Statement of the New York State Nurses Association Before the Assembly Health Committee on the use of Emergency Contraception, January 14, 2003.
Good Morning. My name is Janet Haebler. I am a master’s prepared registered professional nurse. I am Senior Associate Director for Practice and Governmental Affairs for the New York State Nurses Association. On behalf of our more than 34,000 members and the patients they serve, thank you for the opportunity to testify today on access to emergency contraception. NYSNA supports both bills that are the subject of today’s hearing.
Let’s start with the science. Emergency contraception can be administered in two forms, an inter uterine device implanted by a health care professional after unprotected sexual intercourse, or a prescription for oral doses of contraceptive steroids. It is the latter of these that is the focus of the pending legislation.
The World Health Organization acknowledged in their 1998 emergency contraception guide that the pills “do not interrupt pregnancy and thus are no form of abortion.”1 It is commonly accepted in medical literature that abortion is the termination of a pregnancy. Pregnancy begins when a fertilized egg is successfully implanted in the uterine wall. This takes place at the end of the first week after fertilization. Contraception is designed to prevent pregnancy by delaying or inhibiting ovulation, blocking fertilization, or preventing implantation of the fertilized egg. Use of contraception, either before or after the act of coitus, is designed to prevent unwanted pregnancy. Emergency contraception is used by a woman who has engaged in unprotected sexual intercourse, either through failed use of contraception or failure to use contraception.
Emergency contraception is 75-85% effective in preventing unwanted pregnancies by inhibiting ovulation. It is safe. Hormonal emergency contraception has NO known contraindications, mostly due to the fact that it is used for such a short duration. If inadvertently taken by a pregnant woman, the drug(s) will pose no harm to either the woman or the fetus. “An overdose of emergency contraception would not be lethal and these drugs have no addictive potential…hormonal emergency contraception is safer than aspirin.”2 The benefits generally outweigh the risks, even in women who have a history of cardiovascular complications, liver disease or migraines.
Physical examination and laboratory tests are essential when a diagnosis needs to be formed to determine that the patient has the indications for treatment and that there are no contraindications to treatment. Pre-treatment assessment for emergency contraception is done by taking a history; neither a physical examination nor laboratory tests are necessary. “Because hormonal emergency contraception is safe, withholding it from a woman who wants treatment is rarely justified.”3 There is also little likelihood of harm from repeated use.
Hormonal emergency contraception is commonly available in two forms, the Yupze regimen and the levonorgestrel regimen. These came onto the prescription drug market in 1998 and 1999, respectively, and created an environment where the drug combination was easily prescribed, dispensed and used. The differences between the two forms relate to the hormone content in the regimens. Both are effective if taken within the recommended 72 hours following unprotected coitus and require two doses, 12 hours apart. The Yupze method has proven effective five days after unprotected intercourse. “Treatment should not be withheld for women who present later.”4 The most common side effects are nausea and vomiting, with the levonorgestrel regimen found to be less noxious. Other side effects may include dizziness, fatigue, headache, breast tenderness and lower abdominal pain; symptoms that can be treated with over-the-counter medication and usually disappear within a few days.
Emergency contraception is safe and effective; it does not require pre-treatment diagnostic tests and has minimal side effects that can be easily self-treated. If menses has not returned within 4 weeks after use of emergency contraception, the patient should use an over-the-counter pregnancy test. Routine follow-up is generally not necessary, except to discuss effective use of contraception. Compliance with the treatment plan is simple to follow. Patient education is also clear, with materials readily available that prepare both the health care professional and the patient.
The optimal way to ensure that women have access in a timely manner to emergency contraception is to include patient education and an advance prescription upon request during regular encounters with healthcare prescribers. This has been a standard of care for several years, and yet few women are aware of, or have used, emergency contraception. Health care professionals who care for women in their child bearing years have a responsibility to educate themselves and their patients about the safety and availability of emergency contraception. It is important to raise practitioner’s awareness of the need to include counseling regarding emergency contraception as a routine part of contraceptive counseling. To this end, NYSNA has provided information in our newsletter to heighten nurse practitioner, nurse midwife and registered nurse awareness.5
Many women do not have a regular health care practitioner, or do not schedule annual wellness appointments. These women and their families often receive care in community-based settings where registered nurses are the most commonly found health care professional. Some examples of health care settings where a registered nurse may be the only constant health care professional available are in public health venues, home care, college health, occupational health, and planned parenthood clinics. A recent report in the Journal of American College Health indicates only 35% of the 124 university clinics surveyed provide emergency contraception. The majority that did not cited “a lack of staff, legal concerns, religious convictions, and no ‘perceived need’ as reasons why they did not offer treatment 6.”
In 1951, the federal government established that a drug should be treated as an over-the-counter sale unless it was dangerous, addictive, or complex to use. Emergency contraception is none of these. In 2001, a petition was filed with the Federal Drug Administration to switch oral hormonal emergency contraception to over-the-counter status without further study. This change has not occurred to date.
Until the federal government determines that the drug regimen can be designated over-the-counter, the state can establish rules that recognize the safety and efficacy of emergency contraception. A model already exists in state law that can make emergency contraception readily available. The model was created in 1999 to address registered nurses’ role in immunizations and life saving treatment for anaphylaxis. This model is used in A888, and establishes the non-patient specific prescription. Under this model, a duly authorized prescriber (physician, physician assistant, nurse practitioner, or licensed midwife) could allow a registered nurse or a pharmacist to provide emergency contraception upon the request of a woman who indicates that she has had unprotected sexual intercourse.
