Emergency contraception has been available for more than 25 years and could prevent 1.7 million unintended pregnancies and 800,000 abortions each year in the U.S. It is a safe and effective method of contraception, and women who have used it report high levels of satisfaction.

Despite its enormous potential, anti-choice groups oppose the use of emergency contraception. In order to hinder women's access to this important method of contraception, they falsely claim that emergency contraception (EC) is an abortifacient, and they disseminate other misinformation about its safety and efficacy.

Fortunately, public awareness and availability of emergency contraception has increased, and hopefully more women will benefit from this important backup birth control method in the future.

Emergency Contraception Is Not Just a "Morning-After Pill"

Emergency contraception, also called postcoital contraception, can reduce the risk of pregnancy after unprotected intercourse. Emergency contraception is provided in two ways: using hormonal contraceptive pills or inserting a copper-releasing IUD (intrauterine device).

• Emergency Contraceptive Pills (ECPs) contain hormones that reduce the risk of pregnancy if taken within 120 hours (five days) of unprotected intercourse. The treatment is more effective the sooner it begins (Ellertson, et al., 2003; “FDA Approves…”, 1999; Rodrigues, et al., 2001; Van Look & Stewart, 1998). (Because ECPs have a five-day window of effectiveness, the popular term “morning-after pill” is misleading.)

• An IUD can be inserted to prevent pregnancy up to seven days after unprotected intercourse (“IUD Most…,” 1995).

Widespread Use and Availability of Emergency Contraception Could Prevent More than Half of All Unintended Pregnancies and Abortions in the U.S.

Forty-two million, or seven in 10 women of reproductive age, are sexually active and do not want to become pregnant. Nearly half of America’s 6.3 million annual pregnancies are accidental. Unintended pregnancies result in 1.4 million abortions annually, as well as 1.2 million births that women either did not want to have until later or did not want at all (AGI, 2004a). Eighty percent of teen pregnancies are unintended, and each year, more than 8 out of 100 young women aged 15–19 become pregnant; more than half become mothers (AGI, 1999; 2004b).

Widespread use of emergency contraception could prevent an estimated 1.7 million unintended pregnancies and 800,000 abortions each year (Glasier & Baird, 1998; Van Look & Stewart, 1998).

Women Increasingly Turn to Planned Parenthood for Emergency Contraception

Planned Parenthood is a leading provider of emergency contraception in the U.S. The number of women receiving ECPs from Planned Parenthood has grown from roughly 17,000 in 1995 to 634,000 in 2002 (PPFA, 1996; PPFA, 2003). Planned Parenthood offers all safe, available emergency contraceptive choices, but not every method is available at every Planned Parenthood health center. Some Planned Parenthood health centers offer "just-in-case" emergency contraception kits to keep at home, also called EC-to-Go.

Emergency Contraception is a Safe Backup Method of Birth Control

Millions of women around the world have used ECPs safely and effectively (Glasier, 1997; Guillebaud, 1998). ECPs are less effective than the most popular precoital methods of contraception, and in general practice, women only turn to ECPs in emergencies — as a backup to their usual birth control method.

Almost every woman who needs emergency contraception can safely use ECPs — even women with contraindications to the ongoing use of oral contraceptives may use them (Guillebaud, 1998; Van Look & Stewart, 1998). ECPs can also be used safely by adolescents. One study designed to evaluate the safety of ECP use in teenagers enrolled 55 teens between the ages of 13 and 16. ECPs were found to be safe and well tolerated by the teens. The teens took the medicine properly, and they returned to their normal menstrual period at the same rate as adult women taking ECPs (Schorr, 2003).

ECPs should not be used by women who are already pregnant, not because the pills are thought to be harmful, but because they are ineffective at terminating established pregnancies (Van Look & Stewart, 1998).

Many women can use IUDs as EC, but IUD use is not recommended for all women. In general, a woman should not have an IUD inserted if she is pregnant, has a sexually transmitted infection (STI) such as HIV, chlamydia, or gonorrhea, has a history of pelvic inflammatory disease (PID) that has impaired her fertility, or a variety of other conditions that affect her reproductive system (Knowles & Ringel, 1998).

Emergency Contraception Is Not Abortion

Emergency contraception cannot end a pregnancy. According to the Food and Drug Administration (FDA), “Emergency contraceptive pills are not effective if the woman is pregnant; they act by delaying or inhibiting ovulation, and/or altering tubal transport of sperm and/or ova (thereby inhibiting fertilization), and/or altering the endometrium (thereby inhibiting implantation)” (FDA, 1997). A recent study found that most often, ECPs reduce the risk of pregnancy by inhibiting ovulation (Marions, et al., 2002). A more recent study suggests that progestin-only ECPs only work by preventing ovulation or fertilization, and have no effect on implantation (Croxatto, et al, 2003). Emergency contraception reduces the risk of pregnancy and helps prevent the need for abortion; it itself is not a form of abortion (Grimes, 1997; Guillebaud, 1998; Hughes, 1972; Van Look & Stewart, 1998).

