In January of 2006, the ACLU of Kentucky Reproductive Freedom Project released a survey that explored the availability of emergency contracpetion in Kentucky.

PURPOSE OF SURVEY 

Plan B, a brand of emergency contraception, was approved for distribution in the United States by the FDA in 1999.  It is a proven safe and effective method of preventing pregnancy after contraceptive failure, unprotected sex, and sexual assault. 

In 2002, the Alan Guttmacher Institute reported that a typical woman who wants – and has – two children will need to use contraceptives for approximately 30 years of her life.  The Institute also found that more than half of unintended pregnancies occurred during the month women reported using contraceptives and, half of all unintended pregnancies end in abortion.

Wider access to emergency contraception could significantly reduce the need for abortion.  Yet nationally, this drug is met with extreme resistance by many who wish to restrict reproductive rights.  Pharmacists refusing to fill a prescription for emergency contraception because they find it “morally objectionable” are a symptom of this resistance.  This practice makes obtaining Plan B extremely difficult for many women.  This is a major concern in part because Plan B is most effective within the first 72 hours after unprotected intercourse.

This summer, the ACLU of Kentucky Reproductive Freedom Project convened several groups, including the National Council of Jewish Women – Louisville Section, Planned Parenthood of Louisville, Kentucky Religious Coalition for Reproductive Choice, A-Fund, and the Jefferson County and Bluegrass chapters of the National Organization for Women to discuss emergency contraception access in Kentucky. 

The group chose to conduct a statewide telephone survey to assess the availability of emergency contraception in Kentucky and to investigate Kentucky pharmacists’ knowledge and views on emergency contraception.

  FACTS ABOUT EC 

• According to a 2004 report by the American Academy of Family Physicians, 51,000 abortions were prevented in 2000 with the use of emergency contraception.
• EC is 89% effective if taken within 72 hours of unprotected intercourse.
• Just as regular birth control pills, emergency contraception prevents pregnancy by delaying ovulation, preventing fertilization, or preventing a fertilized egg from implanting in the uterine wall. 
• EC should not be confused with RU-486 (the abortion pill).  EC does not disrupt an already established pregnancy; therefore, it does not cause an abortion.
• The American Medical Association, the American College of Obstetricians and Gynecologists, and the American College of Emergency Physicians all believe that EC should be sold over-the-counter.

THE SURVEY 

The ACLU of Kentucky RFP obtained a list of the 1,289 licensed pharmacies in the state from the Kentucky Board of Pharmacy.  The survey instrument was adapted from surveys conducted by the ACLU of Pennsylvania Clara Bell Duvall Reproductive Freedom Project and other ACLU affiliates.

To determine the sample group, we first excluded 151 specialty pharmacies found in nursing homes, respiratory care facilities, and hospice. We then separated the pharmacies by county and selected a sample from each of Kentucky’s 120 counties, depending on the number of pharmacies in that county.  The breakdown formula was:

1-3 pharmacies in the county –  all were selected

                        4-10 pharmacies  –  every third pharmacy

                        11-20 pharmacies  –  every fifth pharmacy

                        21 or more  –  every seventh pharmacy

When any problems with the sample were encountered (would not accept blocked phone calls, disconnected phone numbers or did not answer calls after three attempts, or only provided out-patient services), we went back to the original spreadsheet and chose the next pharmacy listed.  We had to replace thirty-eight pharmacies.  The final sample group included 309 out of 1,100 pharmacies across Kentucky.

A “mystery shopper” telephone survey method was used in which the caller posed as a potential customer seeking to fill a prescription for Plan B.  This is a commonly used research method. 

The survey questions included the following: 1)  “If I come in with a prescription for Plan B, can you fill it today?”2)  If Plan B was not in stock, “Could you order it?”3)  If no, “why not?”4)  “Is there something else I can take as a substitute?” (special combinations of particular brands of regular birth control pills)5)  “Is this the abortion pill?”  

RESULTS 

Question 1)

288 pharmacies responded[1]

a.       13% (38) of pharmacies surveyed had Plan B in stock

b.      87% (250) did not

239 of the 250 pharmacies that did not have Plan B in stock responded to this question

c.       53% (126) said “yes” they would be willing to order Plan B

d.      47% (113) refused to order Plan B

Of the 113 pharmacists that refused to fill the prescription

e.       68% (77) stated that the store “just didn’t carry it,”

f.        10% (11) stated it was because Plan B was “against their personal beliefs,”

g.       9% (10) stated filling prescriptions for Plan B was “against store policy,”

h.       and 12% (14) reported “other reasons.”

Of the 250 pharmacies that did not have Plan B in stock

i.         5% (12) offered information about regular birth control combinations that worked in the same manner as Plan B

250 pharmacists answered this question

j.        60% (149) of the pharmacists stated that Plan B was an abortion pill

k.      31% (78) of the pharmacists stated that Plan B was not an abortion pill

l.         9% (23) were unsure

Six counties had no pharmacies that would dispense Plan B:  Hickman, McLean, Owen, Todd, Wolfe, and Robertson.  Robertson County had no pharmacies at all.

In 17 counties, none of the pharmacies surveyed would dispense Plan B – Caldwell, Carroll, Christian, Cumberland, Daviess, Franklin, Harrison, Jackson, Knott, Lawrence, Logan, Mason, McCreary, Powell, Rockcastle, Simpson, and Trigg.  (See attachment for number of pharmacies surveyed in each county).

