Analysis: Improving access to contraception
Calls to reclassify oral contraceptives in order to increase accessibility through community pharmacy and reduce unintended pregnancies are getting louder. By Professor Claire Anderson
After reading this feature you should be able to:
• Explain how pharmacy can help improve the provision of contraception to women
• Overcome the barriers to pharmacy playing a wider role in contraception services
• Make a plan to achieve a greater role in wider contraceptive provision.
The UK has a very high rate of use of contraception but unintended pregnancy remains a major public health issue. In 2018 almost 200,000 pregnancies in the UK ended in induced abortion.1 Data from the National Survey of Sexual Attitudes and Lifestyles (NATSAL) shows that:
- 45 per cent of pregnancies and one-third of births in England are unplanned or associated with feelings of ambivalence2
- Around 10 per cent of births are unintended and 25 per cent mistimed
- There are more unintended pregnancies in young women from socially economic disadvantaged backgrounds.
All of this suggests a serious unmet need for contraception.
Women who have unprotected sex after using emergency contraception (in the same cycle) are up to three times more likely to conceive than women who do not3,4,5 and without contraception they remain at risk of pregnancy in subsequent cycles. Current UK and US guidelines recommend quick starting (i.e. initiating regular hormonal contraception immediately after emergency contraception).6
The recent Bridge-It study published in the Lancet7 showed that pharmacy provision of a three-month supply of progestogen-only pill (POP) and the offer of rapid access to a sexual and reproductive health clinic along with EC was associated with a 20 per cent increase in use of effective contraception four months later (one month after the progestogen-only pill supplied had run out) compared with provision of EC alone.
The study authors say that an increase of 20 per cent in effective contraceptive uptake was large and clinically significant. Offering three months’ supply of a POP and rapid access to a contraceptive service when a woman is provided with EC might prevent many more unintended pregnancies if this became standard practice in UK pharmacies.
• In 2012 the United Nations declared contraception a human right8
• Public Health England estimates that for every £1 spent on contraception there is a £9 saving for the public sector9
• There are many calls for oral contraceptives to be reclassified as P medicines2 and some calls for emergency contraception (EC) to be reclassified to GSL10
• One-third of contraceptive appointments with GPs and almost half in specialist services are to maintain existing contra-ception2
The MHRA has set up a stakeholder group to discuss the reclassification of POP, which is thought to be imminent. The oral contraceptive pill (OCP) is the most commonly used form of contraception. Despite being one of the most studied medicines in the world for more than 60 years, the OCP is still only available on prescription in the UK, acting as a barrier to both starting to take it and continuing to use it.11
Making oral contraceptives available as a P medicine can be achieved by reclassifying the progestogen-only pill (POP), which has fewer contraindications and precautions and less risk of serious adverse effects than COC because it does not contain oestrogen.12 Taken daily without a break, POPs suppress ovulation to a variable extent: 50-60 per cent of cycles with norethisterone, 72 per cent with levonorgestrol, and 97 per cent with desogestrel.13
POPs thicken the cervical mucus reducing sperm penetration. POPs also affect sperm and egg transportation by affecting tubal motility and cilia and they render the endometrium inactive, which possibly affects sperm transportation or implantation.
Norethisterone and levonorgestrol should be taken at the same time every day and need to be taken within three hours of the due time; a dose over 27 hours after the last dose may reduce the effect on the cervical mucus. For desogestrel, up to 12 hours late is acceptable because of the greater suppressive effect on ovulation.
Although mood changes have been reported with POPs, a recent systematic review found no clear relationship between POPs and depression.14 Ectopic pregnancy may be a risk, and changes in bleeding patterns are common.12
A 2019 systematic review15 identified that more recent and rigorous studies, largely from Mexico and the US, suggested OTC users had higher rates of OC continuation over time. There was some indication that OTC users had lower rates of side-effects but slightly higher rates of use of OCs despite contraindications. Patients and providers generally support OTC availability.
The authors conclude that OTC availability may increase access to this effective contraceptive option and reduce unintended pregnancies.
