Pharmacists' experiences dispensing misoprostol and readiness to dispense mifepristone

Online Medication Abortion Direct-to-Patient Fulfillment Before and After the Dobbs v Jackson Decision

Importance

Online pharmacies have emerged as stakeholders in abortion care since the US Food and Drug Administration (FDA) relaxed in-person dispensing requirements in 2020. The role of online pharmacies in dispensing abortion medications following the Dobbs v Jackson Women's Health Organization decision on June 24, 2022, is understudied.

Objective

To describe medication abortion prescription fulfillment patterns for 1 online pharmacy 1 year before and after the Dobbs v Jackson decision, considering patient, prescriber, and state policy characteristics.

Design, Setting, and Participants

This cross-sectional study assesses deidentified medication abortion prescription fulfilment data from 1 online pharmacy. Prescribers sent prescription requests to the online pharmacy, which dispensed abortion medications to patients by mail. The study sample included prescription requests fulfilled by the online pharmacy between June 20, 2021, and June 24, 2023, for patients aged at least 18 years who received the combined medication abortion regimen. Data were analyzed from July 2023 to July 2024.

Exposures

The US Supreme Court Dobbs v Jackson decision on June 24, 2022.

Main Outcomes and Measures

Patient and prescriber characteristics are described, including patient age, state to which the prescription was sent, medications prescribed, and prescribing prescriber's clinic care modality (in-person only, hybrid [in-person and virtual], and virtual only). States were grouped according to the Guttmacher Institute classification of policy support for abortion (most or very supportive, somewhat supportive, and somewhat restrictive). Fulfillment trends were disaggregated by prescriber modality and state policy environment; 2 states with similar telehealth but differing coverage policies (Illinois and Colorado) were compared.

Results

The dataset included 87 942 observations. Most prescriptions were sent to individuals younger than 30 years (57.1%), with a mean (SD) age of 28.7 (6.4) years. Throughout the study period, the greatest volume of prescription requests came from states with most or very supportive policies and from prescribers at virtual-only platforms. More prescriptions were sent in the year after Dobbs v Jackson (daily mean [SD], 88.5 [47.2] prescriptions in March 2022 vs 201.5 [97.5] prescriptions in March 2023) with fulfillment spikes following the Dobbs v Jackson leak on May 2, 2022, and decision on June 24, 2022. State policy contexts mirrored the overall trends, while prescriber modality trends were unique, with a big spike in fulfillment at 12 weeks after the Dobbs v Jackson decision for hybrid clinics compared with in-person-only clinics and telehealth-only platforms, which saw their largest spikes in mean daily prescription fulfillment the week immediately after Dobbs v Jackson. Illinois and Colorado had similar fulfillment trends, with spikes immediately following the Dobbs v Jackson decision and overall higher fulfillment after Dobbs v Jackson, with a daily mean (SD) of 10.5 (7.0) prescriptions in Illinois and 8.8 (5.7) prescriptions in Colorado in March 2022 versus 26.6 (13.6) prescriptions in Illinois and 16.7 (10.1) prescriptions in Colorado in March 2023.

Conclusions and Relevance

These findings illustrate the increasingly critical role online pharmacies play in direct-to-patient abortion care provision in the US and the strong linkages between virtual-only prescribers and online pharmacies. These findings suggest that barriers to accessing online pharmacies for abortion care should be removed.

Willingness of Pharmacists to Prescribe Medication Abortion in California

Importance

Nearly half of US states have restricted abortion access. Policy makers are exploring pathways to increase access to abortion and reproductive health care more broadly. Since 2016, California pharmacists could prescribe hormonal birth control, providing an opportunity to learn about the implementation of pharmacist-provided reproductive health care.

Objective

To explore the feasibility of broadening pharmacist scope of practice to include prescribing medication abortion.

Design, Setting, and Participants

A cross-sectional online survey was conducted from October 11 to December 20, 2022, among a convenience sample of California licensed community pharmacists to examine their attitudes toward, knowledge of, and confidence in prescribing hormonal birth control and reports of pharmacy-level practices.

Main Outcomes and Measures

Descriptive analyses and log-binomial regression models were used to compare medication abortion and contraceptive provision attitudes by pharmacist and pharmacy characteristics.

Results

Among the 316 pharmacists included in the analysis who worked at community pharmacies across California (mean [SD] age, 40.9 [12.0] years; 169 of 285 [59.3%] cisgender women; and 159 of 272 [58.5%] non-Hispanic Asian individuals), most (193 of 280 [68.9%]) indicated willingness to prescribe medication abortion to pharmacy clients if allowed by law. However, less than half were confident in their knowledge of medication abortion (139 of 288 [48.3%]) or their ability to prescribe it (115 of 285 [40.4%]). Pharmacists who indicated that providing access to hormonal birth control as a prescribing provider was important (263 of 289 [91.0%]) and were confident in their ability to prescribe it (207 of 290 [71.4%]) were 3.96 (95% CI, 1.80-8.73) times and 2.44 (95% CI, 1.56-3.82) times more likely to be willing to prescribe medication abortion and to express confidence in doing so, respectively. Although most pharmacists held favorable attitudes toward hormonal birth control, less than half (144 of 308 [46.8%]) worked in a pharmacy that provided prescriptions for hormonal birth control, and 149 who did not reported barriers such as lack of knowledge or training (65 [43.6%]), insufficient staff or time to add new services (58 [38.9%]), and lack of coverage for services (50 [33.6%]).

Conclusions and Relevance

The findings of this cross-sectional survey study of California pharmacists suggest that most pharmacists were willing to prescribe medication abortion. However, future efforts to expand pharmacists' scope of practice should include training to increase knowledge and confidence in prescribing medication abortion. Pharmacy-level barriers to hormonal birth control prescription, such as insurance coverage for pharmacist effort, should also be addressed, as they may serve as barriers to medication abortion access.