Emergency Contraception (the "Morning After Pill")
Why it Matters in the Debate Over Abortion

Family North Carolina Magazine—March/April 2009

by Alysse ElHage

“So many men. So many reasons to have back up contraception.” —Caption in an ad promoting emergency contraception that was created by Woman’s Capital Corporation (the maker of Plan B). The ad, which ran in 30 college newspapers in 2002, featured a picture of 13 men.¹

In August 2006, after three years of heated debate, the U.S. Food and Drug Administration announced its approval of the emergency contraceptive, Plan B, (also known as the “morning after pill”) for non-prescription use by adult women. In an effort to address concerns about teenagers obtaining access to the drug, the FDA specified that it be kept behind the pharmacy counter. With proper identification, women and men ages 18 or older can now obtain Plan B directly from a pharmacist, while minors still need a doctor’s prescription in the majority of states.² While abortion advocacy groups such as Planned Parenthood applauded the FDA’s decision as a “historic event for the struggle for women’s reproductive health and rights,” pro-life physicians and pharmacists denounced it as poorly decided and dangerous for women.³

Emergency Contraception (EC) is heavily marketed to teens and college students as a “second chance” after sex to avoid pregnancy, and to the public as a way of reducing unwanted pregnancy and abortions. In states across the U.S., including North Carolina, advocacy groups continue to push for nonprescription access to EC for minors, and for laws that force pro-life pharmacists and hospitals to stock and dispense the drug, regardless of their moral and religious convictions.
What is EC, what does it have to do with abortion, and why does it continue to be an issue of contention in this country?

What EC Does

EC is a method of contraception that can reduce the risk of pregnancy after sexual intercourse has occurred—either through the use of higher doses of hormonal birth control pills, or by inserting an intrauterine device (IUD).⁴ The focus of this article is on EC pills that contain higher doses of the hormones found in regular birth control pills. “Plan B” is the market name of the only EC product approved by the FDA for use in this country.⁵ It is important to note that EC is not the same as the chemical abortion drug, RU-486, also known as the “Abortion Pill,” which causes the abortion of an unborn child up to 49 days after the last menstrual cycle.⁶

How EC Pills Work: Plan B consists of two tablets containing the hormone levonorgestrel. The first pill is supposed to be taken immediately (or within 72 hours of intercourse to be most effective), and the second is supposed to be taken 12 hours after the first. Although EC advocates advertise that the drug can be taken up to 120 hours (or five days) after intercourse, it is most effective when taken within 72 hours. According to the FDA, Plan B works in one of three ways:

• To prevent ovulation (“release of the egg from the ovary”);
  
• To prevent fertilization (the “uniting of the sperm with the egg”);
  
• To prevent implantation (“if fertilization does occur, Plan B may prevent a fertilized egg from attaching to the wall of the uterus”).⁷
  

EC and Abortion

The most contentious issue in the debate over Emergency Contraception is whether or not it can cause an early abortion. Plan B’s manufacturer, the FDA, and abortion advocates maintain that EC is not an abortifacient because it will not disrupt or interrupt an “established pregnancy.” However, one of the ways EC works, according to the FDA, is to prevent implantation.⁸

The question of whether EC can cause an abortion hinges on the definition of when pregnancy begins—does it began at fertilization or after implantation has occurred? The American College of Obstetricians and Gynecologists defines pregnancy as beginning after implantation.⁹ This is important because EC proponents use this definition of pregnancy to argue that EC does not cause an abortion because it works before implantation has occurred.

