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Medical contraindications to combined hormonal contraceptive use among women using methods prescribed by a pharmacist

      Abstract

      Objective

      To determine whether pharmacist prescription of combined hormonal contraception is associated with inappropriate prescription to women with medical contraindications.

      Study design

      We conducted a retrosopective cohort study of all short-acting, hormonal contraceptive users (pill, patch, ring, injectable) in Oregon's All Payer All Claims database from January 1, 2016 to December 31, 2018. Our primary outcome was the proportion of women receiving a combined hormonal method who had a Medical Eligibility Category (MEC) 3 or 4 condition. We identified potential contraindications using International Classification of Disease codes. We conducted descriptive analyses of contraindication prevalence and prescription error rate by prescriber type. We used a multivariable logistic regression model to test the association between pharmacist prescriber and population characteristics.

      Results

      Our study sample consisted of 439,240 contraceptive users, of which 3782 (0.86%) received their prescriptions from a pharmacist. Women aged 25 to 29 were more likely than women over age 35 to receive contraception from a pharmacist (adjusted odds ratio (aOR) 2.74, 95% confidence interval [CI] 2.44–3.08). Pharmacist prescriptions were slightly less likely in rural areas (aOR 0.78, 95% CI 0.69–0.89) and among women on Medicaid, relative to those with commercial insurance (aOR 0.21, 95% CI 0.19–0.24). Among women given contraception in a clinical setting, 4.25% had evidence of an MEC 3 or 4 contraindication, compared to 0.9% for women seen by a pharmacist. Rates of prescribing a combined method to women with a potential contraindication were not meaningfully different by prescriber type (2.16% for clinicians vs 0.74% for pharmacists).

      Conclusion

      Rates of contraceptive prescribing with a contraindication were relatively low and did not differ between clinicians and pharmacists.

      Implications

      Pharmacists can safely screen for medical contraindications to combined hormonal contraception.

      Keywords

      1. Introduction

      In 2016, Oregon became the first state to implement legislation allowing pharmacists to independently prescribe hormonal contraception, including the pill, patch, or ring, directly to the patient without a traditional clinic visit [
      • Rodriguez MI
      • Anderson L
      • Edelman AB.
      Prescription of hormonal contraception by pharmacists in Oregon: implementation of house bill 2879.
      ]. Progestin injectables were added to the formulary for pharmacists to prescribe in 2018. Pharmacists voluntarily elect to complete additional training in all contraceptive methods and follow a prescribing algorithm. This algorithm, based on the Center for Disease Control (CDC)’s Medical Eligibility for Contraceptive (MEC) use, is designed to aid providers in safely prescribing contraception [
      Center for Disease Control
      The United States medical eligibility criteria for contraceptive use.
      ]. Since the implementation of this policy in Oregon, 13 other states and the District of Columbia, have passed legislation to allow pharmacist prescription of hormonal contraception (without oversight from a supervising provider) [
      • Adams AJ
      • Weaver KK.
      The continuum of pharmacist prescriptive authority.
      ,

      National Alliance of State Pharmacy Associations. Pharmacist prescribing of hormonal contraception 2019 [cited 2019 November 25]. Available at: https://naspa.us/resource/contraceptives/.

      ]. This rapid, national expansion of a new cadre of contraceptive prescribers has significant public health implications. It is important to understand how pharmacists are prescribing and if their prescribing patterns are distinct from clinic-based care.
      Pharmacist prescription of contraception is increasingly common nationally as states seek innovative solutions to address the acute unmet need for contraception that exists across the United States [

      National Alliance of State Pharmacy Associations. Pharmacist prescribing of hormonal contraception 2019 [cited 2019 November 25]. Available at: https://naspa.us/resource/contraceptives/.

      ]. Opponents of removing the prescription requirement for hormonal contraception or expanding the scope of pharmacists to prescribe have cited safety as a concern [
      • Mitchell M
      • Stauffenberg C
      • Vernon V
      • Mospan CM
      • Shipman AJ
      • Rafie S.
      Opposition to pharmacist contraception services: evidence for rebuttal.
      ]. Whereas clinicians (defined as physicians, midwives, nurse practicioners, and physician assistants) are typically charged with managing health more broadly, a pharmacist's role may be more restricted. In the absence of extensive knowledge of the patient's medical history, pharmacists may not recognize women who have medical contraindications to contraception containing estrogen, and inadvertently prescribe a combined method. In Oregon, the scope of clinical pharmacists includes contraceptive counseling, screening and prescribing combined hormonal methods (pill, patch, or ring) or progestin only methods (pill or injectable). Pharmacists complete a checklist with individuals requesting contraception, to identify possible medical contraindications to combined hormonal contraceptive use, and either offer a progestin only method or refer women [

      Oregon Board of Pharmacy. Oregon standard procedures algorithm. Available at: https://www.oregon.gov/pharmacy/Pages/ContraceptivePrescribing.aspx.

