Massachusetts Standing Orders Increase Emergency Contraceptive Access

A statewide standing order policy in Massachusetts led to a significant increase in emergency contraception fills at pharmacies when compared with results of similar orders in other states, according to a recent study in JAMA.¹

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Emergency contraception is vital for pregnancy prevention following unprotected sexual intercourse or contraception failure. Medications can be used several days after contraception failure and still prevent pregnancy by inhibiting ovulation.²

The first oral emergency contraceptive available in the United States was a dose of pills containing the progestin levonorgestrel. Progestin-based emergency contraception is most effective when taken within 72 hours of unprotected sex, with an 81% to 90% reduced risk of pregnancy.²

Ulipristal (Ella), a selective progesterone receptor modulator, may also be used as emergency contraception and has been available in the US since 2010. It is a single-dose pill that remains effective to prevent pregnancy for up to 5 days after unprotected sexual intercourse. Neither progestin-based pills nor ulipristal are linked to severe adverse events.

Recent restrictions on abortion access across the country have increased the need for better access to emergency contraceptives. To address this issue, Massachusetts implemented a statewide standing order for emergency contraceptives.¹

The standing order allows dispensing of prescription ulipristal and over-the-counter levonorgestrel (Plan B) by pharmacists. Pharmacists in 27 states are able to prescribe oral contraceptives but require extra training before receiving the privilege.

The new study evaluated the association of reduced barriers to accessing the medications with emergency contraceptive fills at retail pharmacies.

The Massachusetts statewide order was issued in August of 2022. Investigators compared changes in emergency contraceptive fills between July 2021 and May 2022 with those documented between August 2022 and December 2023. All changes were assessed using a quasi-experimental difference-in-differences design.

RESULTS

Monthly-fill rates for emergency contraceptives were reported as the primary outcome of the analysis, while ulipristal and prescribed levonorgestrel were reported as the secondary outcome. Outcomes were reported per 100 000 women among women aged 15 to 49 years.

There were 92 500 emergency contraceptive fills from July 2021 to October 2023 included in the final analysis. Before the standing order was implemented, a slight increase in emergency contraceptive fills rates was observed in Massachusetts vs comparison states. However, overall trends were similar.1

An emergency contraceptive fill rate of 78.5 fills per 100 000 women was reported before the standing order, vs 105.3 fills per 100 000 women after the standing order, calculated as an increase of 26.8 fills per 100 000 women.¹

In comparison states, the emergency contraceptive fill rate was 45.8 fills per 100 000 women before a statewide standing order policy and 48.4 fills per 100 000 women after implementation. Massachusetts had an additional 25.2 emergency contraceptive fills per 100 000 women vs comparison states in the adjusted difference-in-differences analysis.¹

For ulipristal, there were an additional 31.6 fills per 100 000 women in Massachusetts vs comparison states. However, no significant differences were observed for levonorgestrel prescriptions, at -6.4 fills per 100 000 women.

These results indicated a 32% increase in emergency contraceptive fills at pharmacies in Massachusetts vs comparison states, as well as a shift from prescription levonorgestrel to ulipristal. Investigators concluded, “policies that reduce prescribing barriers may improve access to emergency contraceptives, particularly ulipristal.”¹

Study takeaways

1. Massachusetts' statewide standing order policy led to a 32% increase in emergency contraceptive fills at pharmacies compared to other states.
2. The policy resulted in a notable shift from prescription levonorgestrel to ulipristal for emergency contraception.
3. The standing order allows pharmacists to prescribe both over-the-counter levonorgestrel and prescription-only ulipristal, removing barriers to access.
4. The study used a quasi-experimental difference-in-differences design to assess changes in emergency contraceptive fills from July 2021 to December 2023.
5. Before the policy, emergency contraceptive fill rates were similar between Massachusetts and comparison states, but the standing order led to an additional 25.2 fills per 100,000 women in Massachusetts.

References
1. Qato DM, Guadamuz JS, Myerson R. Changes in emergency contraceptive fills after Massachusetts’ statewide standing order. JAMA. Published online July 2, 2024. doi:10.1001/jama.2024.11715
2. Emergency contraception. Women's Health Policy. KFF. August 4, 2022. Accessed June 3, 2024. https://www.kff.org/womens-health-policy/fact-sheet/emergency-contraception/