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A small supply of the progestogen only pill (POP) given along with emergency contraception, helped women get started with effective contraception.

Women who have had unprotected sex may seek help from pharmacists to prevent pregnancy. Pharmacists can supply emergency contraception pills. This research looked at the impact of them offering extra contraceptive support at the same time.

It found that women given a 3-month supply of the POP (sometimes called the mini-pill) were more likely than others to go on to use an effective method of contraception.

Pharmacists provided emergency contraception to all the women in the study. Half the women in the study were advised to speak to their usual contraception provider. The others were given a 3-month supply of the POP together with a fast access card to help them get seen at a sexual health clinic.

Four months later, around 20% more women who received the POP were using an effective method of contraception (either a hormonal method or an intrauterine device). However, the fast-access card did not increase use of a sexual health clinic.

This intervention was carried out in pharmacies and could be rolled out widely to increase access to contraception and decrease unintended pregnancies across the UK.

Further information on emergency contraception is available on the NHS website.

What’s the issue?

Women may go to community pharmacies, usually based on high streets, for emergency contraception after unprotected sex or a burst condom. Pharmacists can provide emergency contraception pills, but they cannot usually provide contraception (other than condoms) without a prescription.

Many of these women are at risk of an unintended pregnancy unless they start to use effective contraception. Pharmacists should advise women seeking emergency contraception to get reliable long-term contraception from their GP or a sexual health clinic. But many women struggle to get an early appointment with their GP; opening times at sexual health clinics may not meet their needs.

The POP is an effective method of contraception and could be provided as a temporary measure along with emergency contraception. This approach could give women time to get an appointment at their local contraceptive provider to arrange their preferred long-term method.

This study looked at whether community pharmacists could increase women’s use of effective contraception after emergency contraception. They were asked to provide a short ‘bridging’ supply of the POP to fill the gap between emergency contraception and visiting the GP or sexual health clinic. This pill was chosen because almost all women can take it safely.

The project aimed to help women at risk of unintended pregnancy access effective ongoing contraception.

What’s new?

The study was carried out in 29 pharmacies in Edinburgh, London, and Dundee. It included 406 women who all received emergency contraception. Pharmacists gave half the women a 3-month bridging supply of the POP, plus a fast-pass card to help them get seen at the local sexual health clinic. The remaining women were advised to contact their usual contraception provider.

Women completed a telephone interview or online survey 4 months later.

The study found:

    • around 20% more women who received the POP (58% compared with 41% who did not) reported using reliable long-term contraception
    • fewer women who recieved POP said they had needed emergency contraception again
    • the POP did not have any serious side events.

The fast-access pass did not seem to increase use of a local sexual health clinic. Two in three women (137 out of 198) recalled receiving the pass; 31 of them attended the clinic. Of this small group of 31:

    • 2 women (7%) visited the clinic within 1 month
    • 4 women (13%) received a long-acting reversible (implant, intrauterine or injection) contraceptive at the clinic.

Pharmacists in the study said that offering this extra support was acceptable and feasible, but took more time than standard care. One said: “It’s a time-consuming process. So sometimes you need to manage your time really, really well and be very tight with time to fit it all in.

Many staff at sexual health clinics were in favour, saying for example: “The fact that they need emergency contraception, obviously something has gone wrong, so it’s a good time to [say] … have you had a think about this, or how can you deal with this kind of thing?

But fast-access appointments were not always available. One staff member said: “We don’t have enough time for appointments but also, we don’t have enough appointments for the demand. You know? And because … services have been cut and staff [have] been cut and there’s only so much, really, that you can give.

Women said the pharmacists' support prompted them to think about reliable contraception. For example: “I think it was good because I probably would’ve taken a lot longer to figure it out and how to get it myself. And it was really convenient. It made me kind of realise that it was time to go on one and that it was something I did need to do.”

Why is this important?

Many women seeking emergency contraception would be open to a discussion about long-term contraception. They could lose motivation to have this discussion if they can’t get an early appointment with either their GP or at a sexual health clinic.

Pharmacists are well-placed to provide a short supply of oral contraception to bridge this gap. The bridging supply could help prevent unintended pregnancies in the short-term. It also provides an opportunity for pharmacists to remind women about longer-term reliable contraception.

Long-acting reversible contraception includes implants, coils (intrauterine contraception) and injectable hormones. These methods are considered the most reliable contraception methods. There were initial concerns that providing the POP might reduce the number of women using these other methods. These concerns were unfounded; the study did not find that giving the POP reduced demand for long-acting reversible contraception.

What’s next?

As a result of this study, pharmacists in Scotland can now provide a bridging supply of contraception when women need emergency contraception. The researchers will evaluate the intervention after roll-out to see how it is working. They say it will be important to find out whether the intervention reduces unintended pregnancies.

The research team is also looking at the cost-effectiveness of this bridging intervention. However, they say that the POP is inexpensive. By contrast, a cost-effectiveness analysis of emergency contraception showed that unintended pregnancies cost the NHS more than £1 billion in 2011.

