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Nom original: day2008.pdfTitre: Emergency Contraception: When the Pharmacist Conscience Clause Restricts Access

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inPRaCtiCe

Emergency
Contraception
When the Pharmacist Conscience
Clause Restricts Access
Alice S. Day, RN, BSN

i
Although the
student was fully
aware that she
should take the
medication as
soon as possible,
she felt that she
had no choice but
to wait.

http://nwh.awhonn.org

It was 5 p.m. on a Monday in a rural
town when a 17-year-old high school
senior arrived at the practice as the last
walk-in patient of the day. She explained
to the nurse practitioner (NP) that during sexual intercourse with her boyfriend on Friday evening, the condom
had broken and she was afraid that she
might become pregnant. She had been
away for the weekend, arrived home late
the night before and had attended a full
schedule of classes on Monday. She had
wanted to seek help earlier but felt she
needed to be at all her classes for fear of
her grades slipping and her eligibility for
a college scholarship diminishing. She
was hoping to be the first member of her
family to go to college.
The NP reviewed her situation and
completed a full assessment. She also
gave contraceptive counseling for a
more reliable method of birth control.
When fully informed of her options,
the young woman made an autonomous decision that she would start oral
contraceptive pills as a more reliable

© 2008, AWHONN

343

PRaCtiCe
Unintended
pregnancies
account for 49
percent of all
pregnancies in
the United States,
with 48 percent
of these occurring
despite the use
of contraception
during the month
preceding the
pregnancy; 42
percent of these
unintended
pregnancies end
in abortion.

Alice S. Day, RN, BSN, is
a graduate nursing student at the University of
Vermont, Burlington, VT.
Address correspondence to:
alice.day@uvm.edu.
DOI: 10.1111/j.1751-486X.2008.00347.x

344

form of contraception. She also chose Plan B
as a method of emergency contraception. She
received education on Plan B’s mechanism of
action and possible side effects. A written prescription was given as requested by the young
woman as her state health insurance fully covered the costs of prescriptions. Fortunately the
only pharmacy in town was within a 10-minute
walk of both her home and the practice and
was open until 6 p.m.
The woman arrived at the pharmacy with
the prescription at 5:50 p.m. The pharmacist
behind the counter was a last-minute substitute
for the owner of the pharmacy who had taken
ill earlier that day. He proceeded to tell her that
he wouldn’t fill the prescription because of his
personal moral beliefs and said that he could
refer the prescription to the pharmacy in the
next town, although that pharmacy’s closing
time was also 6 p.m. He also gave the student
the option of returning the following day to
have the prescription filled by the owner of the
pharmacy who was anticipated to be back at
work then. She remembered that the NP had
told her she could buy the Plan B at cost from
the clinic but she had no money and didn’t
get paid for her part-time job until Friday.
Although the student was fully aware that she
should take the medication as soon as possible,
she felt that she had no choice but to wait. This
was the only pharmacy in town and she didn’t
have transportation to travel the 10 miles to
the next closest pharmacy even if they had later
closing hours. The next morning the student
picked up the medication from her local pharmacy and took it as prescribed. Despite her
best efforts, three weeks later she tested positive
for pregnancy.

Unplanned Pregnancy
in the United States
Unintended pregnancies account for 49 percent
of all pregnancies in the United States, with
48 percent of these occurring despite the use
of contraception during the month preceding
the pregnancy; 42 percent of these unintended
pregnancies end in abortion (Finer & Henshaw,
2006). However, the Guttmacher Institute
(2002) estimates that the availability of emergency contraception is responsible for up to 43
percent of the decrease in total U.S. abortions
between 1994 and 2000.

