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Article Excerpt
Despite a general decline in adolescent birthrates in the United States since 1991, the nation continues to have one of the highest adolescent birthrates among industrialized countries, and recent data indicate that U.S. rates have begun to rise since 2006. (1,2) In California, the birthrate among adolescents mirrors the national trend, but the overall decline has been more modest among Latina adolescents. (3-5) Poverty and other socioeconomic factors are known to be associated with higher rates of adolescent pregnancy. (6,7) Adolescent birthrates in California are highest among Latinas and in the largely rural region known as the Central Valley. (2,8) Two-thirds of the 50,000 annual adolescent births in the state are to Latinas, even though the current numbers of Latina and white females in the 15-19 age-group are similar. (2.5) Education about, access to and use of effective contraceptives, including emergency contraception, are critical tools in reducing unintended adolescent pregnancy: In addition to helping decrease abortion rates, (9) reducing the rate of adolescent pregnancy is important because adolescent mothers are less likely than adolescents without children to go to college, and their children are more likely to live in poverty than are children born to older women. (10) Furthermore, pregnant adolescents are less likely than older pregnant women to receive adequate prenatal care, and lack of such care is associated with poor birth outcomes. (11,12)
Addressing adolescent pregnancy requires an understanding of the multiple factors involved at the community level, such as social capital, socioeconomic status, sociopolitical climate and access to health services. Our study considers the role of pharmacy access to emergency contraception in reducing unintended pregnancy among adolescents, and focuses on language barriers to such access. We are aware of no studies that have explored Spanish speakers' experiences with seeking emergency contraception through pharmacy access in rural California. Because Latinas are projected to make up more than half of California's adolescents by 2050, (13) it is important to understand the barriers that some members of this community might face.
BACKGROUND
Facilitating easy access to emergency contraception can help adolescents avert pregnancy when their contraceptive method has failed or they have not used a method. Plan B--a dedicated progestin-only product available in the United States since 1999--is more effective than the Yuzpe regimen of combined oral hormones. (14) Package labeling indicates that Plan B (two 0.75 mg pills of levonorgestrel) can be used up to 72 hours after unprotected intercourse, and that it is up to 89% effective in preventing pregnancy. (15) Studies have shown that the method is effective up to 120 hours (16,17) after unprotected intercourse, but how many pharmacists or health care providers otter the method over this longer period is not known. Pharmacy protocols in California, and in most other states, indicate that the method should be offered over this longer period, * although such use is at the discretion of the pharmacist. (18) In 2003, only 8% of California women reported having ever used emergency contraception, (19) and studies have shown that awareness of the method is relatively low among Latina women in the state, particularly those who are foreign-born, without a high school diploma or living below the poverty level. (20-22)
In August 2006, the U.S. Food and Drug Administration (FDA) permitted pharmacists to dispense Plan B without a physician's prescription to women 18 or older (with proof of age). Nevertheless, barriers to access remain for younger females, those without proper proof of age and those who rely on publicly funded health insurance, like Medi-Cal (the California Medicaid program), ([dagger]) for reproductive health services. (23) Plan B costs between $25 and $50 without insurance coverage, and this cost presents a financial barrier to some women. Low-income California residents at risk for getting pregnant or causing a pregnancy, including adolescents, may be eligible for the state's publicly funded program Family PACT, which provides clients with emergency contraception and other reproductive health services at no cost through participating clinics; enrolled clients also can obtain emergency contraception at no cost from pharmacies. ([double dagger])
Since 2002 in California, adolescents younger than 18 have been able to obtain emergency contraception from designated pharmacy-access pharmacies without a clinician's prescription. (24) Pharmacists can dispense Plan B under a statewide protocol adopted by the State Board of Pharmacy and the Medical Board of California (in 2003), or under a collaborative agreement with a licensed physician (since 2001). At the time of this study, approximately one-fifth of pharmacies in California had enrolled in the pharmacy-access system. (25) The state protocol indicates that if no pharmacist certified to provide Plan B is available, staff--should refer clients to another pharmacy-access pharmacy or to a local Family PACT clinic. (24)
Studies of pharmacy access to emergency contraception in California (25) and Washington (26) have shown that young women like the program because it is convenient and confidential, and allows timely access; however, studies in California have indicated that women's knowledge about pharmacy access and of which pharmacies participate is lacking. (25,27) In studies that employed a mystery-shopper approach, emergency contraception was made available on the same day to 20% of English-speaking shoppers in Albuquerque, New Mexico; (28) 39% in Jacksonville, Florida; (29) and 75% in New York City. (30)
Qualitative studies have revealed that adolescents find it difficult to request emergency contraception from pharmacists or clinicians because of concerns about being negatively judged or previous negative experiences regarding such requests, (31) and that clinicians do not regularly discuss or provide emergency contraception in advance of need. (32) Quantitative studies have found that clinicians do not discuss the method at well-adolescent checkups, (33) and that some pharmacists feel inadequately trained to serve adolescents. (34) Neither advance prescription of nor pharmacy access to emergency contraception increases risky sexual behavior or STDs in adolescents, and easy access to the method does not cause young women to abandon regular forms of contraception; (35,36) however, clinicians and pharmacists continue to harbor concerns about the provision of the method, especially to adolescents. (30,32,33)
Most pharmacy-access pharmacies in California are located in urban areas, and some rural counties may have only one. (24,37) We compared access to emergency contraception in seven rural counties, where adolescent birthrates are the highest in the state (51-70 per 1,000 females aged 15-19), with access in two urban counties, where adolescent birthrates are much lower overall (23-27 per 1,000). ([section])(8) The rural counties have a collective population of more than three million, and have about 8,000 adolescent births annually#; (3,11) 48-57% of the populations in these counties self-identify as Latino. (12) The urban counties have a similar total population (2.6 million) and report about 2,600 adolescent births per year, but 21-22% of their collective population self-identify as Latino. Because the timeliness of use is critical, we examined how pharmacy staff handled "late" requests and whether the method was being offered up to 120 hours after unprotected intercourse. The...
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