Emergency Contraception: Have We Come Full Circle?

Elizabeth Westley Francine Coeytaux and Elisa Wells

Asserting that emergency contraception is "not effective enough" begs two questions: what level of effectiveness is enough and who decides this - women or providers?

This article originally appeared in the journal Contraception.

Two decades ago, Dr. Felicia Stewart, then serving as
Medical Director of the Planned Parenthood affiliate in Sacramento California,
began her campaign to let out of the closet "America’s best-kept secret" –
emergency contraception. The method had been suppressed because many
providers thought the method was "not effective enough," or would lead women to
use it "too much" (in place of using other more effective methods). Advocates
disagreed, believing that emergency contraception could help some women prevent
pregnancy, that women could learn to use the method appropriately, and that
women had the right to this important option. When Dr. Stewart and other
women’s health advocates pushed to move emergency contraception "from secret to
shelf," they had women’s needs in mind – in particular the need for a method
that, unlike others, could be used after
sex and one that was safe enough to provide without the barrier of a medical
interface. The success of this twenty year effort is evident in the many
dedicated emergency contraception products now available worldwide, the
increase in women’s awareness and use of EC, and, in the United States, the
full-on direct to consumer marketing of emergency contraception by a
pharmaceutical company, not to mention the popularity of the method among
women.

Today, in the midst of this forward trajectory of
increased access and awareness, we have encountered a curve ball that has us
circling back to where we started. Recent analyses suggesting that emergency
contraception is not as effective in reducing unwanted pregnancy rates at a
population level as we once hoped seem to have put the brakes on funding
and have revived the original arguments that emergency contraception is "not
effective enough" to be promoted as an option and that women are "abusing" it,
using it repeatedly instead of using other more effective methods. Some in the
field have also again voiced concerns that by providing it directly to women we
are missing opportunities to provide women with a full range of reproductive
health services.

Our response to this recent
round of questioning is that emergency contraception still fills a unique and
important role in the mix of available contraceptive methods, that it is
effective enough to be promoted as a contraceptive option, and that women’s use
of the method does not constitute a problem (in terms of lower effectiveness)
but rather contributes in a positive way to every woman’s significant challenge
of how to avoid unplanned pregnancies over her lengthy fertile years.

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Emergency Contraception Is Unique

Emergency contraception is
unique and fills a much needed niche. It is the only
method a woman can easily use post-coitally, thus occupying a very critical
place in the array of currently available methods. The post-coital niche is
important not only for women who have had no control over their exposure to
sex, as in the case of sexual violence, but also for couples who find
themselves in need of contraception after sex. The growing sales figures for
emergency contraception in the United
States and around the world suggest that
significant numbers of women continue to need a post-coital method.

Some of the researchers who are concerned about the
"low-efficacy" of oral emergency contraceptives are now trying to promote
emergency IUD insertion as an alternative post-coital method. But the logistics
and cost of obtaining it make it an unrealistic option for most women.  And it ignores what many women tell us is the
biggest appeal of emergency contraceptive pills – the convenience of being able
to directly access the method without having to see a doctor or health care
provider.

Emergency contraception is one of only a few methods
that can be obtained without having to make an appointment for a medical office
visit. Women value the privacy, confidentiality, and convenience of accessing
emergency contraceptive pills through pharmacies, which are open long hours and
on weekends. The fact that women are willing to pay more for emergency
contraceptive pills than for a month of oral contraceptive pills requiring a
clinic visit and prescription should tell us a lot about what women want and
how our current family planning services are failing them.

Emergency Contraception Is Effective Enough

Asserting that emergency
contraception is "not effective enough" begs two questions: what level of
effectiveness is enough and who
decides this – women
or providers?