Pharmacists in the study faced time pressures and competing demands. It is possible that some may have forgotten to give women the fast-access card. Likewise, sexual health clinics are overwhelmed and could not always honour the fast-access card. This means the full intervention might not always have been delivered in this trial.

A new emergency contraception drug, ellaOne (ulipristal acetate) became available during this study and may also be used in the rollout. Wider advertising about this new service from pharmacists would encourage more women to use it, the researchers say. They recommend that women have the option to book consultations in pharmacies.

Women still face barriers to accessing effective contraception. The researchers call for imporved access both to routine contraception and emergency contraception.  In this study, the POP was given free of charge by pharmacists. Although the POP will be made free from pharmacies in Scotland, in some areas of the UK, this may not happen. Commissioners in England and Wales will decide under what circumstances it will be free of charge from pharmacies, and what the cost will otherwise be.

You may be interested to read

The paper this NIHR Alert is based on: Cameron ST, and others. Provision of the progestogen-only pill by community pharmacies as bridging contraception for women receiving emergency contraception: the Bridge-it RCT. Health Technology Assessment 2021;25:27

Another paper by the same group describing pharmacists’ approach: Glasier A, and others. Emergency contraception from the pharmacy 20 years on: a mystery shopper study. BMJ Sexual and Reproductive Health 2021;47:55-60

A cost-effectiveness analysis of unintended pregnancies: Thomas CM, and others. Can we reduce costs and prevent more unintended pregnancies? A cost of illness and cost-effectiveness study comparing two methods of EHC. BMJ Open 2013;3:e003815

A paper on this research from the same group: Cameron ST, and others. Use of effective contraception following provision of the progestogen-only pill for women presenting to community pharmacies for emergency contraception (Bridge-It): a pragmatic cluster-randomised crossover trial. Lancet 2020;396:10262

 

Funding: This project was funded by the NIHR Health Technology Assessment programme.

Conflicts of Interest: One author has received fees and funding from various pharmaceutical companies; another was employed by a retail pharmacist during the course of the study.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Commentaries

Study author

Many unintended pregnancies can be prevented if women have easier access to effective contraception. In this study, giving women the 3-month supply of the POP led to more of them still using effective contraception even after this supply had run out. Women found the POP acceptable, and we didn’t see any serious adverse events.Some pharmacists said that taking part in the research study took a lot of time and extended their consultations by around 15 minutes. But we don’t expect that providing the POP outside the context of a research study would be so time-consuming.Sharon Cameron, NHS Lothian Consultant Gynaecologist and Honorary Professor in Sexual and Reproductive Health, University of Edinburgh 

Member of the public

This work should make it easier for women to access the support and care they need to successfully manage their own contraception. I would encourage any woman I know who found herself in this position to access such a service. I have many friends with daughters and would want them to be able to access this kind of service if they found themselves in this situation.To roll out the findings, it would be helpful if these circumstances were normalised. Young women need to be able to talk about and access contraception. They should feel empowered to discuss contraception with potential sexual partners, and to approach appropriate professionals for information and advice.Anything that can help women to take control of their lives and bodies seems like a sensible direction to go in. It strikes me that this kind of service may catch some of those women who have been unable or unwilling previously to access sexual health support, advice and contraception.Una Rennard, Public Contributor, Oxfordshire 

Community Pharmacist 

These findings seem logical and promising. They could mean that in future, I will start to provide the mini-pill as part of emergency contraceptive consultations.Pharmacists might be more engaged with providing the mini-pill after understanding the impact it can have on reducing emergency contraception rates. Women may also be more likely to ask a pharmacist for advice. This could potentially reduce the workload for sexual health clinics too.However, this approach puts extra pressure on community pharmacies at a time when their workload is increasing. It may stretch pharmacists beyond their current area of expertise. Stronger links between pharmacies and local sexual health services might therefore help with rolling this out.Louise Edwards, Community Pharmacist, Norwich 

Midwife

As a clinical midwife, I support women who have unintended pregnancies. I also provide information on contraception when discharging women from hospital after giving birth.This paper has important implications for sexual health services. Women appeared receptive to receiving information and taking practical steps to avoid unintended pregnancies.Involving pharmacists in the provision of information and short-term contraception at the time of providing emergency contraception seems sensible. But the increased workload needs to be considered to ensure adequate resources are available.The stigma attached to sexual and reproductive health services appeared to limit the use of the service. Relocating contraceptive services into community pharmacies may encourage more women to attend for contraceptive advice.An ongoing audit of service use, acceptability and outcomes would be necessary to evaluate this research further. A larger trial with a longer follow-up (as originally planned) should assess the long-term effect of the initiative on reducing abortion or unintended pregnancies. Future research is required to address the issue of stigma and reluctance to attend sexual and reproductive health clinics.Nicola Savory, Midwife, Cardiff
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