Availability of Over-the-Counter Emergency Contraception in 2 Disparate New York City Neighborhoods

Abstract

We conducted a telephone survey of pharmacies in 2 New York City neighborhoods on same-day availability, type, and cost of over-the-counter emergency contraception. There was no difference in availability of over-the-counter emergency contraception between Upper East Side and East Harlem pharmacies (93% vs 94%; P = .71). Average cost of medication was less in East Harlem than in the Upper East Side ($45.16 vs $51.64; P < .001). Efforts should accentuate overcoming cost and knowledge barriers associated with the use of emergency contraception.

Emergency contraception (EC) can reduce the likelihood of becoming pregnant if taken soon after unprotected sex or when other contraceptive methods fail.¹ In New York State, 56% of all pregnancies are unintended, with an estimated annual cost exceeding $1 billion.^2–4 EC is an important form of contraception and has the potential to reduce unintended pregnancies, although studies to date have not demonstrated this effect.^5,6 In an effort to control costs associated with unintended pregnancies, New York State and City lawmakers made EC access a policy goal in 2003 and 2005 by requiring availability in adolescent clinics, other public healthcare facilities, and emergency departments for sexual assault survivors.^7–9 During the same period, after the city council documented that 25% of New York City pharmacies did not carry EC, the New York City Department of Health and Mental Hygiene embarked on a major citywide EC education and outreach campaign with the aim of increasing access of EC at pharmacies and private facilities.^10,11

Currently only 2 EC regimens (the single-dose and 2-dose regimens of levonorgestrel) are available over the counter (OTC) for women aged 17 years or older. We examined the availability of OTC EC in community pharmacies in 2 disparate New York City neighborhoods.

METHODS

We obtained a list from the state pharmacy board of all registered pharmacies located in East Harlem (n = 47) and Manhattan’s Upper East Side (UES; n = 63) neighborhoods.¹² We excluded pharmacies housed in hospitals or nursing homes (n = 14) from the sample because our primary focus was on community pharmacies. During June 2011, we conducted a brief telephone survey of any available pharmacy staff, including technicians, clerks, and pharmacists, which included 6 questions on same day availability, type, and cost of OTC levonorgestrel (Plan B; Plan B One Step; and the generic Next Choice) EC. We performed descriptive statistics using SAS version 9.2 (SAS Institute, Carey, NC). We conducted bivariate analyses using the χ² test for dichotomous variables and the t-test for continuous variables.

RESULTS

We examined the availability of OTC EC in community pharmacies in 2 disparate New York City neighborhoods: the predominantly low-income minority community of East Harlem with that of the mostly high-income White adjacent neighborhood of the UES of Manhattan (Table1). East Harlem has higher rates of adolescent pregnancy, higher rates of births that received late or no prenatal care, and lower rates of condom use at last sexual encounter.

TABLE 1—

Demographics for: OTC Emergency Contraceptive Availability: Upper East Side and East Harlem, June 2011

Characteristic	New York City (n = 8 214 426)	Upper East Side (n = 218 200)	East Harlem (n = 108 100)
Race/ethnicity,a %
White	35	83	7
Black	24	3	33
Hispanic	27	6	55
Asian	10	6	3
Other	4	2	2
Persons in poverty,a %	21	7	38
Condom use at last sexual encounter,a %	38	54	27
Pregnancies per 1000 females aged 15–19 y,b no.	81.1	22.9	137.2
Births to mothers who received late or no prenatal care,a %	28	11	36

Note. OTC = over-the-counter.

^aNew York City Department of Health and Mental Hygiene Community Health Profiles 2006. Available at: http://www.nyc.gov/html/doh/downloads/pdf/data/2006chp-303.pdf, http://www.nyc.gov/html/doh/downloads/pdf/data/2006chp-305.pdf.

^bNew York City Department of Health and Mental Hygiene Teen Pregnancy in New York City: 2000–2009. Available at: http://www.nyc.gov/html/doh/downloads/pdf/ms/ms-nyctp-2000-09.pdf.

Ninety-three percent (89/96) of pharmacies responded to the survey (n = 36 in Harlem and n = 53 in UES). There was no difference in availability of OTC EC between UES pharmacies and those in East Harlem, 93% versus 94%, respectively (P = .71; Table 2). The average cost of the medications was less in East Harlem than in the UES ($45.16 vs $51.64; P < .001). Plan B One Step was the most frequently available form of OTC EC in both communities (81% in the UES and 83% in East Harlem). East Harlem and UES pharmacies stocked the generic form of levonorgestrel, Next Choice, at similar rates (17% vs 21%). All pharmacies that did not have EC in stock stated that they did carry EC but were currently out of stock.

TABLE 2—

Availability and Average Cost for: OTC Emergency Contraceptive Availability: East Harlem and Upper East Side of Manhattan, June 2011

Variable	Upper East Side Pharmacies (n = 53)	East Harlem Pharmacies (n = 36)
EC available same day, %	92.5	94.4
EC not available same day, %	7.5	5.5
Average cost of any EC at pharmacies,* $	51.64	45.16
Average cost of Plan B One Step,* $	52.54	47.07
Average cost of Next Choice,* $	45.99	35.97

Note. EC = emergency contraception; OTC = over-the-counter. We conducted bivariate analyses using the χ² test for dichotomous variables and the t-test for continuous variables.

*P < .01.

DISCUSSION

We found that 2 neighborhoods in New York City that are strikingly different in terms of socioeconomic factors and adolescent pregnancy rates had equivalent EC availability.¹³ Previous research investigating the availability of healthy foods and prescription opioids in New York City neighborhoods found differences in availability of these items on the basis of race/ethnicity and socioeconomic status of the neighborhoods.^14,15 By contrast, our results demonstrate equal EC availability across very different communities in New York City. However, equal availability is only a first step in providing equal access to EC.

Studies have demonstrated multiple barriers to the use of EC, including the misconception that its availability increases irresponsible sexual behavior and lack of knowledge about EC use by both women and their providers.¹⁶ Availability of counseling and costs of EC are also important factors that may affect access. Although the cost of EC was lower in East Harlem ($45) than in the UES ($52), the out-of-pocket cost likely represents a major barrier for low-income women. EC is available free of charge and same day Monday through Saturday in New York City Department of Health and Mental Hygiene clinics; however, it is unknown whether many women are aware of this resource.

There are numerous limitations with this analysis. First, we did not test in-person availability of EC but rather called each pharmacy to check the availability. Our methods are consistent with others who have assessed availability by telephone.¹⁷ Second, we conducted our study at a single time point, and therefore conclusions regarding the impact of EC policy on availability cannot be determined. Finally, we did not have access to sales data or specific data on the use of these EC methods among women from these 2 communities.

Our results demonstrate that 2 very disparate neighborhoods in New York City have equivalent availability of OTC EC. However, equal availability of EC does not translate into equal access to EC for women. Factors such as cost and knowledge represent barriers to accessing EC for many women. Efforts directed at affordability and patient education campaigns are important tools to reduce barriers to EC use.^18–21 Although the use of EC has the potential to reduce unintended pregnancies, studies to date have not demonstrated this effect.^5,6 Increased education of health care providers, pharmacists, and the general public regarding the safety, mechanisms of actions, and availability of EC is needed. Efforts such as the passage of the Affordable Care Act will improve access to contraception, including EC, by decreasing costs. However, additional comprehensive measures directed at educating the public and ensuring access to all types of contraception are necessary if we hope to reduce unintended pregnancies.