The emergency contraceptive pill (morning-after pill) contains a hormone called levonorgestrel and can be bought without a prescription. It’s used to prevent pregnancy after unprotected sex, but many women are uncomfortable with their interaction with pharmacists when buying this drug.
The morning-after pill is licensed by the Therapeutic Goods Administration (TGA) to be used within three days of unprotected sex, but there’s evidence that it’s effective for up to four days. Still, the sooner it is taken, the more effective it is.
It’s available as a tablet and is classified as “Pharmacist Only” medicine. The law requires pharmacists to supply such medicines only for a therapeutic need, and to personally deliver or supervise their delivery, and personally give directions for their use. To establish a therapeutic need, a pharmacist must ask the customer questions about her medical problem, medical history and the medications she’s taking.
Our recent study of emergency contraceptive pill recommendations by pharmacists across Australia found that most of them used the Pharmaceutical Society of Australia’s (PSA) written protocol to guide their supply. Pharmacists tended to follow the protocol rigidly, rather than using their discretion.
As recommended, many provided information to women about the emergency contraception in a part of the pharmacy where confidentiality could be assured. But 62% of the women we spoke to expressed concern about the lack of privacy. What’s more, many women were confused about this type of pill – some thought it caused an abortion (32%) and others that it would cause defects if they were to fall pregnant later (61%).
Only 20% of pharmacists always informed women about how the emergency contraceptive pill worked, while the majority spoke about how long it would remain effective after unprotected sex. Many pharmacists agreed that the pill shouldn’t be supplied if unprotected sex had occurred longer than three days ago.
If a woman had unprotected sex outside of this timeframe, a pharmacist can still supply the emergency contraceptive pill. This supply is called “off label” as it is outside of the TGA-licensed use. In such cases, pharmacists should inform women about the effectiveness of this emergency contraception beyond three days and document that they supplied it. (Or they could recommend the woman have an intrauterine device (IUD) placed instead. This IUD is the most effective form of emergency contraception and can be inserted up to five days after unprotected sex.)
But in situations where the emergency contraceptive pill is supplied within licensed use, documentation is not mandatory. The PSA checklist that women may be asked to complete in the pharmacy when they request the emergency contraceptive pill is also not required. It contains some irrelevant and ambiguous questions.
Completed checklists were initiated to protect both parties in the event that the woman becomes pregnant. They include a statement for the woman to read and sign and are stored in the dispensary and, later, shredded.
The emergency contraception pill is not dangerous under any known circumstances or in women with any particular conditions, so using checklists is an outdated practice. It would better if the pharmacist had an empathetic conversation with the woman about her situation, to minimise any shame or embarrassment she may be feeling.
Many pharmacists in our study thought that supplying the emergency contraceptive pill for future use (“advance supply”) was unacceptable. There’s no evidence that advance supply has a negative impact on sexual health; in fact, advance supply would be good practice. Women need to be able to access this pill as soon as possible after they having unprotected sex.
In 2000, the head of the American College of Obstetricians and Gynecologists recommended that “every woman store [a packet of the ECP] in her medicine cabinet”.
We also found 22% of pharmacists felt it was reasonable for their religious faith to influence supply. Pharmacists can refuse supply on such grounds, but must refer the woman to another supplier. Pharmacists who decline supply on religious grounds do so in the belief this contraception is an abortion pill, but the latest evidence shows that this is untrue.
The emergency contraceptive pill doesn’t prevent implantation of a fertilised egg and, if taken after implantation, has no effect on an existing pregnancy. It’s not the same as a medicine called mifepristone or RU-486, which was recently approved for medical abortion in Australia.
Australian common law states that a person has to be 16 years or older to consent to medical treatment. The revised PSA protocol now includes provision for those under the age of 16 to be able to access the emergency contraceptive pill. The new guideline has been extensively revised to help pharmacists assure that the women they serve can access and use this pill effectively, safely and unobtrusively.
The emergency contraceptive pill is a medicine that all women should be aware of. It’s available from pharmacies and the sooner it’s taken, the more effective it is. Pharmacists should help women access this pill because it can prevent unwanted and ill-timed pregnancies. Such pregnancies may carry a high risk of death or unhealthy state of mind for the rest of a woman’s life, especially where safe abortion isn’t accessible.
