departments do not provide EC services to women who have been raped is a tragic example of neglected preventive health care.^1,2 One 2005 survey found that 55% of Catholic and 42% of non-Catholic U.S. hospitals did not dispense EC in emergency departments.¹ The Department of Justice makes no mention of EC in a 130-page document titled A National Protocol for Sexual Assault Medical Forensic Examinations that was published in September 2004.^3,4 Despite these obstacles, efforts are under way to reduce barriers to EC access in emergency departments. As of 2009, 15 states and the District of Columbia had laws requiring emergency departments to provide information about or access to EC to sexual assault survivors.⁵

Additionally, the Department of Defense Pharmacy & Therapeutics Committee removed the levonorgestrel emergency contraception pill (ECP) from the Basic Core Formulary (BCF; medications that must be stocked at every full-service Military Treatment Facility [MTF]) in May 2002, only 1 month after the drug had been added to the BCF,⁶ because of complaints from conservative members of Congress.⁷ Whether the drug was stocked was left to the discretion of each MTF. Levonorgestrel ECPs were not available to all American soldiers serving overseas, which was of particular concern for women who were raped or faced an unintended pregnancy, until Next Choice® was added to the BCF on February 3, 2010.⁸

Lack of marketing and awareness

Direct-to-patient advertising for ECPs is scarce.⁹ Consequently, many women do not know that ECPs are effective, safe, and readily available in pharmacies.⁹

Lack of discussion with a health care provider

According to data from the 2002 National Survey of Family Growth, only 3% of women reported that a health care provider had discussed EC with them in the previous year.^9,10 Lack of information from a trusted health care provider further limits women’s awareness and knowledge of EC and its availability.

Other barriers

Access to EC remains limited for certain patient populations, such as female patients younger than 17 years, women with low income, and women without proper identification, including undocumented residents.^11,12 Most Medicaid beneficiaries and others seeking insurance coverage for EC still require a prescription. At a price ranging from $45 to $77, the cost of ECPs is prohibitive for many individuals, including college students. Health care providers can help women in these difficult situations by keeping a referral list of other family planning clinics that use a sliding scale to determine charges for those who are low-income or do not have insurance coverage. ECPs can often be obtained from these clinics for a reduced rate or for free.

References:

1. Harrison T. Availability of emergency contraception: a survey of hospital emergency department staff. Ann Emerg Med. 2005;46:105–10.
2. Goyal M, Zhao H, Mollen C. Exploring emergency contraception knowledge, prescription practices, and barriers to prescription for adolescents in the emergency department. Pediatrics. 2009;123:765–70.
3. Hopkins Tanne J. Justice department fails to mention emergency contraception after rape. BMJ. 2005;330:112.
4. U.S. Department of Justice. A national protocol for sexual assault medical forensic examinations: adults/adolescents. Accessed at www.ncjrs.gov/pdffiles1/ovw/206554.pdf, October 21, 2009.
5. National Women’s Law Center. Providing emergency contraception to sexual assault survivors. Accessed February 25, 2010.
6. Department of Defense Pharmacoeconomic Center. Minutes of the Department of Defense (DoD) Pharmacy and Therapeutics (P&T) Committee Meeting. Accessed at www.tricare.mil/pharmacy/PT_Cmte/PT_C/May_02_PT_Minutes.pdf, November 16, 2009.
7. Maze R. Emergency contraception still available. Accessed at www.marinecorpstimes.com/news/2007/04/military_emergency_contraceptives_070430w, October 21, 2009.
8. Department of Defense Pharmacoeconomic Center. Minutes of the Department of Defense (DoD) Pharmacy and Therapeutics (P&T) Committee Meeting. Accessed at www.tricare.mil/Pharmacy/PT_Cmte/2010/PT%20Minutes%20-%20Nov%202009%20-%20signed.pdf, February 22, 2010.
9. Trussell J, Raymond EG. Emergency contraception: a last chance to prevent unintended pregnancy. Accessed at http://ec.princeton.edu/questions/ec-review.pdf, June 24, 2010.
10. Kavanaugh ML, Schwarz EB. Counseling about and use of emergency contraception in the United States. Perspect Sex Reprod Health. 2008;40(2):81–6.
11. Gainer E, Kenfack B, Mboudou E, et al. Menstrual bleeding patterns following levonorgestrel emergency contraception. Contraception. 2006;74:118–24.
12. Dries-Daffner I, Landau SC, Maderas MM, et al. Access to Plan B emergency contraception in an OTC environment. J Nurs Law. 2007;11:93–100.