Improving Access to Emergency Contraception

by Regan Murphy and Amy Allina

Emergency contraception (EC) is a way to prevent pregnancy after unprotected sex or contraceptive failure. It has been around for almost 30 years and approved for use in the United States for more than five years, but numerous barriers keep women from using it widely. One barrier is simple lack of knowledge; only a fraction of women know what EC is and how to use it. Other barriers are logistical. Even women who know about EC may have difficulty finding a health care provider who can see them and write a prescription during the window of time when the method is effective. In addition, many women encounter political, religious and economic barriers when they try to get EC.

If more women knew about and had access to EC, experts estimate that it could prevent a significant portion of the three million unintended pregnancies that take place every year in this country, preventing the need for hundreds of thousands of abortions.

What Is EC? Little Information, Much Confusion

EC comes in two forms. EC pills are basically regular birth control pills packaged in a different dose and with different usage instructions (two doses 12 hours apart, starting within three days after unprotected sex). Two dedicated brands of EC pills are available: Preven, a combined pill containing estrogen and progestin, and Plan B, a progestin only pill. The EC pill is commonly referred to as the "morning after" pill, even though the three-day effectiveness period makes it useful beyond the next morning. The second form of EC is a copper intrauterine device (IUD) that is inserted up to five days after unprotected sex.

There are three possible ways EC might work: by delaying or inhibiting ovulation, by altering sperm or egg transport in the fallopian tubes, and/or by altering the uterine lining to inhibit a fertilized egg from implanting. Current research indicates that in most cases it works by inhibiting ovulation, which means that fertilization never takes place at all. If a woman takes EC after ovulation, EC may still prevent pregnancy through the other mechanisms. All three methods take effect before a fertilized egg implants in the uterus and therefore before a pregnancy (as defined by the American College of Obstetrics and Gynecology) has begun.

Unfortunately, many people think EC is the same as RU486 or mifepristone, a drug that is used for abortion. This confusion is deliberately perpetuated by anti-choice advocates who oppose both abortion and contraception and who claim that EC causes abortion instead of preventing pregnancy. Medical and legal authorities internationally agree that it does not. The High Court in the United Kingdom explicitly ruled that EC is not a method of abortion, finding that "[current medical definitions given in medical dictionaries support the view that pregnancy begins once the blastocyst has implanted in the endometrium."

Lack of information about EC is also widespread. Health care providers, even those who commonly discuss contraception with their patients, are all too often uninformed about this option. Those who know about it do not consistently share that information with women. As a result, many women do not know that there is a way to prevent pregnancy after sex. Surveys have found that 73 percent of women age 18-44 have never heard of EC and only 2 percent of U.S. women have used it.¹ As recently as November 2000, only 20 percent of ob-gyns and 23 percent of family practice doctors said they usually include EC as part of their regular contraceptive counseling.²

Where Can Women Get EC and When? Clinical and Logistical Barriers

EC requires a prescription from a doctor or nurse practitioner. Because unprotected sex often occurs over the weekend or after clinic hours, women may miss its three-day effectiveness window if they have to wait for an appointment with someone who can prescribe EC.

What's more, some pharmacies don't stock EC. This is a particular problem for women in rural areas with less commercial development, who may not be able to travel the distance necessary to find a pharmacy that can fill an EC prescription. When local pharmacies do not stock EC, area health care providers may be discouraged from prescribing it, as doing so could compel them to spend time identifying places elsewhere that do stock it.

Who Can Get EC? Political, Religious and Economic Barriers

Anti-choice activists and opponents of family planning have worked to impose legislative and regulatory restrictions that reduce women's access to EC. These efforts have taken a variety of forms, including restrictions on the kind of facility that is permitted to dispense EC, prohibitions on funding to schools that provide EC to students, and initiatives to exclude EC from health insurance programs.

Religiously affiliated hospitals that refuse to provide EC due to the restrictions of their faith also create barriers to access in communities where these hospitals provide most or all of the health care. Women without health insurance and rape survivors are likely to seek care in hospital emergency rooms and are, therefore, particularly affected by religious restrictions. Though medical ethics and the law demand that such hospitals refer women who want EC to providers who will prescribe it, most do not. A recent survey of Catholic hospitals in California found that 70 percent will not provide EC, even to rape victims.³

Economic barriers to access are also significant. As a prescription product, EC is covered by some but not all insurance plans. Women whose insurance coverage does not include prescriptions, those whose coverage explicitly excludes contraception or more narrowly excludes emergency contraception, and those who lack insurance entirely must rely on underfunded public programs such as Title X family planning for access to EC. A survey of reproductive health services available to adolescents under the State Children's Health Insurance Program found that a third of state health programs surveyed exclude EC, and the programs in Montana and Pennsylvania exclude contraception entirely.⁴

Improving Access to EC

None of these barriers is insurmountable. Successful education campaigns to raise awareness of both health care providers and women have already increased levels of knowledge about EC. There has also been success in reducing clinical and logistical barriers. In California, Washington, Alaska and New Mexico, EC is now available directly from some trained pharmacists. In these cases, the pharmacists offer EC under a protocol established with a doctor or medical authority that allows them to dispense EC. More states may soon adopt similar models, making it easier for women to get EC when they need it. In North Carolina, the Dial EC project provides contraceptive counseling, screening and, for eligible callers, EC prescriptions by phone. Nationally, the Back Up Your Birth Control campaign is making a difference by encouraging women to ask clinicians to prescribe EC in advance so that they can get EC before they need it, should a contraceptive accident occur later.