      ]. Evidence supports that women can safely self-screen for eligibility to use hormonal contraception, and that they are typically more conservative than providers in estimating their risk [
      • Grossman D
      • Fernandez L
      • Hopkins K
      • Amastae J
      • Garcia SG
      • Potter JE.
      Accuracy of self-screening for contraindications to combined oral contraceptive use.
      ].
      By the Board of Pharmacy's algorithm, Oregon pharmacists may not prescribe and must refer women who self-identify as having a CDC MEC condition that suggests risk outweighs the benefit of contraceptive use (Categories 3 & 4). Furthermore, a prescription from a clinician is not a guarantee of safety. Clinician prescribing practices are believed to vary widely, and previous research has suggested low familiarity with CDC guidance [
      • Russo JA
      • Chen BA
      • Creinin MD.
      Primary care physician familiarity with U.S. medical eligibility for contraceptive use.
      ,
      • Zapata LB
      • Morgan IA
      • Curtis KM
      • Folger SG
      • Whiteman MK.
      Changes in US health care provider attitudes related to contraceptive safety before and after the release of National Guidance.
      ].
      Previous research on pharmacist prescription of contraception has suggested that pharmacists are not more likely than clinicians to prescribe contraception to an individual with a contraindication [
      • Anderson L
      • Hartung DM
      • Middleton L
      • Rodriguez MI.
      Pharmacist provision of hormonal contraception in the Oregon Medicaid population.
      ,
      • Gardner JS
      • Miller L
      • Downing DF
      • Le S
      • Blough D
      • Shotorbani S.
      Pharmacist prescribing of hormonal contraceptives: results of the Direct Access study.
      ]. However, the majority of contraceptive users are young and relatively healthy; rates of medical contraindications in the general population vary but have been estimated at 13% [
      • Lauring JR
      • Lehman EB
      • Deimling TA
      • Legro RS
      • Chuang CH.
      Combined hormonal contraception use in reproductive-age women with contraindications to estrogen use.
      ]. Previous studies on this topic have contained fewer than 50 women with medical contraindications, resulting in low power to detect differences by prescriber type [
      • Anderson L
      • Hartung DM
      • Middleton L
      • Rodriguez MI.
      Pharmacist provision of hormonal contraception in the Oregon Medicaid population.
      ,
      • Lauring JR
      • Lehman EB
      • Deimling TA
      • Legro RS
      • Chuang CH.
      Combined hormonal contraception use in reproductive-age women with contraindications to estrogen use.
      ,
      • Rodriguez MI
      • Edelman AB
      • Skye M
      • Anderson L
      • Darney BG.
      Association of pharmacist prescription with dispensed duration of hormonal contraception.
      ]. We build off of earlier work by examining contraceptive prescriptions among commercial and publicly insured people at the state level.
      In this study, we leverage Oregon's All Payer All Claims database to describe the population receiving contraception from pharmacists, and compare pharmacist-prescribing practices with clinic based care. We specifically seek to determine whether pharmacist prescription of contraception is associated with inappropriate prescription to women with medical contraindications.

      2. Methods

      2.1 Study population and data

      Our study population included women in Oregon (ages 12–51) who had at least one prescription for contraception from 2016 to 2018. We included women with both commercial and Medicaid insurance at any point during our study period and imposed no enrollment restrictions. We excluded Medicaid members dually enrolled in Medicare from our study population. We obtained enrollment data, medical and pharmacy claims from the Oregon Health Authority. We utilized Medicaid claims for Medicaid enrollees and the Oregon All Payer All Claims data for commercially insured enrollees. The All Payer All Claims database contains claims from the largest 25 commercial insurers in Oregon, excluding information from small carriers with <5000 enrollees and from certain federal programs such as the Federal Employee Health Benefits Program. It contains claims on over 93% of state residents [

      Oregon Health Authority. All Payer All Claims reporting program 2018 [cited 2019 October 1]. Available at: https://www.oregon.gov/oha/HPA/ANALYTICS/APAC%20Page%20Docs/APAC-Overview.pdf. .