Nursing for Women’s Health

About Plan B
To comprehend the effect that the pharmacist
conscience clause can have in relation to the
prescribing and administration of Plan B, a full
understanding of the action and efficacy of the
drug must be realized.
Plan B is the first progestin-only emergency
contraceptive. It’s recommended for emergency
use only, and not for routine contraception.
When used as directed, Plan B can effectively
and safely prevent unintended pregnancy.
It’s recommended to be taken up to 72 hours
after unprotected vaginal intercourse but can
also be taken up to 120 hours afterward with
reduced efficacy. Reasons for taking the drug
include contraceptive failure such as breakage
or slippage of a barrier method and missed
oral contraceptive pills, as well as all instances
of unprotected sexual intercourse in which no
contraceptive method was used, including rape
(Hatcher, 2006).
Plan B is commonly known as “the morning-after pill” and actually contains two tablets
that can be taken together or 12 hours apart
with the same efficacy. Each tablet contains 0.75
mg levonorgestrel, a synthetic progestin. This is
the same synthetic hormone that has been used
in birth control pills for more than 35 years.
The U.S. Food and Drug Administration (FDA)
approved Plan B for use in 1999 (FDA, 2006).
Plan B works primarily by preventing ovulation and may also prevent fertilization. The most
contentious aspect of Plan B’s mechanism of
action and a primary reason why some pharmacists refuse to dispense it appears to be whether
the drug impairs receptivity to the implantation
of a fertilized egg. If this were the case, Plan B
could be viewed as an abortificient. However, the
scientific literature on this topic shows that no
study conducted to date has been able to demonstrate conclusively that implantation is impaired
(Aschenbrenner, 2006). It’s also worthy to note
that if the mechanisms of action included
interference with implantation (which occurs
approximately seven days after fertilization) later
administration of plan B would be as effective as
earlier administration, which is not the case.
Another important point is that the internationally accepted obstetric definition of a
human pregnancy is the implantation of the
blastocyst, which is formed four days after fertilization (Schenker & Cain, 2004). Therefore, if

Volume 12

Issue 4

The actions of a pharmacist who
exercises this clause in a rural
community can directly affect the lives
of those seeking care.

the drug were taken within 120 hours
of the unprotected event, another two
days would be needed before implantation would occur.
The evidence regarding the time
sensitivity of emergency contraception
is incontestable. Emergency contraception using the Yuzpe or Lancee method
containing both estrogen and progestin
can be used up to 120 hours after the
unprotected event with an effectiveness
rate between 72 and 87 percent (Rodrigues, 2001). If taken within 72 hours of
unprotected vaginal intercourse, Plan
B (which contains only progestin) has
been shown to reduce the risk of pregnancy by 89 percent (Barr Pharmaceuticals, 2006). If taken within 24 hours,
emergency contraception can reduce
the risk of pregnancy by 95 percent
(Ellertson et al., 2003). Even delaying
the first dose by 12 hours increases the
odds of pregnancy by 50 percent (Piaggio, von Hertzen, Grimes, &Van Look,
1999). These findings clearly show that
decreased efficacy of Plan B is associated with an increased delay between unprotected intercourse and the initiation
of the medication. Thus, it’s imperative
that Plan B be administered as soon as
possible after unprotected intercourse
for optimal outcomes.

August | September 2008

Pharmacist
Conscience Clause
The Pharmacist Conscience Clause
is rooted from the conscience clause
introduced to protect health care workers who didn’t want to be involved in
abortion when the Roe versus Wade
decision made abortion legal in 1973.
However, the Pharmacist Conscience
Clause goes a few steps further—not
only does it permit the right of a pharmacist to decline to fill abortificients,
but also contraceptives and any other
drug with which they might morally
disagree. The position statement of the
American College of Clinical Pharmacy
entitled “The Prerogative of a Pharmacist to Decline to Provide Professional
Services Based on Conscience” (2005)
supports the prerogative of every pharmacist to decline to fill any prescription
that they view as conflicting with their
moral, ethical or religious beliefs.
Within this clause, should a pharmacist choose not to fill a prescription,
the patient/client must be referred to
another pharmacist or other health
care provider “in an effective, timely …
manner” (p. 1). However, this is a gray
and non-specific area with no definitions given for the terms of effective or

timely; thus, such wording becomes a
guessing game for interpretation. Because Plan B is a time-sensitive medication, any referral for this prescription
interferes with its efficacy.

Recommendations
for Nurses
The case study and literature review
on the pharmacist conscience clause
and the mechanism of action and time
sensitive efficacy of Plan B clearly show
that the actions of a pharmacist who
exercises this clause in a rural community can directly affect the lives of
those seeking care. There are several
steps nurses can take to ensure that
all women—especially those who are
younger than 18 who may be more
affected by reduced finances and transportation choices—living in rural areas
are given the timeliest access to Plan B
(see Box 1).