Learning app from WHO
The World Health Organization (WHO) has launched a new educational module – ‘Counselling and prescribing of contraception in pharmacies’ – as part of its WHO Academy mobile learning platform. Taking a case study Q&A approach, it covers emergency contraception, progestogen-only pills, combined oral contraceptives, self-injectables, and male and female condoms. Pharmacists need to download the app, which is available from the Apple App Store or Google Play store.
Public Health England estimates that one-third of women cannot access contraception from their preferred setting and a recent All Party Parliamentary Group on Sexual and Reproductive Health inquiry heard that people from deprived or marginalised groups are particularly affected.2
Funding cuts have resulted in reduced local authority-funded provision of contraception services in general, including from community pharmacy, increasing demand on remaining services and on general practice as women are redirected there. It is evident that there are further opportunities to make much better use of pharmacy contraceptive services and for pharmacy to rise to this challenge.
It is widely acknowledged that pharmacy services are more convenient and accessible for women and that they engage with women who are not accessing contraception from other settings. Over 99 per cent of people living in areas of highest deprivation are within a 20-minute walk of a community pharmacy.
UK sexual and reproductive health providers, when surveyed, were largely supportive of community pharmacy-led provision of contraception, with training and referral pathways being required to support contraception delivery by pharmacists. Pharmacists’ capacity and competency to provide a full contraception consultation, safeguarding concerns and women having to pay for contraception were all perceived as barriers.
The APPG inquiry2 heard that there is a significant opportunity to expand the role of community pharmacists in supplying the POP.
Independent prescribing or patient group directions are already in use in some areas. In Lambeth, Southwark and Lewisham, for example, this enables women to attend a pharmacy for their first prescription of a POP. This is not only beneficial for women and alternative service providers but can also encourage the use of contraception and as a result may help reduce unintended pregnancies.
The inquiry was persuaded by a compelling case to change the classification of POPs to make them easier for women to access. This would bring the UK in line with many other parts of the world where POPs are already available without a prescription.
It also recommended that guidance should be offered on the improvement of pharmacy settings to make it easier for women to access contraception, including more privacy for women to discuss needs and making information about contraception more visible in pharmacies.
The APPG inquiry2 in calling for reclassification of the POP stated that, “the restoration of services after the Covid-19 pandemic, along with the repurposing of the functions of Public Health England, provides a unique opportunity for national and local government to reshape contraceptive services according to the needs of women themselves and to make more efficient use of NHS resources”. Let us ensure that community pharmacy is ready for this challenge.
It is widely acknowledged that pharmacy services engage with women who are not accessing contraception from other settings
Emergency contraception – remove barriers to access
Provision of emergency contraception (EC) by community pharmacies has been a successful addition to the range of available sexual health services16 with most women now accessing EC from community pharmacy. Women from socially-economic disadvantaged communities are more likely to access EC from a pharmacy than from other service providers.17
Women over the age of 20 years are more likely to use a pharmacy service than younger women, and those with greater health literacy are also more frequent users. However, there remains variation in pharmacy access, and longer opening hours and weekend opening are not universal. Reduced availability of pharmacy services on Sundays is also a barrier to timely EC access.
There are still moral concerns and stigma about provision of EC and some pharmacists may themselves create barriers to limit access, even though there is little evidence that provision of EC encourages risk behaviours.18 Examples of outdated practice remain in some areas, including supervised consumption and lack of ability to access supplies for future use.
These practices need to be addressed by the profession and commissioners.10 Pharmacy teams need to add value by always being able to supply EC, giving advice, and supporting and providing ongoing contraception if EC is to remain P and not be moved to GSL.