      ].
      We restricted our sample to women using contraceptive methods that can be prescribed by either a pharmacist or a clinician: progestin injectable, oral contraceptive pills (combined hormonal and progestin only), combined hormonal patch and ring. We focused our analysis on women using contraception to prevent pregnancy, and not to manage other medical conditions. We therefore excluded individuals who were not biologically capable of pregnancy (e.g., diagnoses of menopause, permanent contraception) [
      • Rodriguez MI
      • Meath T
      • Huang J
      • Darney BG
      • McConnell KJ.
      Association of implementing an incentive metric in the Oregon Medicaid program with effective contraceptive use.
      ]. We identified receipt of at least one eligible contraceptive using National Drug Classification codes.

      2.2 Variables

      Our primary exposure was contraceptive prescriber type (clinician or pharmacist). We identified prescriber type by linking the National Plan and Provider Enumeration System database with pharmacy claims data by National Provider Identifier. We cross-validated prescriber type using a registry of pharmacists who completed training to prescribe oral contraception in Oregon. This registry was created and maintained by the Oregon State University College of Pharmacy. We included the following individual demographic and enrollment variables: age (12–17, 18–24, 25–29, 30–34, 35+), rural residence (Rural-Urban Commuting Area codes), payer (Medicaid or commercial) and calendar year (2016, 2017, and 2018) [

      USDA economic research service. Rural-Urban Commuting Area Codes. 2018 Contract No.: March 1.

      ].
      We examined use of each method overall, and collapsed these 5 methods into combined hormonal or progestin only methods when assessing for possible contraindications to estrogen.
      We measured potential contraindications to combined hormonal contraception using medical claims data. The contraindication categories are based on the CDC MEC for contraceptive use [
      Center for Disease Control
      The United States medical eligibility criteria for contraceptive use.
      ]. We used diagnosis codes consistent with CDC MEC Category 3 or 4 to identify possible contraindications to combined hormonal contraceptive use. A Category 3 condition is one for which the theoretical or proven risks usually outweigh the advantages of using the method. Similarly, a Category 4 condition is one that represents an unacceptable health risk if the contraceptive method is used.
      For all contraindication categories except postpartum and breastfeeding, we identified conditions based on International Classification of Disease 9 or 10 diagnoses codes from all health encounters 12 months prior to the contraceptive prescription. Postpartum and breastfeeding contraindication extended the contraindication classification window for 21 days after pregnancy, delivery, or breastfeeding diagnosis. The diagnosis codes for all contraindication categories are outlined in the Appendix.

      2.3 Statistical analysis

      We assessed differences in demographic and enrollment variables by prescriber type (clinician vs pharmacist) and payer (commercial vs Medicaid). We used a logistic regression to test the association between prescriber type and key demographic characteristics of our population (age, insurance type, rural location and year since pharmacists became eligible to prescribe). We clustered standard errors on the individual level to account for multiple observations in the study period. For all models, we report odds ratios and 95% confidence intervals.
      We conducted bivariate descriptive analyses of contraindication condition prevalence and combined hormonal contraceptive prescription error rate by prescriber type. The error rate was defined as the proportion of individuals with a medical contraindication who received a combined hormonal contraceptive prescription. Because of the small number of people prescribed combined hormonal contraception by a pharmacist with evidence of contraindication, we provide descriptive statistics for medical conditions when errors occur. All hypothesis tests were 2-sided, and we considered p< 0.05 to be statistically significant. All analyses were conducted using R, version 4.0.3 (R Project for Statistical Computing).