Our expectations for EC’s effectiveness were biased
upwards by an early estimate that expanding access to emergency contraception
could dramatically reduce the incidence of unintended pregnancy and subsequent
abortion. This estimate made a compelling story and is likely a key reason
why donors and others were willing to support efforts to expand access to EC.
Now that we realize that this was an overly optimistic calculation – not
because emergency contraception is ineffective in stopping pregnancy in
individual women who use it, but because women with enhanced access to
emergency contraception do not seem to always use it when they need it – we
seem unable to acknowledge that individual women have a right to use the
contraceptive method that best suits them, not the one that best contributes to
overall demographic indicators.  And we
seem to have forgotten that an important way to increase contraceptive coverage
and reduce fertility at the population level is by enhancing the choice of
contraceptive methods available.

While the exact effectiveness of emergency
contraceptive pills is difficult to determine (estimates range from 59
percent to 94 percent
), we know that using emergency contraception is more
effective than doing nothing.  Even a lower level of effectiveness is
valuable, both to the individual and at the population level. When we realized
that the typical effectiveness of condoms and pills was much lower than their
theoretical effectiveness, did we tell women to stop using them in favor of
more effective IUDs? Do we push everyone towards sterilization because it has
the highest level of real effectiveness? 
We do not for two reasons: because at the individual level, we recognize
this as coercive, and at the population level, we know that providing access to
a wide variety of contraceptive methods is an effective approach to helping a
diverse range of women meet their reproductive needs and desires. Why should
emergency contraception be held to a higher standard with respect to
effectiveness than other methods? And, why should any one method be held up as
a key to reducing the incidence of unplanned pregnancy and abortion when
numerous and complex factors influence these outcomes?

An even more important question is who should be
deciding what is "effective enough"? We tend to hear from policy makers and
providers that the best choices are always methods that are most effective and
have the smallest chance or user error. Yet, even though avoiding pregnancy is the motivation behind using
contraception, it is clear from the wide variety of methods in use that women
(and men) consider many factors when choosing a method. While some may
prioritize effectiveness, many consider other factors, including convenience,
privacy, insurance coverage, avoiding hormones, and the reputation – accurate
or not – of the method. Furthermore, the interplay of these factors changes
over the course of a woman’s life, explaining why the average woman uses
between three and four different contraceptive methods during her lifetime. If individuals have accurate information about the pros and cons of various
methods, shouldn’t they be the ones
to decide which will best meet their current needs?

Effectiveness also has been the main driver behind the
push to use emergency contraception to "bridge" women to other methods.  The idea behind "bridging" is to use the lure
of emergency contraception to then get women hooked into a more effective
method. Again, we need to look at the numerous reasons that affect
contraceptive choice (in addition to effectiveness) and let women determine
which methods best meet their needs rather than reinforce the policy maker and
provider-driven perspective that bridging should lead to a more "effective"
method. We also need to remember that effectiveness of methods depends on their
correct use and that in some instances, emergency contraception is the best method.

Women Need and Want This Option

Women’s health advocates have fought long and hard to
make "choice," not demographic indicators, the foundation of reproductive
health services. Emergency contraception is a prime example of a method that
expands choice, not only because it provides a unique post-coital opportunity,
but also because women can access it for themselves with minimal medical
supervision, an added
value that is clearly recognized by many.

We urge the reproductive health and donor communities
to not give up on emergency contraception just because it is not proving to be
as effective at the population level as we had once hoped. Instead, we need to
protect women’s access to this important choice and ensure that they have the
information they need about where it fits in the array of available
contraceptive methods. With information and access, women can decide for
themselves how emergency contraception fits into their plans to avoid an
unintended pregnancy.

We also urge the reproductive health community to
continue to learn from the experience of promoting EC. We need to find out more
about what women like about emergency contraception and why they are willing to
accept its lower effectiveness and high cost compared with other methods. We
need to better understand women’s perceptions about EC’s effectiveness and what
information is helpful to women in comparing the choice of emergency
contraception with other methods. We need to ask what we can do to help couples
use emergency contraception most effectively and, possibly, avoid the cost of
using it when it will not be effective. The way forward is clear – we need to
continue to ease women’s informed access to this unique and important method
while doing a better job of assisting them in using it effectively. 

Fortunately for women, emergency contraception is no
longer a secret. While it is far from perfect, it remains an important option
for the many women who may have occasion to need it. Let us continue to work
together to ensure that all women who need a "second chance" get it.