The IUD, used as a regular method of contraception, “alters tubal and uterine transport and affects the sperm and ovum so fertilization does not occur” (Stewart, 1998). Postcoital emergency contraceptive insertion of an IUD may involve the same mechanism in some cases, but it is more likely to interfere with implantation (Van Look & Stewart, 1998).

Women Now Have More Options for Emergency Contraception

Yuzpe Regimen:

This method of emergency contraception is named for Canadian Professor A. Albert Yuzpe who published the first studies demonstrating the method’s safety and efficacy in 1974. This regimen of ECPs uses two doses of oral contraceptive pills that combine estrogen and certain progestin hormones (FDA, 1997). The doses are taken 12 hours apart. Various prescription products contain the appropriate hormone combination and can be used as ECPs:

• Many common oral contraceptive pills can be used as ECPs, although their manufacturers do not label the pills for this use. “Off-label” use of approved medications is legal and commonplace in American medicine. Further, in February 1997, the FDA declared ECP use of birth control pills, following the Yuzpe regimen, to be safe and effective. At that time, six suitable pill brands were available on the U.S. market (FDA, 1997). Currently, the following brands of pills can be used as ECPs in the U.S.:

Pill Brand-Manufacturer-Pills per Dose

Alesse®-Wyeth-Ayerst-5 pink pills
Aviane®-Duramed-5 orange pills
Cryselle®-Barr-4 white pills
Enpress®-Barr-4 orange pills
Lessina®-Barr-5 pink pills
Levlen®-Berlex-4 light-orange pills
Levlite®-Berlex-5 pink pills
Levora®-Watson-4 white pills
Lo/Ovral®-Wyeth-Ayerst-4 white pills
Low-Ogestrel®-Watson-4 white pills
Nordette®-Wyeth-Ayerst-4 light-orange pills
Ogestrel®-Watson-2 white pills
Ovral®-Wyeth-Ayerst-2 white pills
Portia®-Barr-4 pink pills
Seasonale®-Barr-4 pink pills
Tri-Levlen®-Berlex-4 yellow pills
Triphasil®-Wyeth-Ayerst-4 yellow pills
Trivora®-Watson-4 pink pills
(OPR, n.d. a).

• The Preven® Emergency Contraceptive Kit, produced by Gynétics, Inc., contains Yuzpe regimen ECPs (two pills per dose), a pregnancy test, and instructions for use. It is approved by the FDA and was the first product specifically labeled and marketed for emergency contraception.

Progestin-Only ECPs:

On July 28, 1999 the FDA approved the first progestin-only ECP available in the U.S. Produced by the Women's Capital Corporation and known as Plan B®, it consists of two pills, taken 12 hours apart, and contains only the hormone levonorgestrel, a progestin. Plan B contains no estrogen ("FDA Approves...," 1999).

Off-label administration of the progestin-only method is also available in the U.S., but it requires taking 20 Ovrette® oral contraceptive pills, and then taking another dose of 20 Ovrette pills 12 hours later (Van Look & Stewart, 1998).

A recent study has shown that a single administration of the two full doses of progestin-only ECPs is also effective (von Hertzen, et al., 2003).

IUD:

A copper-releasing IUD can be inserted within seven days of unprotected intercourse as a method of emergency contraception (“IUD Most…,” 1995).

ECPs Reduce the Risk of Pregnancy by up to 95 Percent and Emergency Contraception IUD Insertion Reduces the Risk by 99.9 Percent

Two time factors influence the efficacy of ECPs: the amount of time elapsed after unprotected intercourse, and the point in a woman’s cycle at which she had sex. The earlier ECPs are taken after unprotected intercourse, the more effective they are (TFPMFR, 1998). The closer a woman is to ovulation at the time of unprotected intercourse, the less likely the method will succeed (Van Look & Stewart, 1998). ECPs are not as effective as correct and consistent use of precoital, reversible contraceptive methods such as the pill, IUD, or contraceptive implants, injections, patches or rings, and they do not protect against sexually transmitted infections (Knowles & Ringel, 1998; Roumen, et al., 2001; Zieman, et al., 2002).