      3. Results

      Table 1 displays characteristics of women receiving short acting contraception in Oregon, comparing those who received prescriptions from clinicians versus those who received prescriptions from pharmacists. Overall, a relatively small number of women received prescriptions from pharmacists: among the 439,240 total women in our study, only 3782 (0.86%) received prescriptions from pharmacists. Table 2 displays the adjusted odds ratios (aOR) for these patient characteristics. Women aged 25 to29 were the most likely to receive contraception from a pharmacist (aOR 2.74, 95% confidence interval [CI] 2.44–3.08), whereas younger adolescent women (ages 12–17) were much less likely to receive contraception from a pharmacist (aOR 0.25, 95% CI 0.18–0.35). Pharmacist prescriptions were also slightly less likely in rural areas (aOR 0.78, 95% CI 0.69–0.89) and among women on Medicaid, relative to those with commercial insurance (aOR 0.21, 95% CI 0.19–0.24). Pharmacist prescriptions were more common in 2017 relative to 2016, but appeared relatively stable between 2017 and 2018.
      Table 1Demographic characteristics and contraceptive method type received by women in Oregon receiving contraception prescribed by a pharmacist vs clinician (2016–2018)
      ClinicianPharmacist
      MedicaidPrivateTotalMedicaidPrivateTotal
      Total women prescribed163,047272,411435,45842033623782
      Total prescriptions written566,0401,169,5071,735,547111310,16811,281
      Combined hormonal pill54.9%80.4%70.9%91.7%93.9%93.7%
      Combined hormonal patch1.5%0.6%1.0%0.0%0.0%0.0%
      Combined hormonal ring7.1%6.8%6.9%2.6%1.8%1.9%
      Progestin only pill34.1%17.6%23.8%6.4%4.5%4.7%
      Progestin only injectable17.7%3.8%9.0%0.5%0.1%0.1%
      Age
      12–1715.0%9.2%11.4%1.9%1.2%1.3%
      18–2434.7%29.2%31.3%34.3%33.0%33.1%
      25–2922.7%21.3%21.8%36.9%33.7%34.1%
      30–3415.8%17.5%16.8%15.0%19.1%18.6%
      ≥3516.7%28.9%24.3%15.2%16.5%16.4%
      Rural residence23.9%13.8%17.6%16.9%11.5%12.1%
      Table 2Association of pharmacist prescriber with demographic characteristics of women in Oregon using short-acting contraception between 2016 and 2018
      VariableAdjusted OR

      (95% CI)
      Age
      12–170.25 (0.18, 0.35)
      18–241.91 (1.70, 2.15)
      25–292.74 (2.44, 3.08)
      30–341.86 (1.64, 2.11)
      ≥35 (ref)-
      Rural residence (ref = Urban)0.78 (0.69, 0.89)
      Medicaid (ref = Commercial Insurance)0.21 (0.19, 0.24)
      Year
      2016 (ref)-
      20171.70 (1.58, 1.82)
      20181.68 (1.55, 1.83)
      Each individual factor adjusts for all other individual factors listed in the table.
      We then examined the safety of contraception prescription by type of prescriber by identifying prescriptions of combined hormonal contraception to women with a MEC Category 3 or 4 condition. Table 3 displays 19 possible contraindications for combined hormonal contraception. We show the number of women with these contraindications who received some type of prescription from clinicians and pharmacists, and the number of women with a contraindication who received a combined hormonal prescription. Because these women have a contraindication to combined hormonal contraception, we define this as a prescribing error.
      Table 3Prevalence of Medical Eligibility Category 3 and 4 contraindications and receipt of a combined hormonal contraceptive method by prescriber type in Oregon (2016–2018)
      ClinicianPharmacist
      n= 435,458 total prescriptionsn= 3,782 total prescriptions
      ContraindicationContraindication With Combined Hormonal Prescription (error)ContraindicationContraindication with Combined Hormonal Prescription (error)
      Any contraindication18,4909,3923428
      (4.25%)(2.16%)(0.90%)(0.74%)
      Medical Eligibility Category 3 conditions
       Diabetes with complications43027111
      (0.10%)(0.06%)(0.03%)(0.03%)
       History of breast cancer18900
      (0.00%)(0.00%)(0.00%)(0.00%)
       Hypertension7,2374,8731310
      (1.66%)(1.12%)(0.34%)(0.26%)
       Deep vein thrombosis55629610
      (0.13%)(0.07%)(0.03%)(0.00%)
       Personal history of thrombophlebitis421700
      (0.01%)(0.00%)(0.00%)(0.00%)
       Women over 35 who smoked Breast cancer2,09793176
      (0.48%)(0.21%)(0.19%)(0.16%)
       Women over 40 who smoked & have hyperlipidemia1434800
      (0.03%)(0.01%)(0.00%)(0.00%)
      Medical Eligibility Category 4 conditions
       Breast cancer695900
      (0.02%)(0.01%)(0.00%)(0.00%)
       Cerebral infarction1548610
      (0.04%)(0.02%)(0.03%)(0.00%)
       Cerebral venous thrombosis17410800
      (0.04%)(0.02%)(0.00%)(0.00%)
       Ischemic heart disease22615000
      (0.05%)(0.03%)(0.00%)(0.00%)
       Systemic Lupus Erythematous44831022
      (0.10%)(0.07%)(0.05%)(0.05%)
       Migraines with aura2,5741,72188
      (0.59%)(0.39%)(0.21%)(0.21%)
       Myocardial infarction583700
      (0.01%)(0.01%)(0.00%)(0.00%)
       Personal history of a clot: Venous thrombosis and  embolism36812410
      (0.08%)(0.03%)(0.03%)(0.00%)
       Pulmonary embolism2038600
      (0.05%)(0.02%)(0.03%)(0.03%)
       Thrombogenic mutation91253054
      (0.21%)(0.12%)(0.13%)(0.11%)
       Currently breastfeeding or < 21 days after breastfeeding2,59532700
      (0.60%)(0.08%)(0.00%)(0.00%)
       Pregnancy or <21 days after pregnancy diagnosis3,07235800
      (0.71%)(0.08%)(0.00%)(0.00%)
      MEC, Medical Eligibility Classification for Contraceptive Use; Category 3, A condition for which the theoretical or proven risks usually outweigh the advantages of using the method; Category 4, A condition that represents an unacceptable health risk if the contraceptive method is used.
      Overall, the rates of women with any potential contraindication who receive combined hormonal prescriptions are much smaller among women receiving prescriptions from pharmacists (0.90%) relative to clinicians (4.25%). Consequently, the error rate was relatively small among pharmacists (0.74%) relative to clinicians (2.11%). The contraindications that were most common among clinicians were hypertension (1.66%), pregnant or <21 days after pregnancy diagnosis (0.71%), currently breastfeeding or <21 days after breastfeeding (0.60%), and migraines with aura (0.59%). The contraindications that were most common among pharmacists were hypertension (0.34%), migraines with aura (0.21%), and thrombogenic mutation (0.13%).