The prevailing opinion in medical science today is that life begins at fertilization, when the male’s sperm successfully unites with the female’s egg to produce a genetically complete human being in the earliest stage of development.¹⁰ “Terminating a human embryo is abortion, whether before or after its implantation into the uterus,” according to the 2,000–member American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG). Dr. Gene Rudd of the Christian Medical and Dental Association (CMDA) notes, “The ‘morning-after pill’ can end a developing human life.”¹¹

Pharmacists are at the center of the debate over EC. For some pharmacists who are pro-life, contraceptives that work to prevent implantation, such as EC, are abortifacient drugs, and dispensing such drugs to women makes them complicit in the possible murder of a developing unborn child. Some of these pharmacists also object to making referrals to other pharmacists who will dispense EC. According to Pharmacists for Life International, making a referral to another pharmacist who will dispense EC and other contraceptives is “material cooperation” in a morally objectionable act.¹²

A 2007 study by NARAL Pro-Choice North Carolina found that 40 percent of pharmacies in a statewide survey do not stock EC. The survey also found that one-fourth of the pharmacists said that EC “was the same as the abortion pill, with nearly five percent saying that EC caused an abortion.” Of the pharmacies who did not have EC in stock, 30 percent of the employed pharmacists refused to order it.¹³

EC and Women’s Health

Although abortion gets the most attention, it is not the only concern about EC. Some pro-life medical organizations, such as the CMDA and the AAPLOG, have raised questions about the possible misuse of the drug, particularly by young people, the health effects of repeat use, and misuse of the drug as a tool for statutory rapists to cover up their activity. Another important consequence of nonprescription access to EC is that it robs physicians of the opportunity to discuss sexual behavior, risks, and more effective contraceptive methods with their female patients. It also makes it more difficult for physicians to monitor their patient’s use of EC, and to intervene in cases where the drug might be misused. The role of the physician in prescribing contraceptives and counseling patients about their use is particularly important for college-age women, who are more at risk for unplanned pregnancy and STDs.

Sexual Risk-taking and STDS: A legitimate question in the debate over EC is whether easier access to the drug will lead to greater promiscuity and eventually an increase in sexually transmitted diseases (STDs). As previously noted, EC is heavily marketed to young people as a “second chance” or a way to avoid at least some of the potential consequences of last night’s mistake. For example, a message in a brochure created by the Pharmacy Access Partnership for adolescents in California contains this message: “You can prevent unplanned pregnancy—even after sex!” It also encourages teens to “have EC on hand before an accident happens.”¹⁴

In countries where EC has been easily available for years, such as the United Kingdom (UK), the rates of some STDs have increased, especially among young people.¹⁵ In one study of EC users in the UK, four out of 12 women said the fact that they could obtain EC from a pharmacy influenced their decision to have unprotected sex.¹⁶

Repeat Use: While EC advocates argue that most women will not use EC repeatedly, a 2004 study of EC use in North Carolina found evidence of repeat use among some women. The 29-month study analyzed data from the “Dial EC” project, a telephone prescription service operated by Planned Parenthood from February 2001 through June 2003 that provided over 9,000 EC prescriptions to over 7,000 callers.¹⁷

Pro-life advocates have raised concerns about the unknown negative health effects from long-term repeat use of EC. Regular birth control pills, which contain lower doses of the hormones found in EC, can cause a number of negative side effects, ranging from weight gain to depression. Some oral contraceptives have also been linked to more serious health risks for women, including blood clots, heart attack, and stroke.¹⁸

Statutory Rape: Another concern about EC is its potential misuse by adult men who are sexually involved with minor girls and provide them with EC to hide any traces of statutory rape. As noted earlier, EC’s nonprescription status means that adult men can purchase Plan B for their minor girlfriends without parental consent or knowledge.

Availability of EC

Between 2006 and 2007, annual sales of Plan B doubled from about $40 million to $80 million.¹⁹ A study published in the American Journal of Obstetrics and Gynecology (AJOG) in November 2008 found that in 2007, only eight percent of pharmacies in a three-city survey were unable to provide EC to patients within 24 hours, compared to 23 percent in 2005. While 18 percent of pharmacists in 2005 said they could not dispense EC because they did not carry the medication, only six percent said the same in 2007.²⁰ The pharmacist refusal rate (i.e., the percentage of pharmacists in these three cities who refused to stock EC) decreased by half during this time—from four percent in 2005 to two percent in 2007.

