High noon for the morning-after pill

With the medical establishment pushing to make it available over the counter, and anti-abortion groups fighting to stop it, little-known emergency contraception could be the next battle in the reproductive wars.

Published June 20, 2001 7:53PM (EDT)

Perhaps the one thing both sides of the abortion debate can agree on is that it would be a good thing if there were a lot fewer of them. Every year, more than 3 million American women have unintended pregnancies, and almost half of those pregnancies end in abortion. This, by any measure, is a national dilemma, regardless of whether your sympathies lie with the embryo or with the woman who must make the decision to terminate her pregnancy.

It's remarkable, then, that the most effective tool for reducing the number of abortions remains so little known and inaccessible. Every woman in America probably knows what an abortion is, but only 15 percent have ever heard of the morning-after pill. Yet according to the medical community, the morning-after pill -- also called emergency contraception -- could potentially cut America's abortion rate in half.

Emergency contraception consists of a high dose of the hormones found in ordinary birth control pills. If taken within 72 hours after unprotected sex, the morning-after pill can prevent pregnancy 75 to 85 percent of the time. Taking it is easy: Women can either pick apart a packet of birth control pills and take about twice the prescribed dose or get a prescription for one of the two FDA-approved drugs that are marketed specifically as emergency contraception. One such product, called Preven, was approved by the FDA in 1998; the other, Plan B, a year later. Emergency contraception is widely endorsed by doctors as being both safe and effective.

The morning-after pill is commonly confused with RU-486, the so-called abortion pill, which ends a pregnancy several weeks after it has begun. Emergency contraception takes effect much earlier. Depending on where a woman is in her menstrual cycle, it has one of three effects: It prevents ovulation, stops fertilization or -- most controversially -- prevents implantation of an egg that has been fertilized.

Emergency contraception has been a relatively minor player in the nation's wracking battle over reproductive rights, but that could change soon. With the medical establishment pushing to have emergency contraception available over the counter, and antiabortion groups and perhaps the Bush administration gearing up to stop it, a major battle could be brewing. If antiabortion forces succeed in demonizing the morning-after pill just as it promises to become more widespread, the nation's great potential weapon against abortion could once again slip into oblivion.

Emergency contraception has been available for decades in this country, but the first emergency contraception product was only approved by the FDA in 1998. Until the FDA's action, most women weren't even aware of its existence: It was used mainly by college students and clients of family planning clinics. Then, in April of this year, the American College of Obstetricians and Gynecologists issued a call to arms, asking doctors across the country to proactively distribute prescriptions for emergency contraception during their patients' annual visits. And the American Medical Association is now pushing to make emergency contraception an over-the-counter product, like Tylenol or Sudafed.

"We're convinced that if emergency contraception was more available and utilized, at least half of [American] abortions could be prevented," says Dr. Thomas Purdon, president of the American College of Obstetricians and Gynecologists. "And since the whole abortion issue is such a divisive and gut-wrenching issue for the U.S., we'd like to be a little more active."

But because emergency contraception can terminate a potential (or actual, depending on your definition) pregnancy, it is anathema in antiabortion circles -- and they're trying to stop it.

Last month, Sen. Jesse Helms, R-N.C., sponsored an amendment to the Elementary and Secondary Education Act, which would withhold funding to school-based healthcare centers if doctors in those centers distributed emergency contraception to teens without their parents' permission. The amendment was never brought to the floor, but Helms is expected to try again. And in San Bernardino County in Southern California, the local board of supervisors is trying to prevent county public health agencies from distributing emergency contraception to women of any age.

Other antiabortion organizations blast emergency contraception as unsafe and immoral. "'Emergency contraception' is actually a misnomer, because the pill can actually serve as an abortion-inducing drug," claims Heather Cirno, spokeswoman of the conservative public policy organization Family Research Council, which opposes abortion in all cases, including rape and incest. "That's something that the abortion lobby doesn't talk to you about."

Two other leading pro-life organizations, American Life League and Concerned Women for America, are also strongly opposed to emergency contraception. Says Wendy Wright, spokeswoman for Concerned Women of America, "One of the ways the so-called emergency contraception works is by not allowing a life that has been conceived to implant in the woman's womb. Implantation is simply the process by which the new life gets nutrition; so it causes the death of that new life. It is an abortifacient.