      4. Discussion

      Our data support the hypothesis that pharmacists can safely screen women for medical contraindications to combined hormonal contraception. Overall, very few women had a Category 3 or 4 contraindication to combined hormonal contraceptive use. The vast majority of these women were appropriately prescribed a safe method. Both pharmacists and clinicians were similarly effective in identifying potential medical contraindications to estrogen use. These findings have important implications for both pharmacist prescription and over-the-counter access to hormonal contraception.
      Our findings support and extend previous research indicating that pharmacists, and women themselves, can safely self-screen for contraceptive use [
      • Anderson L
      • Hartung DM
      • Middleton L
      • Rodriguez MI.
      Pharmacist provision of hormonal contraception in the Oregon Medicaid population.
      ,
      • Gardner JS
      • Miller L
      • Downing DF
      • Le S
      • Blough D
      • Shotorbani S.
      Pharmacist prescribing of hormonal contraceptives: results of the Direct Access study.
      ,
      • Grossman D.
      Over-the-counter access to oral contraceptives.
      ]. Reducing barriers to contraception by expanding the cadres of providers who offer it or removing the prescription requirement supports individuals in achieving their reproductive goals [
      ACOG Committee on Health Care for Underserved Women
      Committee opinion no. 615: access to contraception.
      ]. Our data are in line with recommendations from public health organizations, including the American Congress of Obstetrician and Gynecologists, the American Medical Association, and the American Public Health Association's, supporting liberalized access to contraception by removing the prescription requirement [
      • Committee on Gynecologic Practice
      Over-the-counter access to hormonal contraception: ACOG Committee Opinion Summary, Number 788.
      ]. In Oregon, women complete a self-screening checklist to identify potential contraindications to hormonal contraception [

      Oregon Board of Pharmacy. Oregon standard procedures algorithm. Available at: https://www.oregon.gov/pharmacy/Pages/ContraceptivePrescribing.aspx.

