Emergency Contraception

A NextGen Focus on Your Health

Plan B, a form of emergency contraception often called the "morning-after pill," has been making headlines recently as the subject of a series of controversial FDA decisions. With nearly sixty million potential consumers in the U.S., it is also a "very fundamental public health issue," and if widely used it has the potential to decrease the number of unintended pregnancies annually by up to 1.5 million. (1) Yet not many people understand or even know about emergency contraception, and few healthcare providers ever discuss it with their patients. (2)

What is emergency contraception, how is it understood and misunderstood by the general public, and why is it particularly relevant for young adults? Why do so many medical and public health organizations, as well as women's health advocates, strongly support increasing access to it? Why do other groups have moral and ethical objections to its widespread use? The Next Generation invited Carolyn Westhoff, M.D., Professor of Obstetrics and Gynecology and Public Health at Columbia University, to help address these questions.

Unlike regular contraception, emergency contraception prevents pregnancy when taken after unprotected sexual intercourse. The predominant form in the U.S. is Plan B, which consists of two tablets containing high doses of levonorgestrel, the ingredient in many conventional birth control pills. Plan B is known as the "morning-after pill" because it is most effective if used as soon as possible after intercourse, within 72 hours at most. (3) If used within 72 hours, emergency contraception like Plan B may reduce the likelihood a woman will get pregnant by up to 90 percent. (4)

Given the importance of taking emergency contraception as soon as possible after intercourse, the prescription-only status of emergency contraception is a major factor in women not using it even when they are at risk of an unintended pregnancy. A woman who wants to get Plan B must in most cases contact a doctor's office, schedule an appointment, go to the appointment and get a prescription, get to a pharmacy, and get the prescription filled, all within the narrow window of Plan B's effectiveness. Some hospitals or physicians may refuse to prescribe emergency contraception; some pharmacists may refuse to fill prescriptions for it. In these cases, for women without access to a physician, or for the many women who find themselves in an at-risk situation and must try to get a prescription on weekends, the obstacles to getting emergency contraception on time are especially significant.

How does Plan B work? Dr. Westhoff notes that the process from intercourse to fertilization to implantation of the new dividing cells in the uterus is complex and not fully understood. There are many points in this process where Plan B might interfere: it may prevent or delay ovulation, it may prevent fertilization, it may prevent an egg from implanting in the uterus. (5) The FDA and NIH and other scientific organizations agree that pregnancy begins only after the cells have implanted in the uterus. Confusion about when pregnancy begins may inform the opposition to emergency contraception – many people who oppose EC do so because they believe it is an abortion pill. However, according to the definitions of pregnancy used by scientific organizations, EC only prevents a pregnancy, it does not end one.

Plan B was approved by the FDA for prescription-only use in 1999. In April 2003, the original makers of Plan B filed for over-the-counter status, which would provide easier and faster access to the pill. The status change has been supported by health organizations including the American Medical Association, the American Academy of Pediatrics, and the American Public Health Association; it was also endorsed by the FDA's own advisors. (6) However, the FDA rejected this application in May 2004, citing the lack of sufficient numbers of young teen study participants. After maker Barr Laboratories reapplied in July 2004, proposing that Plan B only be available over-the-counter for women over 16 years old, the FDA repeatedly postponed a final decision, going against its own agency rules and policies and drawing the ire of supporters of emergency contraception. The FDA has previously used the behavior of older study participants to predict that of younger adolescents, and recent studies have suggested that not only do younger adolescents understand how to use Plan B appropriately, but also access to Plan B does not lead to increased or riskier sexual activity nor to decreased use of regular contraception, contradicting main contentions of those who oppose greater access to emergency contraception. (7)

On November 15, 2005, the FDA finally rejected Barr Laboratories' application, over two years after the original application was filed. This latest decision has provoked an outcry among physicians and others who believe that it was politically rather than scientifically motivated. An independent investigation by the United State Government Accountability Office called the decision-making in this case "unusual" and the FDA's rationale "novel," and Susan Wood, the director of the Office of Women's Health at the FDA, resigned in protest, saying that an FDA decision against the advice of both advisory committees and review staff is completely unprecedented. (8) Observing the current controversy, Dr. Westhoff is cautiously hopeful about the future of Plan B: "I'm a pessimist about it getting approved for [over-the-counter] over the next couple years," she says, "but I don't think the game is over. There are a lot of involved parties who are going to keep pushing the issue around."