• The Yuzpe regimen of combined estrogen and progestin ECPs reduces the risk of pregnancy by roughly 75 percent. Not every woman at risk of pregnancy actually becomes pregnant. On average, only eight out of 100 women will become pregnant after having unprotected sex during the second or third week of their menstrual cycles. But if they take ECPs, only two out of those 100 women will become pregnant. Combined hormonal ECPs thus reduce the risk of pregnancy by roughly 75 percent, preventing six of eight likely pregnancies (Knowles & Ringel, 1998; OPR, n.d.b; Rodrigues, et al., 2001; Van Look & Stewart, 1998).

• When used within 72 hours of unprotected intercourse, progestin-only ECPs were found to reduce the risk of pregnancy by 89 percent in a World Health Organization-supported study involving almost 2,000 women in 21 clinics around the world. When taken within 24 hours of unprotected intercourse, they were found to reduce the risk of pregnancy by 95 percent (TFPMFR, 1998; "FDA Approves...," 1999).

More than 8,400 copper-bearing IUDs have been inserted postcoitally since 1976, with only eight pregnancies occurring: a rate of fewer than one in 1,000, reducing the risk of pregnancy by more than 99 percent (OPR, n.d b; Van Look & Stewart, 1998).

Progestin-Only ECPs Greatly Reduce Side Effects

• Combination hormone ECPs induce nausea in 30–50 percent of women, and vomiting in 15–25 percent of women. Anti-nausea or anti-emetic medications taken one hour before ingesting ECPs may reduce these side effects. Breast tenderness, fatigue, irregular bleeding, abdominal pain, headaches, and dizziness may also occur. These side effects usually taper off one or two days after ingesting ECPs (Van Look & Stewart, 1998; Knowles & Ringel, 1998; Raymond et al., 2000).

• Nausea and vomiting are far less common using progestin-only ECPs than using the Yuzpe regimen (Van Look & Stewart, 1998). In a World Health Organization-supported study using levonorgestrel, nausea occurred in 23.1 percent of cases, and vomiting in 5.6 percent. Other side effects were also less common (TFPMFR, 1998).

• In about 10–15 percent of women treated, ECPs change the amount, duration, and timing of the next menstrual period. This effect is usually minor, and menstruation occurs a few days earlier or later than expected (Van Look & Stewart, 1998). If ECPs are used frequently, periods may become irregular and unpredictable (Knowles & Ringel, 1998).

• Side effects of IUD insertion may include abdominal discomfort, vaginal bleeding or spotting, and infection. Possible side effects of IUD use include heavy menstrual flow, cramping, infection, infertility, and uterine puncture (Van Look & Stewart, 1998; Stewart, 1998).

• Neither ECPs nor IUDs prevent the spread of sexually transmitted infections, including HIV. Many women who need emergency contraception are at risk of these infections. At heightened risk are those who have had unprotected sex in a non-monogamous relationship or with a new partner, those who use IV drugs or have a partner who does, and victims of sexual assault. For those at risk of sexually transmitted infections, ECPs are likely to be a safer choice than IUD insertion (Knowles & Ringel, 1998). During IUD insertion, bacteria from a preexisting infection can be introduced into the sterile uterine cavity — untreated, such infections can lead to pelvic inflammatory disease. HIV infection can also increase the risk of pelvic inflammatory disease associated with an IUD (Stewart, 1998).

• Women should discuss with their clinicians any sign of pregnancy after using emergency contraception. The signs include a missed menstrual period, nausea, inexplicable fatigue, sore or enlarged breasts, headaches, and frequent urination (Cunningham et al., 1997).

• Emergency contraception may not prevent ectopic pregnancy — pregnancies that develop outside the uterus. Ectopic pregnancies, left untreated, will cause complications that can cause death. Women should seek medical attention if they have signs of ectopic pregnancy, which include severe pain on one or both sides of the lower abdomen, abdominal pain and spotting, especially after a very light or missed menstrual period, and faintness or dizziness (Knowles & Ringel, 1998).

Users of ECPs Report High Levels of Satisfaction

• A study of 235 women who had used ECPs found that the overwhelming majority — 91 percent — were satisfied with the method, and 97 percent would recommend it to friends and family. These women also reported that they did not intend to substitute ECPs for regular contraceptive use (Harvey et al., 1999)

• Of 119 women who obtained ECPs at Planned Parenthood of New York City clinics, 92 percent stated that they would use the method again if necessary, but reported that they believed ECPs should be reserved for emergencies. Three-fourths of the sample indicated that since using ECPs, they were more likely to use precoital methods of contraception (Breitbart et al., 1998).