      ]. This checklist is then reviewed by a pharmacist to ensure completion and verify that no contraindications were marked. The pharmacist will ask clarifying questions as needed, but if a MEC Category 3 or 4 condition is indicated, the pharmacist, who does not have access to complete medical records, must refer. We observed that less than one percent (0.9%) of individuals receiving a prescription from a pharmacist had a potential contraindication to combined hormonal contraception. Our study adds to the literature demonstrating that women can safely self-screen for hormonal contraception [
      • Shotorbani S
      • Miller L
      • Blough DK
      • Gardner J.
      Agreement between women's and providers' assessment of hormonal contraceptive risk factors.
      ,
      • Grossman D
      • White K
      • Hopkins K
      • Amastae J
      • Shedlin M
      • Potter JE.
      Contraindications to combined oral contraceptives among over-the-counter compared with prescription users.
      ].
      Importantly, we found that younger people (ages 18–24) are significantly more likely than older women (over age 35) to access their contraception through a pharmacist prescription. This finding aligns with earlier research which similarly demonstrated the important role that pharmacists can play in improving access to contraception for a population known to be at higher risk for unintended pregnancy [
      • Rodriguez MI
      • Edelman AB
      • Skye M
      • Anderson L
      • Darney BG.
      Association of pharmacist prescription with dispensed duration of hormonal contraception.
      ,
      • Iseyemi A
      • Zhao Q
      • McNicholas C
      • Peipert JF.
      Socioeconomic status as a risk factor for unintended pregnancy in the contraceptive CHOICE project.
      ,
      • Finer LB
      • Zolna MR.
      Unintended pregnancy in the United States: incidence and disparities, 2006.
      ]. We found that younger adolescent women (ages 12–17) were less likely to obtain contraception from a pharmacist. This finding may be attributable to our study period. During the first 2 years of our study period, adolescents were only allowed to renew a prescription from a pharmacist; initiation of new prescriptions by pharmacists to adolescents became possible in early 2018 [

      Oregon Board of Pharmacy. Oregon standard procedures algorithm. Available at: https://www.oregon.gov/pharmacy/Pages/ContraceptivePrescribing.aspx.

      ].
      In our study, women with Medicaid were significantly less likely than women with commercial insurance to get contraception from a pharmacist (aOR 0.21 [0.19, 0.24]). This is somewhat surprising, as Oregon's Medicaid program has guaranteed coverage for pharmacist prescription of contraception—both the medication and the pharmacist's time in providing counseling [
      • Rodriguez MI
      • Anderson L
      • Edelman AB.
      Prescription of hormonal contraception by pharmacists in Oregon: implementation of house bill 2879.
      ]. This finding may reflect that Medicaid recipients tend to be sicker than the commercially insured, thus having more clinic-based encounters, and obtaining contraceptive care during these encounters. Conversely, it may suggest that pharmacies have not set up the infrastructure to bill insurance companies as clinics do, and instead charge the costs of care to the client. Despite Medicaid and some commercial insurers guaranteeing coverage for both the contraceptive method and pharmacists time in counseling, a previous “secret shopper” study of pharmacies in Oregon and New Mexico demonstrated that about half of all women were paying out of pocket for contraception prescribed by a pharmacist [
      • Rodriguez MI
      • Garg B
      • Williams SM
      • Souphanavong J
      • Schrote K
      • Darney BG.
      Availability of pharmacist prescription of contraception in rural areas of Oregon and New Mexico.
      ].
      Our results should be interpreted with the following limitations in mind. First, our study utilizes administrative data and thus is subject to data collection errors [
      • O'Malley KJ
      • Cook KF
      • Price MD
      • Wildes KR
      • Hurdle JF
      • Ashton CM.
      Measuring diagnoses: ICD code accuracy.
      ]. We used International Classification of Disease 9 and 10 codes to identify medical contraindications to contraceptive use; codes are utilized for billing and not for healthcare, and may contain inaccuracies. Our database does not include information on medical or other factors that influence clinical decision-making in contraceptive safety. MEC Category 3 conditions suggest that the potential risk usually outweighs the benefit of this method, but are not an absolute contraindication. Additionally, prescriptions given to women who are recently postpartum or breastfeeding may be being filled in advance of the start date. It is possible that prescribers accurately counseled women on when it is safe to start these methods postpartum, and prescriptions were filled in advance. Our study is also from a single state, Oregon, which affects our generalizability. Oregon is a Medicaid expansion state, with relatively few uninsured citizens. Our database does not include information on the uninsured; in this analysis, we are unable to identify how pharmacist prescribers are reaching this key population [
      • Rodriguez MI
      • Edelman AB
      • Skye M
      • Anderson L
      • Darney BG.
      Association of pharmacist prescription with dispensed duration of hormonal contraception.
      ].
      Ensuring that individuals have the ability to decide if and when to become pregnant is fundamental to human rights, health, and community development [
      WHO
      Ensuring human rights in the provision of contraceptive information and services.
      ]. Our study supports the safety of expanding access to contraception through self-screening for medical contraindications, thus supporting direct pharmacist prescription or over-the-counter status of hormonal contraception.

      Declaration of Competing Interest

      Dr. Rodriguez has served as a contraceptive trainer for ACOG, Bayer and Merck. All other authors report no conflicts of interest.

      Appendix. Supplementary materials

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