We have come a long way from the early days of the oral contraceptive pill, where the doctor would only prescribe it to women who were married, and then told them soon after that it was time to stop it and have babies. But in most countries we have not come far enough.
The oral contraceptive is one of the safest and most well studied medicines available. However, aided by media sensationalism of adverse events, women worry about taking it for too long. They do not know that women who take the pill live longer than women who do not, helped by its protective effect on ovarian cancer, for example. The Lancet has twice recommended non-prescription availability, once because of its protective effect against cancer[1]
, and another time because it would help women realise how safe it is[2]
. Despite this, and the fact that pharmacists have proven they can manage these supplies without a doctor, oral contraceptives require a prescription in most developed countries.
In February 2017, New Zealand women finally received the announcement that selected combined oral contraceptives and progestogen-only pills will soon become available from specially trained pharmacists. This announcement comes 23 years after it was first considered for reclassification in New Zealand, a consideration derailed at that time by concerns about thromboembolism with third-generation oral contraceptives. In the absence of industry interest, this classification has been driven by Green Cross Health and Natalie Gauld Ltd. Consternation from some medical organisations about oral contraceptives becoming available through pharmacists occurred, even with the proposed careful model of supply. In contrast, an online survey from one of the television stations showed good public support.
There are clear criteria that are used internationally when certain contraceptives should be avoided, and these will be applied in the controlled pharmacist-only model of supply. Pharmacists will only be able to supply the medicine after undertaking additional training, and according to strict criteria. Not only does this model maximise the safety of the reclassification, but it also ensures a comprehensive record of the supply. This is important for further supplies to the same person. It allows for accountability and auditing of the service. This pharmacist-supply model is ideal for complex reclassifications, which are becoming increasingly common in New Zealand[3]
, e.g. vaccines, trimethoprim, and sildenafil, and research supports the model[4],[5]
.
The fact that women mostly obtain their emergency hormonal contraception (EHC) from pharmacies over the GP surgery[6]
shows that convenience and accessibility are important for contraception supply, and a pharmacy is seen as an appropriate access point. However, EHC is not an ongoing solution, and it has had less effect on unwanted pregnancies than was hoped[7]
. Oral contraceptive availability through pharmacy is likely to be different. Pharmacist-supply of ongoing contraception that has a lower failure rate than emergency contraception should be more successful in affecting rates of unwanted pregnancies. To maximise the impact of this policy change, a government subsidy could be used in high need areas to make it affordable.
Research is now needed to show uptake, consumer views, and how this health policy change affects pregnancy and termination rates.
Natalie Gauld
Director, Natalie Gauld Ltd
Honorary Research Fellow
Department of General Practice
University of Auckland
New Zealand
Declaration of interest: Dr Gauld has received funding for reclassifications mentioned in this article from Green Cross Health and Douglas Pharmaceuticals, a training fee from the Pharmaceutical Society of New Zealand, and an undirected research grant from Green Cross Health, the Pharmacy Guild of New Zealand, ProPharma and the Pharmaceutical Society of New Zealand for trimethoprim research. She is a member of the National Executive of the Pharmaceutical Society of New Zealand. The views expressed in this article are hers alone, and do not represent the views of other organisations.
References
[1] The case for preventing ovarian cancer. Lancet 2008;371(9609):275. doi 10.1016/S0140-6736(08)60139-7
[2] OCs o-t-c? Lancet 1993. 342(8871):565–6. doi: 10.1016/0140-6736(93)91401-7
[3] Gauld NJ, Kelly FS, Kurosawa N et al. Widening consumer access to medicines through switching medicines to non-prescription: a six country comparison. PLoS ONE 2014;9(9): e107726. doi: 10.1371/journal.pone.0107726
[4] Braund R, Henderson E, McNab E et al. Pharmacist-only trimethoprim: pharmacist satisfaction on their training and the impact on their practice. Int J Clin Pharm 2016;38(6): 1357–61. doi: 10.1007/s11096-016-0388-0
[5] Gauld N, Zeng ISL, Ikram RB et al. Antibiotic treatment of women with uncomplicated cystitis before and after allowing pharmacist-supply of trimethoprim. Int J Clin Pharm 23 December 2016. doi: 10.1007/s11096-016-0415-1
[6] Marston C, Meltzer H & Majeed A. Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional surveys. BMJ 2005;331(7511):271. doi: 10.1136/bmj.38519.440266.8F
[7] ESHRE CapriWorkshop Group. Emergency contraception. Widely available and effective but disappointing as a public health intervention: a review. Hum Reprod 2015;30(4):751–760. doi: 10.1093/humrep/dev019