Anti-Choice Organizations, Pharmacists, Religious Hospitals, and Hotline Difficulties Threaten Women's Access to Emergency Contraception

• Major anti-choice organizations such as the American Life League, Human Life International, and Stop Planned Parenthood International oppose emergency contraception and have launched national and international misinformation campaigns claiming that it is an abortifacient (STOPP International, 1999; Gallagher, 1998; ALL, 1997). In addition, they falsely assert that testing has not been done to confirm the safety of ECPs (ALL, 1997); they underreport statistics on the efficacy of emergency contraception (STOPP, 1999), and they dismiss evidence of decreased side effects of progestin-only ECPs (Clarke, 2000).

• Individual pharmacists have refused to fill prescriptions for ECPs, presumably based on the false assumption that ECPs are an abortifacient (Cohen, 1999). This problem received widespread attention in May 1999, when Wal-Mart® announced that it would not sell Preven in its approximately 2,400 pharmacies (Canedy, 1999). In February 2004, a Denton, Texas pharmacist refused to fill a rape survivor’s prescription for ECPs, citing “religious convictions” (Austin, 2004). A survey of 195 pharmacies in New York City revealed that 25 percent did not carry ECPs, and of those, none had posted signs required by law, saying they do not carry the pills (Andreatta, 2004).

• Although the Ethical and Religious Directives for Catholic Health Care Services states that "A female who has been raped should be able to defend herself against a potential conception from the sexual assault" (USCCB, 2001), many Catholic hospitals do not provide emergency contraception, even to rape victims. A study of the nation’s nearly 600 Catholic hospital emergency rooms found that only 28 percent offered EC to women who had been raped (CFFC, 2002). Sometimes a Catholic hospital is a community’s only provider — leaving sexual assault survivors with very little chance of being taken to a hospital that will provide her with EC.

• An evaluation of the Emergency Contraception Hotline found that while at least 76 percent of callers were able to obtain a telephone prescription or an appointment with a hotline provider within 72-hours of unprotected intercourse, 11 percent failed (Trussell et al., 2000). Although the hotline provides an important resource for women seeking emergency contraception, lack of available appointments and limited practice hours necessitate additional venues to facilitate access.

Advance Provision and Direct Pharmacist Provision Can Improve Access to Emergency Contraception

• Both the American Medical Women's Association (AMWA) and the American College of Obstetricians and Gynecologists (ACOG) advocate that physicians provide prescriptions for ECPs prior to need at routine office visits. In addition, AMWA recognizes the potential benefits of collaborative drug therapy agreements, through which a pharmacist and a prescriber, such as a physician or nurse practitioner, voluntarily enter into an agreement that grants the pharmacist the authority to write prescriptions under a set of prescribing protocols (AMWA, 1996; Murray, 1999; Wells et al., 1998).

• In July 1997, an emergency contraception collaborative drug therapy agreement pilot project was launched in Washington. In the first 13 months of the project, 9,333 ECP prescriptions were provided, preventing between 504 and 2,100 pregnancies, about half of which would have ended in abortion. ("Pharmacists, Providers...," 1999). Similar programs have since started in Alaska, California, Hawaii, Maine, and New Mexico, and more states are considering legislation that would allow pharmacists to dispense emergency contraception without a prescription (Haddix, 2004).

• Improving women's access to emergency contraception does not increase women's reliance on it as a primary method of birth control. A study found that women who were given ECPs to take home used other birth control methods at the same rate as women who did not have the pills in their medicine cabinets. Women who had the pills at home were more likely to use emergency contraception once. But they were not more likely to use it repeatedly. Women who had home access to ECPs used the method correctly 98 percent of the time and had fewer unintended pregnancies than those who did not have ECPs at home (Glasier & Baird, 1998).

Studies have shown that improving access of ECPs to teenagers increases their use of emergency contraception without reducing the use of regular contraceptive methods.

• A study of adolescent mothers examined the impact of giving teenagers ECPs before they need them. One group of teen mothers received education about ECPs and were given an advance supply of the pills. Another comparison group received only education about ECPs. Eighty-five percent of the group that received the pills used ECPs, as compared to only 19 percent of the education-only group. The group that received ECPs were not more likely to report having unprotected sex within the six months following receipt of the pills (Belzer, et al., 2003).

• Another study about advance provision of ECPs to adolescents had similar findings — the teenagers were more likely to use ECPs they received, and their use of condoms did not decrease after having the pills at home (Roye & Johnsen, 2001).

• A more recent study substantiated the findings of previous studies on advance provision. Adolescent women, aged 15 to 20, were randomized into two groups — one group received ECPs and education about emergency contraception and the comparison group received education alone. In the first month of the study, the teens in the group that received the pills were twice as likely to use ECPs as the comparison group. They also took the pills an average of 10 hours sooner than the teens in the education-only group — an important finding given the timely nature of ECPs’ efficacy. The two groups did not differ in their rates of hormonal contraceptive use at the six month follow-up. Notably, the group that received the pills were more likely to report condom use at six months than the education-only group (Gold, et al., 2004).

