THE RELIGIOUS CONSULTATION
on population, reproductive health & ethics

New York Times (USA), August 24, 2004

The Politics of Emergency Contraception

''Emergency Contraception: Politics Trumps Science at the F.D.A.''

That is the title of an editorial by Dr. David A. Grimes in the August issue of Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists.

Dr. Grimes is hardly the only one distressed by the Food and Drug Administration's decision in May to refuse to grant over-the-counter access to the morning-after emergency contraceptive known as Plan B.

Six months earlier, the agency's advisory committees voted 23 to 4 in favor of removing the requirement that a woman first obtain a prescription from a doctor before she can buy this product. In nearly all cases, the agency abides by the votes of its advisory panels. But not this time. And the reason, Dr. Grimes and other medical leaders have said, is that the agency's ''decision-making process is being influenced by political considerations.''

The politics in this case involve, indirectly, the Bush administration's advocacy of ''abstinence only'' to prevent pregnancy in unwed teenagers and, more directly, its objection to abortion, which emergency contraception is not. And Dr. Grimes points out that the rate of unplanned pregnancies in this country ''is unparalleled among industrialized nations,'' and that ''each year, nearly 2 percent of all women of reproductive age have an induced abortion.''

Women at risk of an unwanted pregnancy deserve to know the reasons that so many leading scientists and organizations have endorsed over-the-counter status for emergency contraception and the reasons that others have objected.

The Need for Intervention

Plan B is a progesterone-based after-the-fact contraceptive meant to be taken as soon as possible after a sexual encounter that places a woman at risk of pregnancy. It is supposed to be used within 72 hours after unprotected intercourse, but it is most effective when taken sooner, within 12 to 24 hours.

There are two other options that can be used when a woman needs postcoital contraception: a drug called Preven that is in effect a high-dose birth control pill, and insertion of a copper IUD, both of which also require a doctor's intervention.

There are many reasons a woman may need postcoital contraception. Condoms can break, diaphragms and cervical caps can become dislodged, IUDs can be expelled unknowingly and birth control pills forgotten.

In addition, some women, particularly teenagers, fail to anticipate a sexual encounter or may need to feel ''swept away'' and are thus unprepared to protect themselves against an unwanted pregnancy. And then there is rape resulting in pregnancy.

As Dr. Fatim H. Lakha and colleagues noted in the July issue of Women's Health in Primary Care, ''Unprotected sexual intercourse is a fact of life.'' When that happens, they said, ''unintended pregnancy can be prevented'' by the use of emergency contraception.

The Objections

Some opponents of emergency contraception confuse it with abortion. But an abortion can occur only after a pregnancy has been established. The National Institutes of Health and the obstetricians group define pregnancy as beginning with the implantation of a fertilized egg in the uterus.

Emergency contraception, on the other hand, has no effect once a fertilized egg implants in the womb. It cannot dislodge an established pregnancy or harm a developing embryo. Nor does it appear to work by destroying a fertilized egg or preventing implantation, which would negate the concerns of those who consider fertilization, not implantation, the start of pregnancy.

The mechanism of action of Plan B and Preven is not definitively known, but the evidence indicates that they delay or inhibit ovulation and make the cervical mucus inhospitable to sperm. A woman need not be ovulating at the time of intercourse to become pregnant. Sperm can live for several days in a woman's genital tract waiting for an egg to fertilize.

Another objection to emergency contraception is the fear that its ready availability would encourage teenage sexual encounters or foster careless sex among couples who might otherwise have used ordinary contraception.

To date, controlled studies have found no evidence that women would neglect to use precoital contraception in favor of an emergency contraceptive, especially since the former is a more reliable way to prevent an unwanted pregnancy.

Nor is there evidence that teenagers would be encouraged to engage in risky sexual behavior. ''This is analogous to suggesting that a fire extinguisher beneath the kitchen sink makes one a risky cook,'' Dr. Grimes wrote.

In fact, one study published this year in The Journal of Pediatric and Adolescent Gynecology found no increase in unprotected intercourse when young sexually active teenage girls were given easy access to emergency contraception through an advance prescription.

A third objection is that without a doctor to explain the proper use of emergency contraception, women, and especially teenagers, would fail to use it properly. Again, studies have shown that women who were able to self-administer emergency contraception did so correctly and at the proper time and suffered no adverse effects.

An Interim Solution

Any delay in reaching a doctor, getting a prescription for emergency contraception and finding a pharmacy that stocks the drug can render it ineffective. Without any intervention, the average woman's chance of becoming pregnant after one act of unprotected intercourse is 8 percent. When Plan B is used within 24 hours of unprotected intercourse, the pregnancy rate is about four-tenths of 1 percent, or 4 per 1,000, rising to 2.7 percent when treatment begins 48 to 72 hours after.

Proper use of emergency contraception, on average, reduces the risk of pregnancy by about 85 percent, and more if the treatment is used within 12 hours. Side effects with Plan B are minor -- nausea in about 15 percent of cases, vomiting in 1 percent and a delay in the next menstrual period in 5 percent.

Side effect rates are higher with Preven, which includes an estrogen component as well as a progesterone.

Unless the F.D.A. allows Plan B to be sold without a prescription, advocates for easy access to the drug advise women to get a prescription from their doctors and fill it well before they need it. Unfortunately, few teenagers would be likely to take such a step, unless they are already receiving regular gynecological care. In addition, the added cost of a medical visit can make access to Plan B prohibitive for many women, especially teenagers.

Six states, including California and Washington, have laws that allow a woman to buy emergency contraception from a pharmacist without a prescription. Other states might consider following suit.

Still, education must coincide with access. Even in California, only 29 percent of the women most at risk of an unintended pregnancy were aware of emergency contraception, according to a new study in The American Journal of Obstetrics and Gynecology.

Finally, every woman must realize that emergency contraception is a backup, not a substitute for more reliable precoital contraception. Emergency contraception is not as effective in preventing pregnancy as, say, oral contraceptives, implants or the copper IUD. And if, after using emergency contraception, a woman fails to menstruate within three or four weeks, she is advised to take a pregnancy test, which is included in the emergency contraceptive packet.

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