A woman’s ability to delay and plan for childbirth is essential to her health, as well as her education and career goals, says Sally Rafie, PharmD, pharmacist at UC San Diego Health and assistant clinical professor at Skaggs School of Pharmacy and Pharmaceutical Sciences at UC San Diego.
“There’s a lot of evidence that when a woman has control over when she has children, and how many, she is more likely to stay in school, earn an advanced degree and work, which in turn positively contributes to her family’s income and stability, as well as her own and her children’s mental and physical health,” she said.
But in order to use birth control, a woman must be able to get what she needs in a timely and affordable manner, whether that be in the form of a pill, implant, patch, shot, intrauterine device or vaginal ring. (This may also apply to transgender or gender non-conforming/non-binary individuals, but for simplicity’s sake, we’ll just use “woman” and “she/her” in this article.)
“Birth control access in this country is challenging,” Rafie said. “Most of our methods are only available with a prescription, and there are a lot of steps involved in getting and filling that prescription.”
In order to get a prescription, a woman is typically required to make an office or clinic visit, but Rafie said not everyone has the insurance, time, transportation and child care needed to get to an appointment during normal working hours. Then the woman must visit a pharmacy to fill the prescription, and insurance companies have different strategies for what’s covered. That means women often have to negotiate to get the best birth control method for them, at the best price.
“And these barriers most affect women who are already socioeconomically disadvantaged, making their lives even more difficult,” Rafie said.
In California and some other states, women can now obtain many forms of prescription birth control directly from a pharmacist, without going to the doctor first.
That’s great news, Rafie said, but pharmacies aren’t required to do it and since only some have opted into the service, that puts the burden on women to find those that do. To make it easier, Rafie and colleagues created
Birth Control Pharmacies, an easy-to-use map that now includes more than 1,000 birth control-prescribing pharmacies nationwide.
These grassroots efforts have made Rafie a go-to expert. Legislators in states that don’t yet offer birth control prescriptions at pharmacies are reaching out for her expertise as they seek to implement new policies.
In an emergency
In addition to standard birth control, Rafie wants to understand the challenges that keep pharmacies from opting to provide emergency contraception, also known as the morning-after pill or Plan B. To this end, she and
Sheila Mody, MD, the director of the Division of Family Planning, in the Department of Obstetrics, Gynecology and Reproductive Sciences at UC San Diego Health, recently received a pilot Dissemination and Implementation (D&I) grant from the UC San Diego Altman Clinical and Translational Research Institute to survey and conduct interviews with pharmacies statewide. They are interviewing pharmacists and pharmacy technicians throughout California to assess their knowledge of emergency contraception and the barriers to prescribing it.
So far, they are uncovering a number of organizational and logistical challenges.
“For example, pharmacists need to be able to carve out extra time in their normal workflow to provide the required counseling when a woman requests emergency contraception,” Mody said. “They aren’t necessarily compensated for that extra time, and so the pharmacy may not have the incentive to offer it.”
Next Mody and Rafie are planning a cluster randomized controlled study to determine the best way to provide pharmacies with the emergency contraception education they need, with a focus on addressing the implementation barriers identified in the survey and interviews. Some pharmacies will receive a standard emergency contraception handout, while others will receive “academic detailing,” an approach that involves face-to-face training that addresses potential logistical barriers to prescribing emergency contraception at their pharmacies.
Where the barriers may be the highest
Both Mody and Rafie are especially interested in improving birth control access in underserved and underprivileged communities. Mody, in collaboration with Bonnie Crouthamel, MD, a family planning fellow, and Morgen Chalmiers, an MD-PhD student at UC San Diego School of Medicine, works with the Syrian and East African refugee women in San Diego to understand their unique reproductive health needs. Mody received a Howell Foundation Grant to conduct focus groups among the East African refugee women to determine what they know, what they want, who they’d prefer to talk to about it, and the best mechanisms for receiving contraceptive information in a culturally appropriate manner.
“Sometimes it’s the little things that can make a big difference,” Mody said. “For example, I often hear from these women that they would feel much more comfortable talking to a doctor about birth control if they had a female interpreter compared to a male interpreter.”
Rafie was recently accepted as a fellow of the
Robert Wood Johnson Foundation Interdisciplinary Research Leaders Program. With this support, she will work with colleagues at UC Berkeley and the non-profit ACT for Women and Girls in California’s Central Valley to learn about the rural community’s birth control needs and preferences for pharmacy services, as well as to understand the drivers and challenges for pharmacies in prescribing birth control.
“If we want to improve health equity among all populations, we need to design programs that meet patients where they are, and take into account the social factors that prevent equal access to health care,” Rafie said. “That’s reproductive justice.”
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