This is the third article in our short series about pharmacies. Click on the link below to read the previous instalments:
Part One: Pharmacy gravy train drives up the cost of prescription drugs
Part Two: Online pharmaceuticals: bricks, not clicks, keep us safe
Part Four: Pharmacists should drop products that aren’t backed by evidence
Part Five: Why you have to show ID to buy cold and flu tablets
Mike Swinbourne
logged in via Facebook
I'm confused by one item in this article. You state that 22% of pharmacists thought it reasonable for their religious faith to influence supply.
Leaving aside the obvious questions about whether or not religion should intrude into situations like this, if a pharmacist has religious objections to such a drug why would they stock it for sale in the first place? If they have it in stock, the only reason to refuse supply should be for medical reasons. If they don't, then it would be easy to direct the customer elsewhere.
Michael Macdonald
Chemist
That assumes that all 22% of those pharmacists own the pharmacy they work in and are able to decide on what is and isn't stocked in store.
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
You're absolutely correct. The only reason to refuse supply should be for medical reasons, however, pharmacists can refuse supply if it conflicts with their religious/moral beliefs, AS LONG as they refer the customer to another avenue e.g. family planning clinic, hospital, GP. As for why pharmacists stock the medication if conflicts with their beliefs, this is influenced by many factors e.g. a pharmacist is employed by a proprietor of a pharmacy, and it's the proprietor who decides what is stocked, not the pharmacist, or several pharmacists work at a pharmacy but have different beliefs, therefore one pharmacist may supply and another may not.
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
This result doesn't differentiate between pharmacists who work at a pharmacy and pharmacists who own a pharmacy. It's an overall figure and as mentioned above, it's proprietors who choose what they stock.
Tim Connors
System Administrator
A bit scary for a small remote country town. "No, you can't have the pill, but you can buy it from the town 180km down the road". Fortunately my last small country town had the luxury of having 2 pharmacies.
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
Totally agree. This situation has happened in real life in Victoria and received media attention last year. The pharmacist refused supply but i cant recall if they referred the customer to another pharmacy/elsewhere. Not sure what the outcome was...but pregnancy is one that could be litigated by a customer if a pharmacist doesn't refer. The other issue is that the pill is more effective the sooner it's taken, so if a customer had to travel far to get it, that would defeat the purpose of the medication!
Qian CHEN
pharmacy student
Is there any guideline says that pharmacists can actually refuse to supply morning after pill or S3 medicines due to moral issue?
Kim Darcy
Analyst
Good questions Mike. On subjects like this where the relevant body/professional is receiving significant government-funding, I think the individual religious belief should be indulged, but only if a relatively convenient alternative supplier of the product/service can be identified.
Kim Darcy
Analyst
Tim, is that really such a problem in Internet time?
Chris Sharp
Pharmacy Student
The pharmacist who owns the pharmacy (and controls what is/isn't stocked) may not be the pharmacist serving you.
Jan Burgess
Retired
"Tim, is that really such a problem in Internet time?"
Firstly, I doubt this particular product is available from online pharmacies.
Secondly, given the three day window, it certainly is a problem for country residents. Delivery time to a country town or property can easily exceed three days.
Riddley Walker
.
Religion: if we all work together, we CAN find a cure.
David Thompson
Research Officer In Men's Health at University of Western Sydney
This very issue of privacy within pharmacies has also been identified as a barrier to use of pharmacy services by men as well. Obviously it's an issue that affects either gender.
The view is that if pharmacies could create private consulting areas, they might become more trusted and therefore act as more of a channel towards better engagement with health services generally.
These and other similar issues are being explored by numerous Medicare Locals and health services as they start to look differently at how improving the way they engage with 'patients' (for want of a better word) to improve health outcomes. This reflection acknowledges that health isn't just an individual's actions but that services and systems have a large part to play as well.
