Earlier this year a new emergency contraception option became available to Australian women in the form of ulipristal acetate, a synthetic steroid that acts as a progesterone receptor modulator to delay or inhibit ovulation. Marketed as EllaOne®, ulipristal acetate is at least as effective as levonorgestrel, Australian women’s other option for emergency contraception. It also has a similar side-effect profile, but has been released in Australia as a prescription-only medication.
Over-the-counter emergency contraception took a while to happen in this country: the AMA fought to prevent levonorgestrel from becoming a pharmacy-supply medication in 2004, on the grounds that pharmacists were not ready to distribute it over the counter, and that the pharmacy environment was not conducive to discussing sensitive issues. However, pharmacist dispensing of emergency contraception is now well-established.
Below, Alexandra Culloden and Michael Moore from the Public Health Association of Australia point out that not all Australian women are on an equal footing when it comes to obtaining a doctor’s prescription, leaving some with less emergency contraception options than others.
Alexandra Culloden and Michael Moore write:
A woman’s right to choose if, when and the number of children to have, has been debated for centuries. In 2016 we live in a world where we are more connected to each other than ever before, however, women’s ability to access adequate contraceptive choice remains patchy at best.
Access to high quality and appropriate reproductive health services, including contraception, is essential for every Australian woman’s health and wellbeing. While contraception should be the responsibility of both men and women, gender inequality can create inequitable relationships where women bear the primary burden of reproductive health and the cost burden associated with contraception.
Current emergency contraception options
Timely access to safe, effective and affordable contraception, including emergency contraception, is a reproductive right and is also good public health practice, however, emergency contraception is poorly understood by many Australians.
Media coverage of a new emergency contraceptive agent that became available in Australia earlier this year highlighted an ongoing debate and differing levels of understanding within the community.
Ulipristal acetate (marketed as EllaOne®) was made available in Australia on the 27 April 2016, 11 years after the first emergency contraceptive (levonorgestrel) was offered as a pharmacy-supplied medication.
In theory, having two different options for emergency contraception is a step forward for Australian women and society as a whole, however, there is one startling difference between the two agents. While levonorgestrel is available from a pharmacist as a schedule three medication, ulipristal acetate is currently only available via prescription from a general practitioner as a schedule four medication.
This is where the issue of equity comes in.
Unequal access
The current schedule four classification of ulipristal acetate impacts some women disproportionately. Those in rural areas, women from low socioeconomic backgrounds and women new to Australia, are more likely than other women to be unable or hesitant to access a general practitioner; due to financial reasons, lack of available health services and/or waiting times.
Women in rural and remote areas, for example, may take several days to access a doctor, particularly if they wish to see a female doctor. While there is a telehealth service available, many will not be aware of this option and those who do access the service are required to pay a consultation fee.
Travel to and from the medical appointment and the pharmacy also presents issues for women who cannot access reliable or affordable transport.
Additional financial considerations include any costs associated with the doctor’s appointment (particularly if bulk billing is not available), and other potential costs such as childcare and leave from employment.
There are a range of reasons why a woman may need access to emergency contraception, including unprotected sex and the failure of other contraceptive devices (such as condoms). Women of all reproductive ages, demographics and circumstances can experience these problems.
A call to reschedule ulipristal acetate
In a recent submission (see “recent submissions, May 2016) to the Therapeutic Goods Association (TGA) in support of rescheduling ulipristal acetate as a schedule three medicine, PHAA strongly encouraged the change to ensure that the health of women following unprotected sexual intercourse remains in line with the right to access safe and appropriate health care.
Ulipristal acetate has been found to be highly effective in preventing pregnancy, particularly during the first 24 hours after unprotected sexual intercourse however the need to obtain a prescription to access the medication provides a roadblock to accessing it.
It is currently available in 25 European countries without a doctor’s prescription, which provides ease of access to women who want to take ulipristal acetate for emergency contraception.
Reclassifying ulipristal acetate as a schedule three medicine and making it available without prescription would be consistent with the classification of the Australia’s other currently available emergency contraceptive agent.
The existing delivery model for levonorgestrel demonstrates that pharmacists can deliver appropriate and safe emergency contraception, and provides a framework for the provision of ulipristal acetate to women in Australia.
PHAA strongly advocates for access to safe, accessible and effective emergency contraception as an essential health service.
Access to effective emergency contraception is cost effective in reducing the impact of unintended pregnancies on individuals and the broader health system, meaning a stronger and fairer health system for all.
Alexandra Culloden is Senior Policy Officer and Michael Moore is Chief Executive Officer of the Public Health Association of Australia. On twitter @_PHAA_
