Emergency Contraception Should Be Fully Available in the U.S.
The time has come to do the obvious about the whole abortion mess: Provide emergency contraception over-the-counter. Right now. In every state. In every pharmacy. For every woman who needs it. And at a reasonable price.
One way you can tell the time has come for this total no-brainer is that the American Medical Assn., not exactly known for its out-on-a-limb stances, endorsed the idea in December. In Great Britain, Finland and France, emergency contraception can already be obtained without a prescription.
Another way is that even the National Right to Life Committee, which opposes abortion and strenuously opposed RU-486 (the abortion pill), is not opposed to this--or, more specifically, takes no position on prevention of fertilization. Like standard birth control pills, emergency contraception (EC) pills--better, though less accurately, known as “morning after” pills--are hormones that act, at least in part, by blocking ovulation, which occurs before fertilization.
So far, only one state--Washington--has gone out of its way to make emergency contraception pills easily accessible to women, 24 hours a day, seven days a week, by allowing them to get them from pharmacists without a doctor’s prescription. Alaska, Oregon and other states may follow suit.
But the real breakthrough would come if the U.S. Food and Drug Administration allows the emergency contraceptives to be sold over-the-counter, like aspirin. The FDA says it is waiting for either of the two companies that make EC pills--the Women’s Capital Corp., which makes Plan B, and Gynetics Inc., which makes Preven, to submit applications to switch their products from prescription to over-the-counter status.
The need for safe, effective and accessible emergency contraception is unarguable. In this country alone, there are 3 million unwanted pregnancies a year, half of which are due to broken condoms or other contraceptive failures, according to the Alan Guttmacher Institute in New York, a private, nonprofit group. Half of unwanted pregnancies end in abortion.
In fact, one in every two U.S. women between 15 and 44 has had an unintended pregnancy, though only 1% has ever used emergency contraceptive pills, said James Trussell, a professor of economics and public affairs at Princeton University and a leading scholar on contraception issues.
Indeed, survey data show that only one in 10 U.S. women know that emergency contraceptive pills are available, despite the fact that in 1997 the FDA ruled that regular birth control pills, taken in a special dosing pattern, are a safe and effective method of emergency contraception if taken within 72 hours of unprotected sex. Or that, since then, the agency has approved two other pills, Preven (a combined estrogen and progestin pill) and Plan B (a progestin-only pill)--specifically for emergency contraception.
This lack of awareness is a shame because there is now no question that emergency contraception is very safe and highly effective, as a 1998 World Health Organization study of nearly 2,000 women in 21 countries, and other studies, have shown.
Overall, emergency contraception reduces the risk of pregnancy by at least 75%, and it works best if taken as soon after unprotected sex as possible.
For instance, if 100 women have unprotected sex once during the second or third week of their monthly cycle, when the chance of pregnancy is highest, eight, on average, will become pregnant. With emergency contraception such as Preven or standard birth control pills that combine progestin and estrogen, only two women would become pregnant. With pills such as Plan B that contain only progestin, only one would, Trussell said.
While half of women who take the combined hormones experience nausea and 20% of them vomit, these side effects are reduced considerably in women who take progestin-only pills such as Plan B, the World Health Organization study shows. Some women who use the combined hormone approach also take an over-the-counter drug called meclizine (Dramamine II) to control nausea.
And emergency contraception does not appear to be dangerous either to a woman or to her fetus, if she turns out to be pregnant. “There is no known contraindication,” said Dr. Phillip Stubblefield, chairman of the department of obstetrics and gynecology at Boston Medical Center. Emergency contraception pills are not advised for women who are sure they are pregnant, but that’s not because they are dangerous--it’s because they would not work. “They will not provoke an abortion,” he said.
Even if a woman who took the pills turned out to be pregnant, the pills would have no effect on the fetus because they would have been taken long before fetal organs start forming. Moreover, studies of women who inadvertently took standard birth control pills without knowing they were pregnant showed no increased risk of birth defects.
Still, scientists acknowledge that they are not quite sure of all the biological pathways though which emergency contraception works. The method clearly can block ovulation, noted Trussell, and that is probably its chief mode of operation. Emergency contraception may also block implantation of a fertilized egg, although data on this point are mixed, and it may block fertilization.
However it works, emergency contraception has been a clear boon to women in Washington state who participated in the 1998-99 pilot project run by PATH, the Program for Appropriate Technology in Health, a nonprofit, health advocacy group.
In the pilot project, which has now become a standard program throughout the state, women who had had unprotected sex within the previous 72 hours were able to go to a pharmacy, have a 15-minute consult with a pharmacist, and walk away with EC pills. They never had to see a doctor, thanks to a collaborative agreement between the state’s doctors and pharmacists that allows the pharmacists to write and fill emergency contraception prescriptions.
During 16 months of the pilot program, nearly 12,000 prescriptions for emergency contraception were filled, says Jane Hutchings, a program director at PATH. That translates to an estimated 720 pregnancies prevented. And since roughly half of unwanted pregnancies end in abortion, by inference, it means 360 abortions were prevented, too.
But ultimately, it’s over-the-counter availability that will make emergency contraception most effective. Many women’s health advocates endorse the idea, though they note that women who have a history of migraine headaches or blood clots should probably take pills that do not contain estrogen. Women’s health advocates also urge that EC pills be sold at a reasonable price--perhaps $20--since over-the-counter drugs are not usually reimbursed by insurance.
Granted, there may be some opposition to the whole idea. In Italy last fall, for instance, a church-state battle erupted when emergency contraception pills went on sale. The Vatican condemned the pills as a form of abortion and urged pharmacists not to sell them.
Even in the United States, some doctors may resist being left out of the (income-producing) loop if women can simply go to a drugstore and get the emergency contraception they need. But because emergency contraception pills do not interrupt an established pregnancy, they are unlikely to provoke the kind of furor that accompanied approval of RU-486.
In other words, there is no reason not to make them widely--and cheaply--available.
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Judy Foreman writes a syndicated column on health issues. She is a fellow in medical ethics at Harvard Medical School. She can be reached at foreman@bellatlantic.net. Her column will run occasionally in Health.