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
Great point, privacy is definitely a barrier to use of health services and creating the illusion of privacy can overcome this barrier. Many pharmacies do have private counselling spaces for customer interaction, however, where these aren't available, creating an illusion of privacy is critical e.g. offering to speak to the customer in a quieter area, away from other customers or lowering one's tone of voice. Pharmacists and other health professionals need to adapt their skills according to different situations and the needs of their customers - should they do this all the time, customer perceptions of the experience will probably change.
Michael Foster
logged in via LinkedIn
Are men able to buy the morning after pill?
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
Men can purchase the emergency contraceptive pill as long as the pharmacist has the opportunity to speak directly with the woman. Many pharmacists may decline supply if they can't speak to the woman. The main reason for this is because in rare cases, non-consentual intercourse (rape) may have occurred.
Michael Foster
logged in via LinkedIn
Interesting. Digging a little deeper and along the lines of preventative medicine, what would happen if I went in with a female friend and requested it? If we hadn't had sex is the a grounds to not supply it?
It's always seemed rather unfair that the woman has to put herself on the line to get it even though both were party to requiring it.
Xao Ping Wang
Health Advocate
Michael, as Safeera rightly pointed out, some men would buy it to prevent pregnancy after non-consensual sex. Although a woman suffering domestic violence can still be forced to use emergency contraception against her will if she fears reprisals from her partner, with or without him being present.
Michael Foster
logged in via LinkedIn
It's a pretty soft reason. The same could be said of condoms.
Delete this account as requested!
logged in via email @iinet.net.au
It's worse than a soft reason it's frankly illogical.
Can you please provide evidence of a link between readily available birth control and sexual assault Xao Ping Wang?
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
True, it is unfair. Hypothetically the correct response would be to supply the pill as you (the couple) may need it in the future even though you may not have had unprotected sex on that occasion. Advance supply is perfectly ok and pharmacists need to recognise this. More importantly, those who have a moral objection to it should update their knowledge about its mechanism of action as highlighted in the article, as most wrongly think it interferes with an established pregnancy.
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
So true. And even for taking regular contraception - there are many instances of men forcing women to use regular contraception against their will.
Miles Ruhl
Thinker
Not sure if that again is just subjective to the individual pharmacist as I have purchased the MAP for my wife before without her being there and with no questions asked by the pharmacist in relation to anything other than the time that had passed since the deed and whether or not we had planned for kids, to which I replied I already had 2!!!
She understood completely :-)
Xao Ping Wang
Health Advocate
The highest quality care involves a skilled professional being able to give a health consumer ("patient") the best advice possible in a manner that best preserves their dignity and autonomy.
Privacy within a pharmacy is a big issue, but for all health consumers for all of their interactions with a pharmacist or a pharmacy assistant, not just for emergency contraception. I have never been to a pharmacy where private rooms have been used, and in some cases I have been asked about some rather intimate…
Read moreSafeera Hussainy
Lecturer in Pharmacy Practice at Monash University
Counselling rooms would be fantastic. Pharmacies need to be refitted to accommodate this set up. If other health professionals can, why can't pharmacies? They have beauty therapy rooms but not counselling rooms! Though I don't necessarily agree that a lot of customers withhold information because of the lack of rooms - I have practiced for many years and body language (eye contact etc) and the fact that many customers have wanted to consult me for advice in future encounters tells me that they never didn't reveal any health information that was needed.
Generic medicines are another kettle of fish indeed.
Geoff Taylor
Consultant
Useful if it explained how levonorgestrel does work.
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
Geoff, are you referring to the guideline pharmacists use to guide their dispensing? If yes, there is now an updated explanation of its mechanism of action.
Luke Weston
Physicist / electronic engineer
Given that levonorgestrel is not dangerous under any known circumstances or in women with any particular conditions, it needs to be taken at the soonest practical time after unprotected sex in order to do its job with the greatest reliability, and given concerns about timely access by patients to pharmacies with the drug in stock, potential religious opposition by pharmacists or pharmacy bosses, and shame or embarrassment that might be felt by patients speaking to a pharmacist about the issue (especially depending on the nature of the questions asked, or silly ideas like written checklists) why can't we just consider moving the drug to Schedule 2?
That seems like it would solve all these problems.