CONCLUSION 

This survey uncovered significant findings that call for a multi-faceted approach to the problem of EC access in Kentucky.  Not only did we find that many pharmacies do not stock Plan B, but many pharmacists are ill-informed about its existence or its function.

• While 57% of the pharmacies surveyed were willing to provide Plan B, getting it in a timely manner remains a serious problem in Kentucky.  If emergency contraception is not in stock, the pharmacy must order it.  This can take a day or more, especially if ordered on a Friday.  The survey showed that only 13% of the pharmacies had Plan B in stock at the time of our call.

• Six counties offered no access to Plan B at all.  This is a serious problem for any woman seeking a time sensitive medication, but especially for women in rural areas where the closest pharmacy with Plan B in stock could be 100 miles away. 

• The number of pharmacists who gave callers inaccurate information also was alarming.  More than half of the pharmacists surveyed told the caller that Plan B was an abortion pill, perpetuating the misconception that Plan B causes an established pregnancy to abort instead of preventing a pregnancy from occurring.  Other pharmacists didn’t know what Plan B was and a few hung up on our caller leaving them with no information or resources. 
• Women often depend on the expertise of a pharmacist for information about medication.  This misinformation and lack of information prevents many women from obtaining the medical care they deserve.

Many factors contribute to pharmacies’ stocking and dispensing practices.  Some pharmacists reported that they did not stock Plan B because of lack of demand for the medication.  Without patient or physician requests, pharmacies are reluctant to stock Plan B which, in turn, means they are less likely to learn about it. 

PROPOSED ACTION 

The ACLU of Kentucky Reproductive Freedom Project, along with supporting organizations, proposes several strategies to improve access to emergency contraception in pharmacies throughout Kentucky. 

• Because consumer requests are an impetus for pharmacies to carry the medication, an educational campaign for the general public will dispel many misconceptions and increase awareness about EC as a back-up method to prevent pregnancy. 
• The campaign will include print ads for newspapers and bus shelters, informational cards (business and post card size), an EC website specific to Kentucky, informational brochures to be distributed through doctors’ offices, pharmacies, rape crisis centers, health clinics, university health fairs…
• We will not only educate the public about EC but also about how to handle a doctor or pharmacist that denies a prescription for EC.
• We also will initiate EC educational opportunities for doctors and pharmacists, as well as encourage a collaborative relationship between them so that women can be better served.
• This may involve individual/local actions at pharmacies (distributing information, asking questions about EC, create multiple requests for EC at a pharmacy…)
• We will generate complaints to the KY Board of Pharmacy as women are denied a prescription (currently the Board claims pharmacy denials isn’t a problem in Kentucky.  They want individual complaints before they will look at their “pharmacists’ right to refuse” policy).
• We will attempt to work with the KY Pharmacist Association to provide instructional opportunities for pharmacists regarding EC. 

Excerpts of pharmacists’ comments from the 2005 Kentucky Survey: 

Accurate Information:

Caller contacted pharmacy on Friday and pharmacist stated he couldn’t get it in until Monday – urged caller to go somewhere else because “you should really get it filled sooner than Monday, and as soon as possible.”

Response to “Is this an abortion pill?” – “It depends on how you define life beginning…if taken within 72 hours it prevents a fertilized egg from implanting.”

“No this is not an abortion pill…did you see the show on TV last night?” (referring to the Nightline segment with Dr. Susan Wood, former Director of the FDA Office of Women’s Health.

Pharmacist decided to order Plan B even if the caller didn’t come to pick it up.

A Wal-Mart pharmacist stated “It is against store policy to carry it…It doesn’t cause an abortion…If you don’t have luck with other pharmacies, call back and I’ll see what I can do to help.”

“We deal with this kind of thing all the time.  You need to come in within 72 hours and if you want to remain anonymous, we can arrange that.

“In my opinion, Plan B is not an abortion pill…gets tied up in religion and I don’t think they’re right.”

Pharmacist said, “This is a controversial drug but I believe I have a duty to fill prescriptions regardless of my moral beliefs.”   Also said it was a “moral decision that is made between patient and doctor.”  He said he would order the drug just so it is in stock for me or the next person.

“Some people think it’s the abortion pill, but it’s not.”

Inaccurate information:

“It’s not RU-486 but is should only be used for an emergency.  If you use it more than once the effectiveness decreases.  You need to use it in the first 24 hours.”

“I’m not familiar with what Plan B does but you can only get it through the health department – it’s not available in drug stores.”

“Is that a vitamin?”

“I don’t think pharmacies in Kentucky carry it.  It’s given out by doctors.”

“I didn’t think that was legal in the U.S.”

“That isn’t a drug.  If you come in we can read the prescription and tell you what the drug is.”

Pharmacist thought caller was referring to an insurance plan.

Pharmacist wouldn’t answer any questions until caller gave her name.

 “A lot of pharmacies are not going to fill that.”

“Yes this in the abortion pill…It’s just the trade name.  Everyone knows what it’s for.”

“You are taking it because you want an abortion.”

“We don’t give that kind of drug.  It’s the abortion pill and that’s why we don’t participate in it.”

“It’s against my beliefs.  I don’t think it’s a correct drug.”

Plan B “causes a spontaneous abortion.  Your body absorbs the embryo.”

Pharmacist wasn’t familiar with drug but said, “It would have to be similar to the abortion pill in order to be taken the morning after.”

“There isn’t anything called the abortion pill, but if there was, this is it.”

“They put extra estrogen in it to make an abortion.”

“…if the egg is fertilized, it will abort the fetus.”