Efforts to Improve Access to Emergency Contraception

France became the first country in the world to distribute its brand of ECPs, known as NorLevo®, in pharmacies without prescription or parental consent. NorLevo is also distributed free-of-charge along with other methods of contraception at family planning centers (Ollivier, 1999).

In January 2000, France's Deputy Education Minister, Segolene Royal, took the unprecedented step of granting its school nurses the right to dispense ECPs in both junior and high schools (Daley, 2000; McNeil, 2000). The initiative was accompanied by a nationwide sex education campaign that included information on emergency contraception. Provision of ECPs in schools received widespread support from students, health practitioners, and the union of school nurses (Ollivier, 1999; McNeil, 2000).

However, in July 2000 the Council of State, France's highest administrative court, overruled this decision citing a 1967 law that says hormonal contraception may only be distributed under prescription by pharmacies. The ruling followed a strong show of opposition by the Catholic Church and was lauded by the National Confederation of Catholic Family Associations, which also expressed regret that the court did not take additional steps to reaffirm parental authority in such matters (McNeil, 2000). In October 2000, the French Parliament amended the law to once again allow school nurses to dispense emergency contraception (Kolata, 2000).

Restrictions on the dispensing of emergency contraception are easing in other countries as well. Women in Albania, Belgium, Denmark, Finland, Israel, Morocco, Norway, Portugal, South Africa, Sweden, the United Kingdom, and many other countries can obtain emergency contraception without a prescription (CRR, 2002).

Steps are being taken to make ECPs available over- the-counter in the United States. At public hearings held in June 2000, advocates including the National Women’s Health Network, the Reproductive Technologies Project, and the National Abortion and Reproductive Rights Action League testified at the FDA in support of reclassifying ECPs as over-the-counter drugs (“Advocates Testify…,” 2000). Prominent groups such as the American Medical Association and American College of Obstetricians and Gynecologists have since voiced support of
making ECPs available over-the-counter (ACOG, 2001; Foubister, 2001).

On February 14, 2001, the Center for Reproductive Rights filed a petition with the FDA on behalf of more than 70 medical, public health, and other organizations, to grant over-the-counter status to ECPs (CRR, 2003). No decision was ever issued for this petition. The makers of Plan B filed a second petition in 2003. In December 2003, two FDA advisory panels found that Plan B meets the criteria for availability without a prescription, and recommended granting over-the-counter status. Five months later, despite these recommendations, the FDA chose to deny the petition. A dozen members of Congress called for the resignation of key FDA officials for denying the over-the-counter petition based on political and ideological — not scientific — reasons. Forty-one members of Congress asked that the FDA reconsider its decision (Kaufman, 2004). The distributor of Plan B, Barr Pharmaceuticals, Inc., will continue working with health organizations and advocates to get the FDA to reverse its decision (Cox, 2004).

In light of emergency contraception’s history of safety and efficacy, The Planned Parenthood Federation of America strongly supports making ECPs available to women over-the-counter. We believe this is the best way to broadly increase access to emergency contraception, and consequently decrease unintended pregnancies and abortions in the United States.

Survey Shows High Levels of Support for Increased Access to Emergency Contraception in the U.S.

A survey conducted on behalf of the Reproductive Health Technologies Project found widespread support for emergency contraception among voters and licensed pharmacists in New Jersey and Oregon. Among its findings

• Approximately 60–70 percent of voters and pharmacists, including Catholics, support the idea of emergency contraception being widely available.

• The majority of pharmacists — 56 percent in New Jersey and 67 percent in Oregon — support adding ECPs to the protocol of drugs that they can prescribe directly for patients through collaborative drug therapy agreements.

• Eight in 10 New Jersey voters and seven in 10 Oregon voters oppose refusal clause legislation, which would allow pharmacists to refuse to fill prescriptions because of religious or moral objections.
(RHTP, 2000)

How to Get Emergency Contraception

To contact the nearest Planned Parenthood for emergency contraception, call 1-800-230-PLAN. For a list of other nearby emergency contraception providers, call the national Emergency Contraception Hotline, operated by the Reproductive Health Technologies Project, at 1-888-NOT-2-LATE. Provider information is also available on the Emergency Contraception Web site (http://www.not-2-late.com or http://ec.princeton.edu).

Emergency contraception may also be available in health clinics, the offices of private physicians, and in hospital emergency rooms.

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