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
Bingo! I totally agree with you. This is a something the manufacturers would need to move forward. It's already happened in other countries and even in a US school where girls/women can access emergency contraception via vending machines. That led to a huge uproar, but I believe it's fantastic.
Yoron Hamber
Thinking
Don't see how this has to do with religion?
And a pharmacist that thinks so needs another profession, as i see it.
Priest?
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
Exactly, it shouldn't have anything to do with religion, but unfortunately some pharmacists are behaving paternalistic about it and making decisions for women when they shouldn't be.
rachael watkins
Nurse
Yeah maybe the pharmacist could contribute to raising the child, or give the 16yr old a place to live when her parents kick out. Maybe sit with the girl/woman as she puts the baby up for adoption, then be on call for her every day she wonders if shes done the right thing. The price of making decisions for other people.
At least women dont have to go to doctors first anymore.
Read moreI heard a story of a mother who had no choice but to take her 4yr old to the doctors with her to get the morning after…
James Jenkin
EFL Teacher Trainer
Hi Safeera, interesting point about paternalism. Do you think pharmacists should make any decisions for customers? For example, should a pharmacist prevent someone from buying codeine if they think they'll abuse it?
Peter Hindrup
consultant
If you owned a chemist shop and found that an employee was refusing to sell an item because of their religious/moral beliefs, why wouldn't they instantly become an ex employee?
That sort of nonsense is soo 1950's! When the pill first became available in New Zealand -- around 1960 -- it was supposedly available only to married women!
Inevitably there were Doctors who ignored the law and provided scripts. Eventually, of course, the nonsense was simply discarded.
Reminds me of a time long ago when I consulted a solicitor on an idea I had to get me out of a jamb. His reply was legal, but immoral! He was offended when I told him that I consulted him for legal opinions, and that if I wanted moral opinions I would consult a priest.
Refusing to supply a woman with this pill could surely be construed as intentionally causing positive harm? If so, then why is the pharmacist not open to charged with causing actual bodily harm?
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
The pharmacist won't risk litigation if they refer the woman to another avenue, but as someone has already pointed out, if the woman is in a rural area and has to travel miles to get to another pharmacy, then access becomes more problematic and the effectiveness of the medicine decreases as time goes on...it is nonsense as pharmacists are not putting themselves in the woman's shoes, thinking of the consequences of an unwanted pregnancy.
Edward Pritchard
general manager (retired)
If the girl has already ovulated and her partner's sperm has successfully fertilised her egg, no further genetic material is required; her 23 chromosomes have already merged with his 23 chromosomes and a new person is now being formed. In other words she's pregnant. If the girl then takes levonorgestrel and its effect is to stop the pregnancy (during either passage of the fertilised ovum through her fallopian tube or subsequently during implantation), levonorgestrel is acting as an abortifacient (that may or may not be an issue). Alternatively levonorgestrel is certain to be ineffective if the girl has already conceived.
The literature is a tad ambivalent on this issue. In my view pharmacists should point out to potential users the reality.
Safeera Hussainy
Lecturer in Pharmacy Practice at Monash University
I would like to reiterate that the latest evidence shows that levonorgestrel DOES not work after ovulation, and only before. Therefore, it CANNOT interfere with implantation and an established pregnancy. This message is important to spread amongst the general public and health professionals as the latter are using previous, outdated information to support their decision to not supply. Some people may rejoice in the fact that levonorgestrel doesn't work after ovulation, but this isn't good either as a medicine is needed in this circumstance.
Edward Pritchard
general manager (retired)
Thank you Safeera, that's exactly the point that I was hoping someone with detailed pharmaceutical knowledge, like yourself, would point out.
LEVONORGESTREL ONLY WORKS BEFORE OVULATION, AND NOT AFTER.
If ovulation/conception has already occurred, save your money for a new pair of booties and a bunny rug, because a pill is not going to make any difference.
The industry/TGA literature more than a tad misleading.
Note: And the 'upside' is, for those who suspect they might have a potential problem, despair not. On average, it's not all that easy to get pregnant. Healthy 24 yr old girls only have a 25% of falling pregnant in any one month, even when they're making a very determined effort to optimise their chances of producing a baby.