The idea of a morning-after pill is not new. For years doctors have known that high doses of the hormones found in birth-control pills, taken within 72 hours after sex, can prevent pregnancy. By mixing and matching packages of birth-control pills, doctors created the appropriate dosage themselves. Now, two brand-name morning-after pills are available, marketed specifically to prevent pregnancy and with markedly fewer side effects than makeshift methods.; ;
The challenge now facing the health-care profession is to get the word out.
About a year ago, Planned Parenthood of Greater Orlando received an emergency-contraception public-awareness grant. "We used to get maybe one call a day" about the morning-after pill, says CEO Sue Idtensohn. After running radio and television educational spots, "Now we get eight or 10 calls a day."
This goal of educating women about emergency contraceptive pills was high on the agenda as the American Medical Association held its semiannual meeting Dec. 3-6 in Orlando. The first order of business for the AMA's Committee on Medical Service and Health System Reform was to discuss a report advocating ways to increase access to emergency contraception.
"This is an important report," said Marilyn Laughead, a delegate from the American College of Obstetricians and Gynecologists. She noted that 50 percent of unintended pregnancies end in abortion, and that emergency contraception could lower that number considerably. She also endorsed the report's recommendation that emergency contraception eventually be available over the counter. "This is probably safer than some [over-the-counter medicines] that we have right now," she said.
There are two brand-name emergency contraceptive pills, Preven and Plan B (as in, if plan A doesn't work, go to plan B). In February 1997 the U.S. Food and Drug Administration declared emergency contraceptives to be safe and effective. Preven and Plan B are currently available only through a prescription, although a pilot program in the state of Washington allows women to get the pills directly from a pharmacist. Four other states have similar programs in the works.
The need to first get a prescription and possibly a physical exam causes significant limitations for the use of morning-after pills, which are meant for use within three days after unprotected sex, condom disasters or rape. The AMA report notes: "For women who have limited access to health care services, who are uninsured, and who have no established relationship with a physician, these requirements can be an overwhelming obstacle." The earlier in the 72-hour period that the pill is taken, the more effective it is.
Consequently, the AMA report offers several recommendations, including encouraging physicians to discuss emergency contraceptives as part of routine family-planning counseling; enhancing efforts to make the pill more accessible, and even requesting the FDA to make the pills available over the counter, on pharmacy shelves next to aspirin, cough syrup and condoms.
Planned Parenthood has made a similar request to the FDA. "A lot of women will come to the clinic because they sort of know about it," says Idtensohn. Rather than this vague sense of the pill's existence, Idtensohn wants to get the pill "into the lexicon of women's medical information." At the Orlando clinic, she explains, patients can get an on-site prescription and receive Plan B right away.
Idtensohn notes that when a "morning-after pill" is mentioned, many people -- doctors as well as patients -- confuse it with RU-486, the abortion pill. This mix-up has had a specific, unfortunate result: WalMart pharmacies won't carry emergency contraception, and in some rural areas WalMart is the only pharmacy available. (The Orlando Planned Parenthood clinic does not provide abortions and does not carry RU-486.)
At the AMA meeting, Deborah Johnson, a delegate from the American Medical Women's Association, emphasized what she called "the ABCs" of health care: Access, what's Best for the patient, and Cost. "Certainly no one wants a woman to get pregnant when it's unintended," said Johnson, adding that contraception is much less medically complicated than pregnancy.
While the report was generally praised, a few people raised specific concerns. For example, making the pill available over the counter might actually make it less accessible to low-income women, since Medicaid for the most part pays for prescriptions but not for over-the-counter drugs. Others questioned whether the AMA should even be involved in FDA actions.; ;
The strongest objection came from Kissimmee family physician John Littell, who voiced what Idtensohn called "the tinge of it being an abortion pill." Littell balked at the fact that the report calls the pills "contraception." "Most people accept that the sperm meeting the egg is the moment of fertilization, the beginning of human life," said Littell. Depending on when pills like Preven and Plan B are taken, they might prevent ovulation, which would mean that sperm and egg never come in contact. But if taken after ovulation, the pills would prevent a fertilized egg from being implanted. That's not contraception but rather an abortifacient, insisted Littell, a regional director for the Catholic Medical Association.
"I don't deny women the right to get an abortion," said Littell. "They just need to know what they're doing."
Joseph Annis, a member of the AMA council that wrote the report, agreed that the mechanism for how the pill works is "up in the air." "I must admit a personal conflict of interest with my religious background," said Annis. "But I put that aside in the interest of patient access."