Conclusion
The pharmacist conscience clause was
not intended to obstruct the access
to an oral contraceptive. Yet this is
precisely what is occurring in rural
communities when pharmacists allow
their personal beliefs to override the
health needs of their patients. The im-

Nursing for Women’s Health

345

PRaCtiCe

Box 1.

Recommendations for Nurses Prescribing Plan B in Rural Areas
1. Call ahead to ensure that there is a pharmacist on duty who will fill the prescription
at the patient’s pharmacy. (This point is even more pertinent if the patient is being
seen at the end of the day).
2. Provide Plan B prescriptions to women of childbearing age ahead of time, so that
they’ll be able to take the medication as soon as they need it without having to
visit a pharmacy. This recommendation is endorsed by the American College of
Obstetricians and Gynecologists (ACOG, 2006).
3. Contact local politicians to increase awareness of this issue and to increase the level
of support to professional organizations to fully address the effects of this clause.
One possible way to do this would be to support an amendment to the pharmacist
conscience clause that would prohibit a lone pharmacy in a rural town from refusing
to fill a Plan B prescription.
4. Contact the insurance providers of your patients to advocate for direct reimbursement
to rural family practice clinics for the dispensing of Plan B.

plications of the pharmacist conscience clause
in relation to Plan B shows a clear need to focus
on evidence-based practice and to seriously
consider following the recommendations in
Box 1 to help women in rural communities access Plan B in a timely manner consistent with
the promotion of optimal outcomes. NWH
http://nwhTalk.awhonn.org

Food and Drug Administration. (2006). Plan B:
questions and answers. Retrieved May 19, 2008,
from http://www.fda.gov/cder/drug/infopage/
planB/planBQandA20060824.htm
Finer, L. B., & Henshaw, S. K. (2006). Disparities
in rates of unintended pregnancy in the United
States, 1994 and 2001. Perspectives on Sexual and
Reproductive Health, 38(2), 90–96.

References

Hatcher, R. A. (2006). Contraceptive technology
(18th ed.). New York: Irvington.

American College of Obstetricians and Gynecologists. (2006). ACOG steps up to get emergency
contraception to women). Retrieved May 19,
2008, from http://www.acog.org/from_home/
publications/press_releases/nr05-08-06-1.cfm

Piaggio, G., von Hertzen, H., Grimes, D. A., Van
look, P. F. A. (1999). Timing of emergency
contraception with levonorgestrel or the Yuzpe
regimen. Lancet, 353(9154), 721–721.

Aschenbrenner, D. S. (2006). Over-the-counter
access to emergency contraception. American
Journal of Nursing, 106(11), 34–36.
American College of Clinical Pharmacy. (2005).
Position statement: prerogative of a pharmacist to
decline to provide professional services based on
conscience. Retrieved May 19, 2008, from http://
www.accp.com/position/pos31_200508.pdf
Barr Pharmaceuticals. (2006). Label Information:
Plan B (levonorgestrel) tablets, 0.75 mg. Retrieved May 19, 2008, from http://www.fda.gov/
cder/foi/label/2006/021045s011lbl.pdf
Ellertson, C., Evans, M., Ferden, S., Leadbetter, C., Spears, A., Johnstone, K., & Trussell, J.

346

(2003). Extending the time limit for starting the
Yuzpe regimen of emergency contraception to
120 hours. Obstetrics and Gynecology, 101(6),
1168–1171.

Nursing for Women’s Health

Rodrigues, I. (2001). Effectiveness of emergency
contraceptive pills between 72 and 120 hours
after unprotected sexual intercourse. American
Journal of Obstetrics and Gynecology, 184(4),
531–537.
Schenker, J. G., & Cain, J. M. (2004). The FIGO
committee for the ethical aspects of human
reproduction and women’s health. International
Journal of Gynecology and Obstetrics, 86(2),
267–275.
The Guttmacher Institute. (2002). Emergency
contraception: steps being taken to improve access.
Retrieved May 19, 2008, http://www.guttmacher.
org/pubs/tgr/05/5/gr050510.html

Volume 12

Issue 4


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