Furthermore, Dr. Westhoff says, people need to understand that "[emergency contraception] is safe. A person can't mess it up. Anyone can decide for herself if she needs it, she doesn't need a specialist to decide." By comparison, drugs such as aspirin and acetaminophen (Tylenol) that are currently available over-the-counter can be fatal if used incorrectly. (9)

What else do young people in particular need to know about emergency contraception? First, because female fertility is highest between the ages of 19 and 26, the chances of a woman of this age becoming pregnant from even one act of unprotected sex within two days of ovulation is as high as 50 percent. For women of all ages in one large study, the risk of pregnancy was only 8 percent. (10) However, campus health centers may not provide emergency contraception, or it may be more difficult to get a prescription in a timely fashion. According to a 2002 survey by the Feminist Majority Foundation, 39 percent of non-religious college health clinics do not provide emergency contraception, and 84 percent are not open on weekends. (11) [Find out more about access to emergency contraception at your campus health care center.] Young women may also be more at risk for unprotected sexual intercourse, especially sexual assault: about 9 percent of high school students report having been raped, and up to 25 percent of college women have experienced rape or attempted rape. Half of all rapes of women are of teenagers under the age of 18. (12) Finally, 52 percent of abortions in the US are for women under the age of 25; of these, 33 percent of all abortions are for women aged 20 to 24 and 19 percent are for women 19 and younger. (13) Since emergency contraception use could help prevent up to 700,000 of the pregnancies that end in abortion every year, it is important for young women especially to have knowledge about and access to emergency contraception. (14)

However, studies have shown that even when emergency contraception is available, it is "very underutilized," says Dr. Westhoff. Especially for young people, there is "no norm here for people to automatically think of" emergency contraception after unprotected sex. Dr. Westhoff compares the encouragement of this "positive health behavior change" to the repetition of information crucial to sex education, as well as to the "multi-modal approach" of smoking cessation and prevention campaigns. Factors such as reduced cost, physician advice, and social marketing (through media such as magazines and billboards) would all help women to understand emergency contraception and come to regard it as an important option. Most of all, "You need an environmental situation that's conducive [such as] actually having it available in drugstores so it's there when you need it. And having it OTC would be a great opportunity to add in educational material, so it can become part of that whole multi-modal approach to encouraging additional health behavior change." As a gynecologist and epidemiologist, where does Dr. Westhoff think emergency contraception should ideally be available for the best individual and public health outcomes? In every pharmacy, she replies, "right up there with the chewing gum." 

Miya Bernson is an Associate Editor for the Next Generation and a member of the Harvard College Class of 2006.

Carolyn Westhoff, M.D. is a Professor of Obstetrics and Gynecology and Public Health at Columbia University.

  1. Dr. Carolyn Westhoff; http://www.kff.org/womenshealth/3344-03.cfm. (Text)
  2. Kaiser Family Foundation, 2004 Kaiser Women's Health Survey, July 2005. Cited in http://www.kff.org/womenshealth/3344-03.cfm. (Text)
  3. Plan B. Washington, D.C.: Women's Capital Corporation, 2003 (package insert). (Text)
  4. Rodrigues I et al., Amer. J of Ob/Gyn, 2002. Cited in http://www.kff.org/womenshealth/3344-03.cfm. (Text)
  5. Westhoff; http://www.kaiseredu.org/topics_im.asp?id=400&imID=1&parentID=72. (Text)
  6. AMA, Policy H-75.985, August 2005; APHA et al., Letter to Diane Stuart, 06 Jan 2005; and Center for Reproductive Rights, Emergency Contraception is Safer than Aspirin, List of Petitioners, February 2001. All cited in http://www.kff.org/womenshealth/3344-03.cfm. (Text)
  7. Wood A et al., N Engl J Med 2005;353:1197-9. (Text)
  8. Government Accountability Office, "Decision Process to Deny Initial Application for Over-the-Counter Marketing of Emergency Contraceptive Plan B Was Unusual." Publication GAO-06-109, November 2005; Wood S, N Engl J Med 2005;353:1650-1. (Text)
  9. Wood A et al., N Engl J Med 2005;353:1197-9. (Text)
  10. Wilcox A et al., N Engl J Med 1995;333:1517-21.; Baird D et al., Fertil Steril 1999;71:40-9. ; and Dunson DB et al., Hum Reprod 2002;17:1399-403. All cited in Westhoff C, N Engl J Med 2003;349:1830-5. (Text)
  11. http://www.feministcampus.org/network/health_centers/default.asp (Text)
  12. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance-United States, 2003. MMWR 2004;53(SS-02):1-96.; Fisher BS, Cullen FT, Turner MG. The sexual victimization of college women. Washington: Department of Justice (US), National Institute of Justice; 2000. Publication No. NCJ 182369.; and Tjaden P, Thoennes N. Full report of the prevalence, incidence, and consequences of violence against women: findings from the national violence against women survey. Washington: National Institute of Justice; 2000. Report NCJ 183781. All cited in http://www.cdc.gov/ncipc/factsheets/svfacts.htm. (Text)
  13. Jones RK et al., in Perspectives on Sexual and Reproductive Health, 2002, 34(5):226-235. Cited in http://www.guttmacher.org/pubs/fb_induced_abortion.html. (Text)
  14. Jones R et al., Perspectives on Sexual and Reproductive Health, December 2002. Cited in http://www.kff.org/womenshealth/3344-03.cfm. (Text)

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