A little over two months ago the Irish people voted overwhelmingly to allow the Oireachtas to legislate for termination of pregnancy. This was a significant vote which will require a comprehensive strategy from Government and which may have implications for pharmacists.
In the first instance, there will be healthcare professionals who have fundamental ethical or religious objections to the provision of abortion services, including the dispensing of so-called abortion pills; those objections must be respected and the right not to participate must be protected.
The Irish Pharmacy Union has communicated our views on this to the Minister for Health and the media, and has pointed out that our code of conduct already provides for such situations by requiring pharmacists to ensure that where they are unable to provide prescribed medicines or pharmacy services to a patient they must take reasonable action to ensure these medicines/services are provided and the patient's care is not jeopardised. As such, a pharmacist who for ethical or religious reasons cannot provide a specific service to a patient must direct that patient to someone who will.
The prevention of unplanned pregnancies will also form a key part of the Government's strategy, with plans for a free contraception service for all women already announced. Some years ago, the Health Service Executive carried out the Irish Contraception and Crisis Pregnancy Study 2010, which found that nearly half of the women surveyed (47 per cent) would prefer to get their contraception from a pharmacy and that 15 per cent of women and 9 per cent of men experienced difficulty in accessing contraception. Barriers to access included locality, cost and embarrassment.
According to the study, difficulty in accessing contraception remains an important issue and the authors suggested that “more readily available access to affordable contraception would increase the use of contraception”. The study recommended that “strategies that facilitate choice in accessing contraception should be implemented” and that “the role of community pharmacists in the provision of sexual health advice and services needs to be further developed”.
The IPU therefore submitted a proposal to the Minister for Health outlining a scheme by which women could access contraception directly from their community pharmacist without prescription and without charge. There is no clinical reason why women should still require a prescription for oral or transdermal contraceptives. The oral contraceptive is one of the safest and most well-studied medicines available. The renowned medical journal, the Lancet, has long recommended non-prescription availability; there are numerous studies showing that it is safe for women to obtain contraceptives without a doctor's prescription and that women will still visit doctors for gynaecological exams and screening for cervical cancer and sexually transmitted infections.
In several states of the USA, women can now access contraception directly from a pharmacist without a prescription
The supply of hormonal contraception under protocol without prescription by a specially trained pharmacist is becoming increasingly accepted worldwide. In Ireland, we have a de facto version of this service when a woman uses an online doctor to renew her prescription, as the online doctor is essentially an algorithm, with the blood pressure and BMI checks being carried out by the pharmacy.
Last year, the New Zealand ministry of health medicine classifications committee recommended reclassification of certain oral contraceptives from "prescription" to "restricted" medicines, saying that they were satisfied that "pharmacists can supply oral contraceptives to women who meet the specified criteria with the same levels of safety as other healthcare professionals".
In several states of the USA, women can now access contraception directly from a pharmacist without a prescription. Women seeking contraception answer a health questionnaire at the pharmacy and get their blood pressure checked. If there are no problems identified, then they can get a contraceptive prescription. Questions asked include inquiries into chronic diseases, smoking habits, current and past use of different types of contraceptives, and blood clot history.
In a study conducted by researchers from the University of Washington, which measured the effectiveness of pharmacists’ counselling and interview processes, 70 per cent of women reported continuing use of their prescribed birth control. Both women and pharmacists reported satisfaction with the experience, and nearly all study respondents said they’d be willing to continue seeing pharmacist prescribers for contraception and other services.
Things have moved on since a condom required a prescription
It isn’t only pharmacists and women’s rights activists who advocate for better access; expert medical organisations do too. The American Academy of Family Physicians supports access to contraception without prescription. It says oral contraceptives are safe and effective and that women correctly self-identify contraindications. Also, the American College of Obstetricians and Gynecologists has said that oral contraceptives should be available without prescription, that women can self-screen for contraindications, and that cervical cancer/STI screening are not medically required to safely provide contraception.
If the Government is serious about reducing unplanned pregnancies by improving access to contraception, then the Minister must engage with us on our proposal. Things have moved on since a condom required a prescription. Now it’s time we made more progress on contraception and caught up with the rest of the world.
Darragh O’Loughlin is secretary general of the Irish Pharmacy Union