"Birth control pills need a prescription," Wright adds. "What's happening with emergency contraception is that they are being handed out without a prescription. It's a higher dose of something else that requires a prescription for good reason. The groups promoting these morning-after pills are putting young women's lives and health at risk."

The Bush administration's stance on emergency contraception remains unclear. Although few observers think he would overtly try to overturn or gut Roe vs. Wade, Bush has taken a much harder antiabortion line than observers thought he would: His first significant act after being sworn in was to cut off funding to international organizations that provide abortions. And his appointment of antiabortion conservative Tommy Thompson as secretary of health and human services also worried pro-choice advocates.

But even if the Bush administration doesn't move directly to limit the use of emergency contraception, its aggressive funding of abstinence-only sex education is certain to make it less known to young women.

Right-to-life groups and conservative moralists worried about lax sexual behavior each have their own reasons for opposing emergency contraceptives. Right-to-lifers usually define pregnancy as beginning with conception: when the sperm penetrates the egg. So, in these conservatives' eyes, the morning-after pill is no different from RU-486, the notorious "abortion pill." (The medical community, by contrast, tends to define pregnancy as implantation -- when the fertilized egg implants itself into the uterine lining.) At a political level, emergency contraception represents the thin end of the wedge for right-to-lifers: If preventing a fertilized egg from implanting itself on the uterine wall is not considered an abortion, the antiabortion position could begin to erode. It's not the easiest position for antiabortion groups to argue: After all, many women might instinctively feel more comfortable knowing they had destroyed a tiny 16-cell blastocyst, which might or might not later have proved to be a viable embryo, than knowing that they had destroyed a 4-week-old fetus. On the other hand, the issue's low profile works in the pro-lifers' favor: If such a small percentage of the population is even aware of emergency contraception, who would even notice if it's gone?

As for the moralists, they believe that emergency contraception is bad for the same reason that frank sex education is bad: In their minds, it encourages unwanted behavior. Attitudes toward the morning-after pill neatly reflect one of the great divides in the culture wars: One group favors teaching kids what can happen if they have sex and providing emergency contraception, while the other preaches abstinence and hopes that teenagers will stop having sex.

When I was in college at University of California at Berkeley in the early 1990s, the existence of the morning-after pill was a collective secret that was passed from undergrad to undergrad soon after each class's arrival. The school health clinic dispensed the pills for free, and a significant number of my dorm mates, friends and acquaintances made that next-day pilgrimage to the clinic nurse after a torrid night that ended in a broken condom or, worse, an encounter without any protection at all.

The morning-after pill was not seen as an alternative to protection -- the pills made you nauseated and ashamed -- but it was a relief to know that they were there, just in case. The alternative was to anxiously wait the weeks until your next period, praying that you weren't pregnant. (Of course, the other alternative was to not have sex at all, but that argument didn't seem to take at my university.)

But Berkeley is a liberal outpost where awareness of emergency contraception is widespread and the pills are easy to obtain. Most American women don't know about emergency contraception at all, let alone how to get it or when to take the pills. For those who do, the process of acquiring it is relatively onerous: You need to visit your doctor, get a prescription and fill it within 72 hours.

The desire to make the morning-after pill easily available to all women has motivated reproductive rights activists and physicians to take action. "Emergency contraception is so time-sensitive, and we want teens and everyone to have increased access in the most convenient manner," says Betsy Cavendish, legal director of the National Abortion and Reproductive Rights Action League (NARAL). "Every single hurdle could spell the difference between getting pregnant and not getting pregnant. You want it to be convenient, not to have to make doctor's appointments [that require you to] leave school or your job. The whole process can be quite cumbersome."

To make it less so, Planned Parenthood of Chicago has launched a service that will dispense prescriptions for the morning-after pill via its Web site to women in Illinois and Georgia. Women merely fill in a form, and a nurse practitioner will call the prescription in to a local pharmacy. (Alternatively, women can get a prescription by telephone from 47 Planned Parenthood clinics, according to the AP story.)

