Must be affordable and easily available to all women
by DIANE SAIBIL
From Women and Health Protection and the Canadian Women’s Health Network
Good news!
On April 19, 2005 Health Canada joined an international trend by announcing that it would move forward federally with a proposal to change the emergency contraceptive pill (ECP), also known as Plan B or "the morning after pill," from a prescription drug to a non-prescription product. In concert with this move, the National Association of Pharmacy Regulatory Authorities (NAPRA), which determines access status for non-prescription drugs for most of the provinces, also immediately made ECP a "Schedule II" status drug. This means that ECP is now available across Canada "behind-the-counter," without a visit to the doctor or a doctor’s prescription, but requiring pharmacist assistance.
We strongly endorse Health Canada's decision to change the status of ECP from a prescription to a non-prescription product. But to make ECP even more accessible to all women in Canada, governments need to go a step further and make ECP available without a scheduled status—that is, without pharmacist assistance or intervention as a requirement.
Continued concerns
Access behind-the-counter: Increasing access to ECP can help reduce unintended pregnancy. Given that this is a safe, effective and easy to use medication, a key consideration is the need for timeliness in its use. ECP is most likely to prevent a pregnancy if taken within 24 hours of intercourse. As more time passes, the effectiveness rate decreases. It is clear that timely access to the medication is crucial and the determination of its scheduling status must take this into account.
ECP must be available to women and adolescent girls in a location that is accessible daily, including on weekends and holidays, and that is accessible to rural as well as urban consumers. It should be easy to find and purchase.
Behind-the-counter (Schedule II) status means that only pharmacies can carry ECP—a significant limitation in small towns and rural communities. Some pharmacists, due to religious or other convictions, have already declared their unwillingness to dispense ECP. While such pharmacists are expected to refer clients to other sources for these products, this can still pose substantial problems for timely and equitable availability, particularly in small towns and rural areas where there may be only one local pharmacy.
The right to privacy: Current guidelines for pharmacists require a consultation with a woman before providing ECP. This is, in our view, an unnecessary intervention that interferes with women’s right to privacy. Women should not be treated as patients when there is no evidence of medical necessity. Women and teenagers are able to diagnose their need, understand the labeling and directions, and use ECP safely and effectively without medical intervention. A greater role for pharmacists as health educators is welcome. But it is inappropriate to make counseling mandatory for every woman or girl seeking to purchase ECP.
The need for ECP is a private matter and it must be available in a manner that respects an individual’s privacy to the greatest extent possible. If ECP is only available by consultation with a pharmacist, the purchaser may well find herself having this consultation at a very public prescription counter. While pharmacists are encouraged to provide a private area for consultations, a private room away from the retail area frequently does not exist.
Complete privacy is obviously impossible because of the need to purchase ECP in a public place. However, being able to take a product off the shelf and directly to the checkout counter provides a greater degree of privacy than having a discussion at a prescription counter.
Even greater privacy can be achieved if the consumer has a number of options available for purchasing the product. Imagine a woman or an adolescent girl having to purchase her ECP on a Sunday at the only pharmacy in town open at that time. On arriving at the pharmacy, she discovers that a family friend is working at the cash register. Having another option of where to purchase the medication would greatly enhance her privacy and, therefore, increase the likelihood of her making the purchase and taking the pills within the optimal time frame.
Costs behind the counter: Finally, there is the question of cost. Government and private drug insurance plans do not generally cover non prescription drugs or pharmacists' consultation services. Therefore, it is likely that the cost of ECP will increase as provinces remove emergency contraception from provincial formularies, with the result that low-income women and women with drug plans will have to cover the cost themselves.
As predicted by researchers Joanna Erdman and Rebecca Cook, behind-the-counter status for ECP has resulted in women having to pay the cost of the medication, plus a pharmacist consultation fee. Consultation fees range from $15 to $45. If ECP is available over-the-counter, there is no consultation fee, resulting in a more affordable cost.
Although not the responsibility of those regulating the schedule status, provincial governments should see ECP as an essential drug to which all women can have access, no matter what their income level.
A call to action
Access to emergency contraception is a key element in any comprehensive program addressing women’s reproductive and sexual health. It is of particular importance to the health of teenaged girls and young women, the age group at greatest risk, relative to the general population of women, of unintended pregnancy.
Effective access to emergency contraception requires that it be readily available, quickly, regardless of a woman's age. It must be accessible to rural as well as urban women and to women of limited financial means. Finally, it must be accessible in a way that respects women's right to privacy, as well as their right to freely make informed health care choices. The use of emergency contraception represents a responsible and informed decision by a woman seeking to prevent an unintended pregnancy and must be respected as such.
Women and Health Protection (WHP) and the Canadian Women's Health Network (CWHN) want access to emergency contraception to be improved. A lack of awareness about emergency contraception, the costs of obtaining it, and existing regulations unnecessarily restrict this access.
As a first step in improving access, we are planning to submit a request to Canadian regulatory authorities for Plan B to become an "off-schedule" medication, available for sale at any retail outlet. We invite and encourage you to give your support to this position.
For more details, and to join our initiative, see www.whp-apsf.ca [1] or contact: 1-888-818-9172.
Emergency contraception: The Facts
What it is: The emergency contraceptive pill (ECP), also known as Plan B or "the morning after pill," is a hormonal product, taken orally, to prevent pregnancy after unprotected intercourse. This same hormone is used in some birth control pills.
Effectiveness: ECP has been shown to have an overall 89% rate of effectiveness if used within 72 hours of unprotected intercourse. The rate climbs to 95% if the medication is taken within 24 hours of intercourse, but it drops to only 58% if taken more than 49 hours after intercourse. Some experts have noted that ECP can provide benefit if taken up to 5 days after intercourse.
Safety record: ECP is safe. There have been no reports of deaths or other serious consequences from taking Plan B. Pregnancy is listed as a contraindication only because, like all contraceptives, ECP will not work if a woman is already pregnant. If a woman takes ECP while pregnant, it will not affect her pregnancy and it will not harm the fetus. ECP does not cause an abortion.
Side effects: Women using Plan B may have side effects like nausea, diarrhea and spotting. Their period may come early or late and look a little different.
Ease of use: No individualized instruction is needed when taking ECP because the dose is identical for all women. Explanations for use are simple and easy to follow.
Other jurisdictions: Women have direct access to ECP in a growing number of countries, including Brazil, Dominican Republic, France, Israel, Kenya, Madagascar, Malaysia, Netherlands, South Africa, Sweden, Thailand, UK, and Vietnam.