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
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
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.
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
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
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
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
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.
<< The New York Times -- 8/24/04 >>
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