An Introduction to Emergency Contraception

By Mary Worthington

The debate concerning emergency contraception (EC) continues to rage.  The two main issues are 1) pharmacists' rights to refuse to dispense the drug and 2) over-the-counter status (OTC) for the drug.  In this article, I will briefly highlight some of the main points concerning this debate and specifically address the prescribing warnings and indications of "Plan B," which is the most popular name brand of EC. 

Pro-choice groups regularly lobby for and promote contraceptive use, including EC.  They claim that EC has the potential to prevent many abortions and even give advice on how to obtain the drug or dosing suggestions to make regular contraceptives into EC. [1]  Most pro-life groups do not have a position regarding contraception, however many pro-life groups have stepped forward in opposition to EC because its use can prevent the implantation of a fertilized human person, thus preventing pregnancy.  Several major pro-life organizations responded heartily to the Food and Drug Administration's call for guidance in considering OTC status to EC. 

EC is nothing new.  The first EC, also called the morning-after pill, Preven, hit the market in the United States in 1998 after being approved by the FDA.  Other forms of EC have included Ovral and Yuzpe. 

What's behind the EC debate

According to the medical encyclopedia provided by the National Institutes for Health, "the first trimester of pregnancy begins when a fertilized egg implants into a woman's uterus."  A clarification is given that "this occurs about 7 days after the egg is fertilized." [2]  Philosophical, theological, ideological, medical and scientific opinions rarely agree whether the fertilization of a new human being at the point of union of sperm and egg is cause for the protection of that life, hence the confusion whether preventing implantation is ethically sound or not.  As mentioned earlier, EC can prevent both ovulation and implantation.  All chemical contraceptives, including the IUD, have this abortifacient effect as well. 

Because of this abortifacient effect, many pharmacists feel uncomfortable with dispensing EC and hormonal birth control pills.  More and more pharmacists are coming forward to refuse to dispense pills.  This has caused many pro-choice groups and abortion providers, such as Planned Parenthood, to engage in campaigns to assert political pressure that requires pharmacists to fill prescriptions despite conscientious objections. 

In July, 2005, Illinois governor Rod Blagojevich issued an executive order that required all pharmacists in the state to fill contraception prescriptions and required all insurance companies to cover such prescriptions.  His actions have caused other states to look at similar programs, but have also put the governor under fire.  Several pharmacists from a Walgreens who were fired for refusing to obey this law responded by suing the governor.  This story is still developing. 

A closer look at Plan B

Though the Plan B prescribing information warns that the drug is not a substitute for routine birth control, no mention is made therein of determining when a woman is ovulating as an indication for taking the regimen.  On the contrary, its use is suggested "after known or suspected contraceptive failure or unprotected intercourse." [3]  A woman fearing pregnancy therefore could potentially take the Plan B regimen several times per month.  Of these several times, perhaps only one is during her naturally fertile time.  Multiple dosing introduces her body to dangerous overdosing.  The package warns against overdosing by saying, "Emergency contraceptives are not as effective as routine contraception since their failure rate, while low based on a single use, would accumulate over time with repeated use." [4] 

The effective ingredient in Plan B is the synthetic progestin levonorgestrel.  Two pills to be taken 12 hours apart, with the first taken as soon as possible after sexual intercourse, each contain .75 mg of levonorgestrel for a total of 1.5 mg.  The prescribing information for Plan B states uncertainty in how the regimen works, but suggests that it both prevents ovulation and implantation, but does not interrupt implantation once it has begun. 

Is levonorgestrel in other types of contraception?

Yes, levonorgestrel is present in several combined oral contraceptives.  In a daily dose of these contraceptive pills, there is between .10 mg and .15 mg of levonorgestrel combined with varying amounts of estrogen as active ingredients.  A Plan B dose of levonorgestrel is 12 to 15 times the daily dose of one of these combined contraceptives. 

Women's natural fertility cycle

In a healthy, normal cycle, ovulation occurs once per cycle and usually 14-16 days before menstruation.  Natural Family Planning specialists have found ways to determine the point of ovulation by monitoring body temperature, cervical mucus and discharge, natural hormones in blood levels and more.  Using these signs, the date of ovulation can be determined with certainty.  Monitoring these signs is often called charting, and it is a discipline that requires dedication and patience from the woman, her spouse and her physician.  When women are not educated about their bodies' natural cycles, they do not know how to react when artificial contraceptives fail, and may turn to EC, even when it is not necessary.  This is one more reason why EC is dangerous to women's health, and therefore, unacceptable.

Warnings for OTC status of EC

Following a January 2005 study of EC in the Journal of the American Medical Association, the American Association of Pro-life Obstetricians and Gynecologists issued a release warning against OTC status for EC.  They called the idea "bad medicine," warned that stipulations for age would not be practical in real-world situations, and cited studies which showed that real-world use of EC did not decrease unintended pregnancy or abortion. 

Given the accumulating sound scientific evidence that OTC access to EC doesn’t impact unintended pregnancy or abortion rates, this accusation is simply reckless rhetoric and political grandstanding. Further, to continue to claim that OTC access will cut unintended pregnancy rates and abortions in half, when sound scientific evidence exists to the contrary, is to betray public trust.  [5]

Then, in August, 2005 the Food and Drug Administration called for input from the general public on the debate.  Concerned Women for America joined the American Association of Pro-Life Ob/Gyn's, Family Research Council, and Christian Medical Association to issue a thorough 37-page report [6]  The report responded to all of the major questions asked by the FDA with medical and legal reasoning. 

Conclusion

To date, 16 states including Colorado, Maryland and New York are considering measures to offer OTC status despite the FDA indecision.  With the help of legal teams, many pharmacists are boldly standing up against filling prescriptions for chemical contraceptives and EC.  This debate is likely to continue to rage for several years if not longer, especially in light of speculations that some or all surgical abortions may become illegal as the Supreme Court prepares to address the Partial Birth Abortion Ban of 2003.

ENDNOTES:

[1] Planned Parenthood, "Emergency Contraception — The Basics;" Nov. 2005; accessed Feb. 25, 2006. www.plannedparenthood.org/pp2/portal/files/portal/medicalinfo/ec/pub-emergency-contraception.xml.
[2] National Institutes of Health Medline Plus Medical Encyclopedia. "First trimester pregnancy;" updated: Apr. 20, 2003; accessed Feb. 25, 2006. www.nlm.nih.gov/medlineplus/ency/article/000887.htm.
[3] Prescribing information for Plan B.  Accessed Feb. 25, 2006.  www.go2planb.com/PDF/PlanBPI.pdf
[4] Prescribing information for Plan B.  www.go2planb.com/PDF/PlanBPI.pdf
[5] AAPLOG press release on JAMA Emergency Contraception Study, Jan. 12, 2005; accessed Feb. 25, 2006. www.aaplog.org/newsreleaseEC011205.htm.
[6] GaryL. Yingling, J.D., M.S. and Rebecca L. Dandeker, J.D. "Comment to Docket No. 2005N-0345; RIN 0910-AF72" on behalf of Concerned Women for America, et al. Nov, 1, 2005; accessed Feb 25, 2006.  www.cwfa.org/images/content/planbfiling_CWA_%20FRC_e_%20al_11-01-2005.pdf
 

ABOUT THE AUTHOR

Mary Worthington is the co-founder of No Room for Contraception.  She has been active in the pro-life movement for six years, and has had a special interest in exposing the harms of contraception for the past ten years.  Mary is a graduate of Franciscan University of Steubenville with a BA in Theology and minor in Human Life Studies.