NHS Digital statistics on sexual and reproductive health services
- In 2019/20 there were 1.90 million contacts with dedicated sexual and reproductive health services in England (down from 1.93 million in 2018/19 and 2.57 million in 2009/10)
- 82% of all contacts were by females, with 12 per cent involving the provision of a new main method of contraception, 17 per cent a change in main method and 41 per cent the maintenance of an existing main method. Eight per cent involved pre-contraceptive advice and 5 per cent emergency contraception
- 18 per cent of contacts were made by males. Of these 12 per cent involved the supply/maintenance of a main method and 2 per cent pre-contraception advice
- Females aged 18-24 years were most likely to use a service for contraception (12 per cent) but 2 per cent of females aged 13-15 years also had a least one contact
- Over the last 10 years uptake of long acting reversible contraceptives (LARCs) has been increasing, while uptake of user dependent methods has been decreasing
- The proportion of females who choose LARCs is lowest in younger age groups (35-40 per cent of those under 25 years of age compared to 58 per cent of those aged 35 years or over) but implants are driving uptake in younger groups. Twenty-six local authorities recorded a LARC uptake of 55 per cent or more (up from 14 in 2018/19)
- 1.24 million prescriptions for LARCs and 6.83 million scripts for user-dependent contraceptives were dispensed in the community in 2019 (the latter part of a gradual long-term decline)
- Sexual and reproductive health services have seen a 14 per cent fall in the number of emergency contraception items they provided in 2019/20 compared to 2018/19 and a 45 per cent fall since 2009/10
- Those aged 18-19 years were most likely to use the service for emergency contraception but 3,701 females aged 13-15 years of age were provided with emergency contraception at least once during the year.
N.B. Figures exclude services provided in hospital out-patient clinics and those provided by GPs as well as contraceptives purchased OTC at a pharmacy or other retail setting.
Professor Claire Anderson is professor of social pharmacy at the University of Nottingham.
1. Abortion Statistics, England and Wales DHSC 2018
4. Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, Gainer E, Ulmann A. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011; 84(4):363-7
5. Li HWR, Lo SSt, Ng EHY, HOPC, Efficacy of ulipristal acetate for emergency contraception and its effect on the subsequent bleeding pattern when administered before or after ovulation. Hum Reprod 2016, 31:200-207
6. Centers for Disease Control and Prevention. U.S. Selected Practice Recommendations for Contraceptive Use, 2013: Adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use, adapted from the WHO Selected Practice for Contraceptive Us. 2nd Edition Recommendations and Reports June 21, 2013 / 62(RR05); 1-46
7. Cameron ST, Glasier A, McDaid L et al. Use of effective contraception following provision of the progestogen-only pill for women presenting to community pharmacies for emergency contraception (Bridge-It): a pragmatic cluster-randomised crossover trial. Lancet. 2020; 396(10262):1585-1594
8. UNFPA, Choice, not chance, 2012
9. PHE, Contraceptive services: estimating the return on investment, 2018. Department of Health
11. Upadhya KK, Santelli JS, Raine-Bennett TR, Kottke MJ, Grossman D. Over-the-Counter Access to Oral Contraceptives for Adolescents. J Adolesc Health. 2017 Jun; 60(6):634-640
12. Faculty of Sexual & Reproductive Healthcare Clinical Guidance (2015) FSRH Clinical Guidance, Progestogen-only Pills, Royal College of Obstetricians and Gynaecologists
13. Gauld NJ, Braund R. 2019. Contraception and the Pharmacist’s Role, in: Babar, Z.-U.-D. (Ed.), Encyclopedia of Pharmacy Practice and Clinical Pharmacy. Elsevier, Oxford, pp. 473-486
14. Worly BL, Gur TL, Schaffir J. The relationship between progestin hormonal contraception and depression: a systematic review. Contraception 2018; 97: 478-489
15. Kennedy CE, Yeh PT, Gonsalves L et al. Should oral contraceptive pills be available without a prescription? A systematic review of over-the counter and pharmacy access availability. BMJ Global Health 2019; 4:e001402
16. Black KI, Geary R, French R et al. Trends in the use of emergency contraception in Britain: evidence from the second and third National Surveys of Sexual Attitudes and Lifestyles. BJOG 2016; 123:1600-7
17. Gonsalves L, Hindin MJ. Pharmacy provision of sexual and reproductive health commodities to young people: a systematic literature review and synthesis of the evidence. Contraception 2017; 95:339-63
18. Mooney-Somers J, Lau A, Bateson D et al. Enhancing use of emergency contraceptive pills: a systematic review of women’s attitudes, beliefs, knowledge and experiences in Australia. Health Care Women Int 2019; 40:174-95