North Carolina: According to a 2007 study by NARAL Pro-Choice North Carolina, the majority of pharmacies in North Carolina stock Plan B. Another recent NARAL study concluded that, “most large, public schools [colleges] offer emergency contraception on-site.” Of the 46 colleges with student health centers in North Carolina, 18 “provide EC pills on-site”; two provide written prescriptions for EC; 19 refer students to another clinic that provides the pills; and four do not provide prescriptions, referrals or information about EC. Overall, 47 percent of North Carolina’s university student health centers provide EC on site or offer a written prescription for the pills.²¹

Pregnancy and Abortion

In their efforts to promote unlimited access to EC, advocates make two basic claims—(1) that it will reduce unplanned pregnancies and (2) that it will reduce abortions. However, several reproductive health researchers have recently raised questions about the effectiveness of EC to do either, pointing to studies in other countries where EC has been easily available for years.

Dr. James Stanford of the Department of Family and Preventative Medicine at the University of Utah, who has conducted several studies of EC, wrote in a January 2008 editorial published in Clinical Pharmacology and Therapeutics: “The zealous promotion of emergency contraception is based on the appealing idea of a second chance to prevent pregnancy rather than on evidence of its impact in actual studies or public health surveillance.”²² He cited a study in Scotland, where approximately 17,000 women were provided free EC pills and no difference in abortion rates were found in comparisons with women in surrounding communities. In addition, he noted that abortion rates in the UK have been increasing, despite over-the-counter access to EC since 2001.

Similar points were raised by EC advocate, Dr. James Trussell, director of the Office of Population Research at Princeton University, and Dr. Elizabeth Raymond in an October 2008 review of the latest data on EC. Trussell designed the national EC telephone hotline and maintains the Website Not-2-Late.com. According to Trussell and his co-author, “no published study has yet demonstrated that increasing access to ECPs [Emergency Contraceptive Pills] reduces pregnancy or abortion rates in a population, at least in part because even when provided with ECPs in advance, women do not use the treatment often enough after the most risky incidents to result in a substantial population impact.”

Consent and Conscience

Plan B’s manufacturer states on its website that the drug “can’t terminate an existing pregnancy,” and EC proponents continuously tell women the same in their promotional materials. However, as noted earlier, one of EC’s stated methods of working is to prevent a living embryo from attaching to the lining of the uterus after fertilization. For many Americans, including pro-life pharmacists, who believe that life begins at fertilization, this is nothing short of abortion.

“The FDA labeling states that the medication will not abort an implanted pregnancy, but allows that it may stop implantation of a fertilized egg (an embryo),” notes AAPLOG in a press release. “We object to this deceptive doublespeak … Adequate, informed consent dictates that the woman using this medication be plainly informed of this abortifacient potential.”²³

Women should be provided with accurate information about how EC works, including the fact that it can destroy a human embryo. In addition, the ability of women to access EC, or any contraceptive for that matter, should not trample the ability of pharmacists and other health care professionals to decline to stock and dispense a drug that violates their religious or ethical convictions.

Aside from the fact that there is little to no evidence that access to EC reduces unplanned pregnancies or abortion, there are safer ways to achieve these goals than promoting drugs that raise moral quandaries for many health care professionals and potentially put the wellbeing of women at risk. If national, state, and health leaders spent even half as much time, money and effort on promoting sexual purity on college campuses and in schools as they do promoting “quick fixes” for casual sex, there would likely be a dramatic decrease in the number of unplanned pregnancies, and there would be less need for EC. Instead of advertising a “back up” method of birth control, women would be better served by hearing the truth—that casual sex can lead to STDs, unplanned pregnancy, and emotional heartache, and that the best way to avoid these negative consequences is to postpone sex until marriage.

