A federal study released recently shows that use of emergency contraception (EC) in the United States, known colloquially as the “morning after” pill, has more than doubled in the past decade. This is good news. It demonstrates the critical and expanding role the method may now be playing in enabling women, particularly young women, to prevent unplanned pregnancies. But there are still serious hurdles women face in accessing this method of birth control. While access has expanded, there is still work to be done.
The study, conducted by the Centers for Disease Control and the National Center for Health Statistics, strengthens the case for promoting EC widely and making it more readily available. Based on interviews with more than 12,000 women from 2006-2010, the research finds that EC use among all sexually experienced women between the ages of 15-44 has increased to 11 percent (up from a baseline of 4.2 percent). That number is even higher among women 20-24, one of the highest risk groups for unplanned pregnancy. Nearly a quarter of this cohort now reports having used EC.
This is no coincidence. In 2006, nearly a decade after EC first entered the market under the trade name Plan B and after years of stalling and political maneuvering by the Food and Drug Administration (FDA), the agency finally ruled that the product can be provided without prescription to women over the age of 18. A year later, a federal judge ordered the FDA to make it available to women over the age of 17. An important provision of the Obama administration’s Affordable Care Act (ACA) also now promises to cover the cost of all methods of contraception, including this one.
The government study confirms what we already know: accidents happen. Half the participants report having used EC out of fear that their initial birth control method had failed; the other half used it because they had unprotected sex. This reminds us that even women who have a “plan A” need a “Plan B,” or, as the product is now also marketed, a “Next Choice.” Nearly one-third of all U.S. women using contraception rely on the pill, and approximately 16 percent use condoms – both effective methods when employed perfectly, but also ones prone to human error. Condoms break, and sometimes women forget to take a daily low-dose pill. And then there are still the many women who, because of lack of access, cost, forgetfulness, or spontaneity, still don’t consistently use birth control and need protection after the fact.
One of the most common arguments against EC is that it is really just an early abortion method masked as contraception. This simply has no basis in science, as most recently explained by the International Federation of Gynecology and Obstetrics. Unlike medication abortion, which terminates a pregnancy in its earliest stages, EC actually prevents a pregnancy from occurring.
The next most popular and equally erroneous claim is that increased access to EC – and, for that matter, any program or product that provides access to abortion, contraception, or sexuality education – will promote risky sexual behavior. Studies from diverse countries over many years tell us this is not thecase. But new research coming out of New York City now confirms that access to EC right here at home does not encourage young people to become more sexually active. In fact, it does just the opposite. The NYC Department of Health recently reported a 12-point drop over 10 years, from 51 to 39 percent, in the proportion of public high school students who are sexually active. Over the past few years, the proportion of sexually active students using contraception, including Plan B, increased from 17 to nearly 27 percent. Both trends coincided with an expansion of school-based health centers that provide free contraception (including EC), counseling, and sexuality education.
So now we have homegrown data to show that when young people have access to sexual health information, no or low-cost products and services, they make better and safer decisions about their reproductive and sexual lives.
But while the federal data illustrates an overall increase in EC use, it also reveals an educational and economic divide among women who use it, suggesting the need for better information and access for low-income women. The CDC study finds that EC use is highest among college-educated women (12 percent), compared to women who have only completed high school or received a GED (7 percent). A 2011 studyconducted by researchers at the Boston University School of Public Health also found that while a majority of pharmacies in low-income neighborhoods do have EC available, they often provide incorrect information about eligibility.
Add this to a number of other potential barriers, and it is clear why EC use isn’t higher.
The drug is not actually sold over the counter, where it would be most accessible, but rather behind the counter, where a pharmacist must retrieve it. (Still, this makes it more widely available in the 72-hour window after unprotected intercourse when it works most effectively.) Nine states around the country have a “conscience clause” on the books that permits pharmacists to deny filling a prescription on religious or moral grounds. Only 17 states and the District of Columbia explicitly require hospital emergency rooms to provide EC and related services to sexual assault victims.
The cost of EC is prohibitive for many potential clients. Plan B and Next Choice, the two most popular products on the market, range in price from $35 to $60 at a pharmacy and from $10 to $70 at Planned Parenthood and other public health clinics, which offer an income-based sliding fee scale and often include counseling and other services.
Even at these high prices, the limited market for the product may not provide private drug companies any incentive to advertise it beyond women’s magazines or other niche marketing sites. This means that young women just becoming sexually active, and all women who do not regularly visit a clinic or a private physician, may never learn about it. Age restrictions requiring a photo ID and concerns about confidentiality may also be intimidating and restrict use.
There are also a number of potential hurdles to EC provision under the Affordable Care Act. Will women be able to use their private insurance or Medicaid benefits to purchase it at a drug store? Or will they need to visit a Planned Parenthood or community clinic? What about the many states that are not planning to participate in the Medicaid expansion? How will low-income women in those states receive information about and access to EC and, for that matter, regular methods of contraception?
In recent years, Planned Parenthood has put forward an effective reproductive health information campaign using online and cell phone platforms. Millions of women, and especially young people, are now texting or visiting its website each month to learn about and gain access to EC, along with other important sexual health information.
The Obama health care plan needs to imitate and vastly expand this marketing approach if it is to be effective. At long last, the Affordable Care Act promises to provide a national policy that prioritizes women’s health and primary, preventive care. But we must seek greater clarity about its implementation. Our next challenge will be to buttress the ACA with an inventive, far-reaching public information campaign so a broad and diverse population can understand and access its many benefits. How about calling this campaign “Morning After in America"? For those Americans old enough to remember Ronald Reagan, this surely has a familiar ring!