As for the medical community, it has been aware of the existence of emergency contraception since the 1970s. But it wasn't until the early 1990s, when Dr. James Trussell, professor of economics and public affairs at Princeton University, began studying emergency contraception, that doctors truly realized the pills' potential.

"We decided that promoting emergency contraception was the single best way to reduce the incidents of unwanted pregnancy in the U.S., because it involved nothing new -- the technology was already there, it was merely a matter of educating providers and women about it," explains Trussell, who, a decade later, has authored a dozen studies on the subject.

Yet even today, only 10 percent of all doctors have ever even prescribed it. It took nearly 10 years for Trussell and his colleagues to persuade America's cautious medical organizations to not merely publicly endorse the use of emergency contraception, but to promote it. But momentum is picking up: Last December, the American Medical Association issued its first statement of support for making emergency contraception available over the counter.

"It's virtually certain to happen," says Trussell. "The expert medical consensus is that this drug is very safe and effective, instructions are simple, you can't overdose on it, the woman herself diagnoses the condition -- which is unprotected sex -- and it's perfect to go over the counter."

In the meantime, the American College of Obstetricians and Gynecologists (ACOG) launched an educational awareness program in April, calling for doctors across the country to proactively issue prescriptions to their female patients -- essentially giving away prescriptions in advance in case of accidents, and eliminating the need for frantic emergency trips to the doctor.

"We believe that the most effective way to utilize emergency contraception is to have it available over the counter, but we don't know how long it's going to be before it will happen," explains Purdon, president of ACOG. "It's better to be proactive and have a prescription tucked away and know what pharmacies you'll be able to go to if and when the occasion arises."

(Interestingly, in Washington state and several European countries, a third alternative is already available: Women can go straight to a pharmacist, who can prescribe and dispense emergency contraceptives, rather than visiting a doctor. This system is also being considered in Alaska and California.)

A major hurdle in the move toward over-the-counter adoption, however, is the fact that the emergency contraception products Plan B and Preven are being produced and marketed by small, independent pharmaceutical companies (Women's Capital Corp. and Gynetics, respectively), which lack the political clout and marketing resources to take on the massive task. For various reasons, none of the major pharmaceutical companies will touch emergency contraception. First, there's an economic disincentive: Since only 2 percent of all women ages 18-44 have ever used emergency contraception, the market is too small for the big players in the industry. (Of course, the market is arguably so small only because no one has marketed the product -- what Trussell describes as a "chicken and egg problem: Until people know about it, they won't buy it.") Second, companies also have worries about the legal liability for new contraceptive products: Pharmaceutical giant Wyeth-Ayerst, for example, was burned by Norplant, which was eventually pulled off the market after a series of expensive lawsuits. Last but certainly not least, there's the question of public controversy: Pharmaceuticals are extremely wary of provoking the kind of controversy that has plagued RU-486, the abortion-inducing oral drug.

And controversy is certain to follow emergency contraception, as several recent developments show. Though Sen. Jesse Helms' attempt to block school-based clinics from distributing the morning-after pill did not make it to the Senate floor, observers think Helms isn't finished.

"We do think it will come up again -- it was simply a matter of energy. There was pressure to press the bill and Helms didn't have the energy to keep pushing. He was too busy fighting the Boy Scout issue," says Heather Boonstra, senior public policy associate for the Alan Guttmacher Institute. (Helms wanted to withhold federal funds from organizations that took action against the Boy Scouts because of their anti-gay policies.) "We do anticipate that it will come up again and this battle over access isn't over."

(This isn't the first time that Helms has tried to restrict access to emergency contraception. In January, he proposed a bill to "prohibit the provision of Federal funds to any State or local educational agency that distributes or provides morning-after pills to schoolchildren.")

The irony of Helms' amendment is that emergency contraception usage among teens is hardly widespread in the first place: Of the 1,400 school-based health centers in the U.S., only a small percentage actually dispense contraceptives on campus, and even fewer dispense emergency contraceptives. But pro-choice activists consider the Helms amendment to be a step closer to stricter and more widespread restrictions on emergency contraception. As a National Family Planning and Reproductive Health Organization press release puts it, "If [the amendment] is enacted, anti-family planning lawmakers are likely to renew efforts to restrict access to emergency contraception in other federal programs, and to impose parental consent requirements."

