The Morning After: Emergency Contraception Access in Quebec

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BY NATHALIE PARENT with the Fédération du Québec pour le planning des naissances

 

As of December 2001, women in Quebec can purchase emergency oral contraception (EOC) medication at a pharmacy without a prescription from a doctor, but only after a compulsory consultation with a pharmacist.

Negotiations between the pharmacists and the government over who would pay for this service dragged on for nearly two years. During this time women themselves had to pay for the consultation. Finally, in December 2003, the government signed an agreement with the Association québécoise des pharmaciens propriétaires du Québec (Quebec Association of Pharmacists) that the Régie de l’assurance maladie du Québec (Quebec Health Insurance Board) would cover the costs of the EOC consultation. For any woman with a valid Quebec healthcare card this obligatory consultation would be free of charge.

A Little Known Agreement
Last spring, three months after the agreement came into effect, the Fédération du Québec pour le planning des naissances (FQPN) learned that many pharmacists in Quebec either did not know about the new arrangement or were choosing not to honour it. They were continuing to charge a $10 to $30 consultation fee directly to women seeking emergency contraception. In fact, after making several calls to pharmacies in the Montreal and Sherbrooke regions, we discovered that there was enormous confusion surrounding the terms of the agreement and that very few pharmacists were accurately applying it.

The FQPN contacted both the Régie de l’assurance maladie du Québec and the Association québécoise des pharmaciens propriétaires du Québec. The Association responded by sending a memo to its members reminding them that the EOC consultation was now available free of charge for all women in Quebec.

But even after this letter was sent out, members of the FQPN learnt that some pharmacists were still charging consultation fees. Something had to be done and so we asked our members for assistance in conducting a province-wide inquiry into the situation.

What We Learned
With the help of our members we telephoned 54 pharmacies in 27 cities in 11 regions in Quebec. The pharmacists were asked the following questions: How much does EOC cost? Do you, as a pharmacy, charge a consultation fee? If so, how much? Is the consultation carried out in privacy? And what do you see as the purpose of the consultation? The women conducting the survey also made note of the type of reception and the quality of the information they received.

Out of 54 pharmacies contacted during September and October 2004, 10 pharmacies, 19%, were making women pay for the consultation. That meant that almost one out of five pharmacists were not respecting the right of a woman to have this service free of charge. The fees charged varied between $10 and $25. Some pharmacists believed that the insurance companies would reimburse them; others thought that payment depended on a woman’s drug insurance plan. Some believed that the consultation was free only with a doctor’s prescription. Others knew absolutely nothing about the agreement. During our calls, some pharmacists checked up on the information we gave them. One even called the Régie de l’assurance maladie du Québec, and ended up apologizing to us when he confirmed that the consultations should, indeed, be free.

The great majority of pharmacists assured us that consultations were held in privacy and most reported having office space for this purpose. But that wasn’t always the case. One respondent in the Eastern Townships said he did hold his consultations at the counter, but first made sure there were few people around. A pharmacist in Charlesbourg mentioned that she would consult with a client away from the counter if she felt her client was uncomfortable otherwise. Another said he spoke to women in his office if sexual abuse was involved. Two pharmacists said that they had no place at all for a private consultation.

The most commonly prescribed emergency contraceptive pill in Quebec is Plan B. A progesterone-only pill, Plan B has far fewer side-effects than Ovral, the other leading emergency contraceptive medication. The price of Plan B varies between $20 and $29.99. Ovral involves taking four tablets of high-dose estrogen and progesterone and costs $5 to $25. All insurance plans reimburse the costs of EOC and the final amount paid by a woman will vary, based on her plan. EOC is completely free for women 18 years old or younger, and for full-time students under 25 years of age.

When asked about the purpose of the consultation, the answers the pharmacists gave us were quite varied. Some said they asked for the date of the women’s last menstrual period to confirm that there was a real risk of pregnancy. Others said they used the consultation to determine the best method of EOC and to explain the side-effects. Still others wanted to discuss the woman’s overall health and explain any possible side-effects. One pharmacist even talked about checking a woman’s vital signs, which surprised us since Plan B has no risks associated with it.

Many of the pharmacists said that they used the consultation to inquire about the possible risk of sexually transmitted diseases. Some questioned women to find out if there was any sexual abuse involved so they could refer them to the appropriate resources. Others used the consultation to talk about contraception. A pharmacy in Asbestos had clients fill in a questionnaire that could take 10-15 minutes to complete. That was somewhat excessive we felt.

The final results of our inquiries are quite troubling. Too many pharmacies do not respect the fact that EOC-related services are free. The FQPN will contact the Association québécoise des pharmaciens propriétaires du Québec as well as the Régie de l’assurance maladie du Québec to demand changes to the current situation. Along with the Coalition pour la santé sexuelle et reproductive (Coalition for Sexual and Reproductive Health), we are considering other demands, the most important being that EOC be sold as an over-the-counter drug, with no requirement to consult with a pharmacist.

EOC Over The Counter
The FQPN supports the position taken by the Canadian Women’s Health Network (CWHN) that would see over-the-counter sales of EOCs. We believe that forcing a woman to consult with a pharmacist creates an absolutely unnecessary obstacle to obtaining EOC. In the case of women who live in small communities, it can also mean a serious invasion of privacy.

The CWHN has stated that there is no medical argument to justify a mandatory consultation with a healthcare professional before obtaining emergency contraception. The World Health Organization has declared Plan B risk-free and not requiring a physical examination. The United Kingdom, Norway, Sweden, Finland, Israel, France, Belgium, Denmark, Morocco and Portugal already offer Plan B over the counter.

In their instruction manual on EOCs, the Quebec Order of Pharmacists states that "there is no absolute medical contra-indication for using EOC" (pg. 23). "The risks for its use are non-existent and any side-effects are reversible without serious consequences" (pg. 24). It also mentions that there are many benefits to using EOC, since it is fast, short term, non-invasive and has a high success rate. Lastly, it specifies that any questions asked by the pharmacist "should be limited to ones that will allow him or her to evaluate the need for taking an EOC or the possibility of an existing pregnancy" (pg. 27).

The FQPN and the CWHN believe that women, given the appropriate information, can decide for themselves if EOC is right for their situation. Without a mandatory consultation, access to EOC, which has been proven to be a safe and effective drug to prevent unwanted pregnancies, would greatly improve.

More Accessible, But More Expensive?
The one disadvantage of selling EOC as an over-the-counter drug is that it would no longer be covered by drug insurance plans and women would have to pay the full price. The FQPN intends to take steps to ensure that the drug remains free of charge for certain groups of women, such as young people, even if sold over the counter. One solution would be establishing distribution centres where EOCs could be provided at a wholesale price or free. It is clear that there is still much that remains to be done.

Reprinted from À notre santé …sexuelle et reproductive, the newsletter of the Fédération du Québec pour le planning des naissances, www.fqpn.qc.ca

For more information on emergency oral contraception and the position of the Canadian Women’s Health Network visit our website at: www.cwhn.ca/resources/cwhn/ec.html