NYSNA was pleased that the sponsor of the legislation included legislative intent affirming that the bill does not represent a scope of practice change for either registered nurses or pharmacists. Under this bill, the pharmacist can dispense for patient self-administration without a specific patient’s name on the prescription. The bill language is different in the section allowing prescribers to write a non-patient specific prescription for a pharmacist’s use from the prescription for a registered nurse’s use. This is due to the different scopes of practice, founded on educational preparation, experience and practice of these distinct disciplines.
As an example, pharmacists are explicitly instructed to share with the patient information on follow-up health care and referral information. A registered nurse does not need this specificity since part of their legal scope of practice includes case finding, patient assessments, forming a nursing diagnosis and implementing treatment plans. In accordance with their scope, a registered nurse must be competent to deliver care in order to do so without being subject to professional misconduct and/or malpractice. Therefore, not every registered nurse will participate by attaining a non-patient specific prescription for emergency contraception to carry the drugs and provide them to patients in need. Those that do will be competent to do so. Every pharmacist, whose skill and authority rests in dispensing drugs, will be prepared to dispense emergency contraception through a non-patient specific order when they work within written procedures and have met the training requirements in emergency contraception.
While the sections of the bill related to pharmacy practice are detailed, the section of the Nurse Practice Act authorizing execution of non-patient specific orders (Education law section 6909-5) needs only to be amended to include orders written by licensed midwives. This section was written broadly in the Laws of 1999 since the scope of registered nurse practice is broad. The authority to execute non-patient specific orders is limited to the authority granted by the Legislature to prescribers to write such orders, and further defined, when needed, within a regulatory framework. Therefore, it is the practice of physicians, nurse practitioners and licensed midwives that defines the parameters of non-patient specific prescriptions.
The prescriber can allow a registered nurse to administer or make available emergency contraception to a patient to self-administer. (Emergency contraception can be administered vaginally to reduce nausea and vomiting.) The prescriber can only allow a pharmacist to dispense for patient self-administration. The ability to develop written procedures or protocols for a pharmacist to dispense emergency contraception without a patient specific prescription is limited to those providers who deliver gynecological or family planning services.
A woman requesting emergency contraception can approach any pharmacy to request the drug(s). Since it is important to take the doses as close as possible to exposure (within a week at most) a woman should not have to face difficulty in filling a prescription when it is most in need. Many women now have to shop around to determine who stocks the drugs. When this legislation becomes law, access will be improved, but only if the pharmacists who have attained the authority to use non-patient specific prescriptions for emergency contraception are clearly identified. Pharmacists should assist the community served by promoting through literature, advertising, signage or other means that emergency contraception is available and indicate if it is only available with a patient specific prescription. The state education department regulates both pharmacies and pharmacists and should provide some guidance on this issue to improve information for the public on accessing emergency contraception in pharmacies.
Likewise, a rape survivor should not have to, after the trauma of rape, search to meet her health care needs to prevent pregnancy. “Pregnancy occurs in up to 5% of rapes, and victims often abort 7.” A standard of care for rape survivors includes emergency contraception 8. Failure to provide a rape victim who requests emergency contraception8 with the drug regimen abandons this patient at a time of heightened emotional and physical stress.
In May 2002, the NYS Department of Health revised and renamed the “Protocol for the Acute Care of the Adult Patient Reporting Sexual Assault” which included a standard that prophylaxis against pregnancy “should not be delayed 9.”
While asserting that starting prophylaxis treatment as close to rape is optimal, the protocol does not require that a hospital directly provide the drugs. Counseling is required, thus eliminating the employer imposed gag order that exists on physicians and registered nurses found in some hospitals operated by religious entities. The protocol continues to allow the provider to elect not to directly provide the drug treatment regimen.
NYSNA supports A15, which would require every emergency department that treats rape survivors to make emergency contraception directly available upon request. This legislation is consistent with a California case (Brownfield v. Daniel Freeman Marina Hospital, 208 Cal App 3d 405, 413-14 [1989]) that held a hospital liable for failing to provide a rape victim with information about and access to emergency contraception.
In conclusion, the New York State Nurses Association stands ready to work with you and other members of the Legislature to advance public health policy that makes emergency contraception more accessible. I am certainly available to answer any questions that you might have. Thank you.
1 World Health Organization. (1998). Emergency contraception, a guide for service delivery. Geneva, Switzerland: Author.
2 Grimes, D. & Raymond, E. G. (2002). Emergency contraception. Annals of Internal Medicine, 137(3), 180-189.
3 Ibid.
4 Ibid.
5 Webber, N. (2003, January). Do women know about "last-chance contraception?" Report of the New York State Nurses Association, 34, 3.
6 McCarthy, S. K. (2002). Availability of emergency contraceptive pills at university and college student health centers. Journal of American College Health, 51(1), 18-22.
7 Smugar, S. S., Spina, B. J. & Merz, J. F. (2000). Informed consent for emergency contraception: Variablity in hospital care of rape victims. American Journal of Public Health, 90, 1372-1376.
8 Ibid.
9 New York State Department of Health. (2002). Protocol for the acute care of the adult patient reporting sexual assault. Albany, NY: Author.