Behind the Helms amendment lies the long-running debate about sex education and teens' access to contraceptives. Do they encourage teen promiscuity, as Helms and his supporters believe, or do they encourage more responsible behavior and help prevent unwanted pregnancies?

Teen pregnancy is at an all-time low, but the U.S. still has higher rates of unintended pregnancy and abortion than any other developed country.

However, according to recent studies, including a comprehensive report from the National Campaign to Prevent Teen Pregnancy and a rumored upcoming report by Surgeon General David Satcher, frank sex-ed programs can result in teens' pushing back their first sexual experience up to three years and making increased use of contraceptives.

Conservatives like Sen. Helms "wrongly believe that impeding access to contraception will reduce teen sexual activity," says NARAL's Cavendish. "We think that the premise that making contraceptives available sparks a promiscuous society is just wrong." She adds, "Like many anti-choice advocates, he's confusing emergency contraception with abortion."

"There are a lot of very misguided people out there with a lot of misguided ideas; there are people who fervently believe that emergency contraception will cause the moral decline of the universe," says researcher Trussell. "In no other country are we getting the kind of really strange reaction to people using contraception. The goal is to prevent unwanted pregnancy."

"We should be making emergency contraception available to both teenage boys and girls," says Claire Brindis, a professor of adolescent medicine at UCSF. "The mythology is that by having this kind of method available it will encourage teens to go out and have sex.

"I believe kids will go out and have sex anyway. In fact, there's evidence that proves that access to contraception doesn't increase sexual debut. But many politicians seem to think knowledge is dangerous."

According to Rod McKenzie, chairman of Gynetics and creator of Preven, emergency contraception usage is growing fastest in family planning clinics, particularly those in colleges and universities. In these clinics, pill usage is expanding 25 to 35 percent every year, says McKenzie, with California showing the most rapid growth, and the city of San Diego in particular. This, perhaps, is why California has become one of the first battlegrounds for the distribution of emergency contraception.

In March, the board of supervisors for San Bernardino, a traditionally conservative county outside Los Angeles, voted in favor of eliminating access to emergency contraception in all of the county's public health clinics. Since those clinics are funded under the federal family planning Title X provision, the board of supervisors submitted its request for a waiver to the California Family Health Council in early April, a state organization charged with overseeing the use of federal funds. In letters submitted to the CFHC, the board of supervisors used the vague (and inaccurate) argument that "high dose estrogen has known side effects and risks" to support its request.

More familiar was the supervisors' argument that emergency contraception is, in fact, a type of abortion. "There continues to be debate in the scientific community as to whether the morning after pill ... should appropriately be considered pregnancy prevention, termination, or emergency contraception," the letter argued. (The board of supervisors' office did not return my phone call seeking comment.)

The CFHC denied the San Bernardino request on June 1, so the county's women still have access to emergency contraception at local clinics. Although supervisor Bill Postmus, who led the charge against emergency contraception, originally pledged to appeal the decision, he was outvoted 3-2 last week. Margie Fites Seigle, CEO of the CFHC, believes that the supervisors were counting on a friendly reception with the conservative Bush administration. "I think that certainly there was a feeling from some of the members of the board of supervisors that there was the potential of a more friendly hearing in Washington, should this get to that point," she says.

Will Washington move against emergency birth control? Now that the Senate is no longer controlled by the GOP, with its powerful religious-right faction, pro-choice activists are breathing more easily. Some recent developments, such as a federal court ruling on June 12 that will force some employers to provide health insurance covering contraceptives, have also encouraged them. And as long as the majority of the medical establishment continues to fight for widespread option of emergency contraception, the odds are slim that it will disappear.

But nothing regarding politics and pregnancy is ever final. And while liberals and conservatives battle it out over sex education programs and abstinence and whether emergency contraception really is abortion, 1.3 million teen and adult women still troop to abortion clinics every year.

For Purdon, head of the American College of Obstetricians and Gynecologists, it's a practical matter. "While we certainly respect people's right to have their own moral and philosophical views about this, from a practical matter these numbers are real numbers and this kind of thing is happening every year in the U.S.," he says. "For equal rights for women, it's imperative that they have that choice."

By Janelle Brown

Janelle Brown is a contributing writer for Salon.

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