Perhaps the most dramatic opportunity to increase access to EC will come from making it available without a prescription. The company that manufactures the Plan B EC pill plans to ask the Food and Drug Administration for approval to sell its product over the counter. The National Women's Health Network has taken an official position in favor of making EC available without prescription, and we support the Plan B initiative. (See www.womenshealthnetwork.org/advocacy/ecpos.htm for the full position paper, or contact the Network office to request a copy.)

Greater research and education may also undercut efforts to impose political and religious barriers to EC. Proponents of restricted access for teens and others have argued that making EC available will lead people to have unprotected sex because they'll feel safe in relying on EC as an after-the-fact contraceptive. Research findings do not support this case. Having advance access to the method does not appear to increase women's risk behaviors, such as frequency of unprotected intercourse. In fact, in one study the group that received EC in advance reported using condoms significantly more than the control group. The group also reported fewer new pregnancies and sexually transmitted diseases.⁵ Another recent study found that teenagers who were educated about EC did not have sex more often or use EC more often.⁶

Economic barriers to EC may be the most persistent and difficult to address within the constraints of the current U.S. health care system. To date, legislative efforts to improve coverage of prescription drug costs, including emergency contraception, have had limited success. If EC is made available over-the-counter, women whose insurance pays for the method may lose that coverage and have to pay the cost out of their own pockets. Although it will still be possible for clinicians to prescribe EC by using standard birth control pills, that leaves the logistical barrier of having to go to a doctor or nurse practitioner to get a prescription. And it does nothing to address the needs of the millions of women who do not have prescription insurance coverage or insurance at all.

What is necessary to ensure that all women who want EC are able to get it, regardless of economic status? Expanded public funding for family planning programs, legislative and regulatory requirements that insurance plans include contraceptive coverage, or more radical reform of the health care system to ensure that the costs of all needed care are covered.

Wide Support for EC

"The impact of unintended pregnancy on the lives on black women is serious. The economic hardships and emotional stress that are often associated with an untimely pregnancy can impose significant burdens on women and their families. EC has the potential to prevent millions of these pregnancies." —National Black Women's Health Project, February 2001

"The need for women to take emergency contraception as soon after unprotected intercourse as possible makes the case for OTC [over-the-counter] status compelling. Having EC available over the counter would ensure that women could gain access to this important pregnancy prevention tool when it is needed most." —Medical Students for Choice, November 2002

"Although not totally effective, EC is an important option for women who want to reduce the likelihood of an unintended pregnancy after unprotected sex. It is really a relief for women to know that there IS something they can do 'after the fact'—and our first challenge is to make sure that they know about this option. —Boston Women's Health Book Collective, November 2002

"The Coalition believes that victims have the right to be informed about and have access to all medical options, including those that minimize the risk of pregnancy as a result of sexual assault, rape or incest.... Only the victim/survivor has the right to decide whether or not to choose emergency contraception. The ability to make choices concerning her own body is critical to begin the journey of the healing process for a victim of sexual violence." —Pennsylvania Coalition Against Rape, 2002

Regan Murphy is an intern with the Network. Amy Allina is the Network's program director. To order an EC information packet ($8 for members, $10 for non-members) or a fact sheet (free) from the Network's Information Clearinghouse, call 202-628-7814 or visit www.womenshealthnetwork.org.

References

¹ Kaiser Family Foundation and Lifetime Television. Vital Signs Index No. 2: Emergency Contraception (Selected Findings), 2000.

² Kaiser Family Foundation. Third National Survey of Women's Health Care Providers on Reproductive Health, November 2000.

³ Data from research conducted by Ibis Reproductive Care, Inc., on behalf of Catholics for a Free Choice, November 2002.

⁴ Gold R, Sonfield A. "Reproductive Health Services for Adolescents Under the State Children's Health Insurance Program." Family Planning Perspectives 2001; 33(2): 81-87.

⁵ Data presented at national meeting of the North American Society of Pediatric and Adolescent Gynecology, June 2002. Research contact: Melanie A. Gold, DO, FAAP, FACOP, Children's Hospital of Pittsburgh.

⁶ Graham A, Moore L, Sharp D, Diamond I. "Improving Teenagers' Knowledge of Emergency Contraception: Cluster Randomised Controlled Trial of a Teacher-Led Intervention." British Medical Journal 2002; 324: 1179.