Endnotes:

1. Women’s Capital Corporation (Plan B), “So Many Men” poster, EC Outreach Materials: National/International Outreach Materials, Go2EC.org, as accessed at: www.GO2EC.org/ECOutreachMaterials.html
   
2. AGI PR, “Plan B Decision by FDA a Victory for Common Sense,” 8/24/06.
   
3. Cite planned parenthood PR
   
4. Planned Parenthood Federation of America, Emergency Contraception, Fact Sheet, January 2006, pg. 1.
   
5. Kaiser Family Foundation, “Emergency Contraception,” Fact Sheet: Women’s Health Policy Facts, November 2005, pg. 1.
   
6. N.C. Family Policy Council, “Two More RU-486 Deaths, FDA Issues Advisory,” Family Policy Facts, 3/24/2006.
   
7. Food and Drug Administration (FDA), “FDA’s Decision Regarding Plan B: Questions and Answers,” as found at: www.fda.gov/cder/drug/infopage/planB/planBQandA.htm
   
8. Op. Cit. Duramed (Plan B), “How Plan B Works;” Also: Op. Cit. Food and Drug Administration.
   
9. Gold, Rachel Benson. “The Implications of Defining When a Woman is Pregnant,” The Guttmacher Report on Public Policy, May 2005, pg. 8.
   
10. Earll, Carrie Gordan, “Emergency Contraception (Morning After Pill),” Bioethics/Sanctity of Human Life Quick Facts, Focus on Social Issues, Updated Jan. 19, 2006.
    
11. Rudd, Gene, MD. “The Morning-After Pill, Abortion and Informed Consent,” Christian Medical and Dental Association, 2001.
    
12. Pharmacists for Life International, “Why a Conscience Clause is a Must NOW,” www.pfli.org.
    
13. NARAL Pro-Choice NC, “Access to Emergency Contraception in North Carolina Pharmacies,” June 6, 2007.
    
14. Pharmacy Access Partnership, “EC Promotional Opportunities,” Teen Card, as accessed at: www.pharmacyaccess.org/ECPromotionalOpps.htm.
    
15. Op. Cit. Wright, “The Morning-After Pill: Why the FDA Was Right,” pgs. 6&7. Also: Letter to the Food and Drug Administration about Plan B, Gary L. Yingling, J.D. and Rebecca L. Dandeker, J.D. (on behalf of Concerned Women for America, Family Research Council, Christian Medical and Dental Association and the American Association of Pro-Life Obstetricians and Gynecologists), 11/1/05, pgs. 20-21 (Connection Between Plan B and STDs).
    
16. P. Bissell, R. Harness and A. Anderson, “The sale of emergency hormonal contraception in community pharmacies in the UK: The views of users,” International Journal of Pharmacy Practice, Suppl. (2002), pg. R47. Cited in: Wright, Wendy, Carol Denner, R.N, & Jill Stanek, R.N., “The Morning-After Pill: Why the FDA Was Right,” Concerned Women for America, pg. 8.
    
17. Raymond, Elizabeth, et. al., “The North Carolina DIAL EC project: increasing access to emergency contraception pills by telephone,” Contraception, v. 69 (2004) pg. 367-372.
    
18. “Birth Control Methods,” National Women’s Health Information Center, U.S. Department of Health and Human Services, Office on Women’s Health, pg. 8, www.womenshealth.gov.
    
19. AHC, “Update on Emergency Contraception: Has status change increased access?” Contraceptive Technology Update, September 2007.
    
20. Gee, Rebekah, Shacter, Hannah, Kaufman, Elinore, et. al. “Behind-the-counter status and availability of emergency contraception,”American Journal of Obstetrics and Gynecology, November 2008, pg. 478.e1.
    
21. Harlan, Sarah, MPH, “Emergency Contraception Availability in NC College and University Health Centers,” NARAL Pro-Choice North Carolina, NEED DATE
    
22. Stanford, James, “Emergency Contraception: Overestimated Effectiveness and Questionable Expectations,” Clinical Pharmacology and Therapeutics, v. 83, n.1 (2008) pg. 19-21.
    
23. Source: AAPLOG, “FDA Decision on Plan B Is Bad Medicine for Women,” AAPLOG News Release, 8/28/2006.