References Consulted

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    pills: a simple proposal to reduce unintended pregnancies. Family Planning Perspectives. 1992;
    24: 269-273.
  • Pillsbury B, Coeytaux F, Johnston
    A. From secret to shelf: how collaboration is bringing emergency
    contraception to women. Los
    Angeles: Pacific Institute for Women’s Health;
    1999; 32 p.
  • Blomberg R. Mainstreaming emergency contraception: a report to the
    board of the Compton Foundation on the Foundation’s Emergency
    Contraceptive Initiative, 2002-2007. Redwood
    City; 2008: 34 p.
  • Raymond EG,
    Trussell J, Polis C. Population effect of increased access to
    emergency contraceptive pills: a systematic review. Obstet Gynecol.
    2007; 109: 181-188.
  • Polis CB, Schaffer K, Blanchard K, Glasier A,
    Harper CC, Grimes DA. Advance provision of emergency contraception for
    pregnancy prevention. Cochrane Database Syst Rev. 2007; (2).
  • Landau SC, Tapias MP, McGhee BT. Birth control within reach: a national
    survey on women’s attitudes toward and interest in pharmacy access to
    hormonal contraception. Contraception.
    2006; 74: 463-70.
  • Jain AK. Fertility reduction and the quality of family planning services.
    Studies in Family Planning.
    1989; 20:1-16.
  • Trussell J, Raymond E. Emergency contraception: a last chance to
    prevent pregnancy. October 2008. Accessed March 24, 2009 at.
  • Raymond E, Taylor D, Trussell J, Steiner MJ. Minimum
    effectiveness of the levonorgestrel regimen of emergency contraception.
    Contraception 2004;69:79-81.
  • Rosenfeld JA, Everett,
    K. Lifetime patterns of contraception and their relationship to unintended
    pregnancies. Journal of Family Practice. 2000; 49: 823-828.

 

Culture & Conversation Human Rights

Let’s Stop Conflating Self-Care and Actual Care

Katie Klabusich

It's time for a shift in the use of “self-care” that creates space for actual care apart from the extra kindnesses and important, small indulgences that may be part of our self-care rituals, depending on our ability to access such activities.

As a chronically ill, chronically poor person, I have feelings about when, why, and how the phrase “self-care” is invoked. When International Self-Care Day came to my attention, I realized that while I laud the effort to prevent some of the 16 million people the World Health Organization reports die prematurely every year from noncommunicable diseases, the American notion of self-care—ironically—needs some work.

I propose a shift in the use of “self-care” that creates space for actual care apart from the extra kindnesses and important, small indulgences that may be part of our self-care rituals, depending on our ability to access such activities. How we think about what constitutes vital versus optional care affects whether/when we do those things we should for our health and well-being. Some of what we have come to designate as self-care—getting sufficient sleep, treating chronic illness, allowing ourselves needed sick days—shouldn’t be seen as optional; our culture should prioritize these things rather than praising us when we scrape by without them.

International Self-Care Day began in China, and it has spread over the past few years to include other countries and an effort seeking official recognition at the United Nations of July 24 (get it? 7/24: 24 hours a day, 7 days a week) as an important advocacy day. The online academic journal SelfCare calls its namesake “a very broad concept” that by definition varies from person to person.

“Self-care means different things to different people: to the person with a headache it might mean a buying a tablet, but to the person with a chronic illness it can mean every element of self-management that takes place outside the doctor’s office,” according to SelfCare. “[I]n the broadest sense of the term, self-care is a philosophy that transcends national boundaries and the healthcare systems which they contain.”

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In short, self-care was never intended to be the health version of duct tape—a way to patch ourselves up when we’re in pieces from the outrageous demands of our work-centric society. It’s supposed to be part of our preventive care plan alongside working out, eating right, getting enough sleep, and/or other activities that are important for our personalized needs.

The notion of self-care has gotten a recent visibility boost as those of us who work in human rights and/or are activists encourage each other publicly to recharge. Most of the people I know who remind themselves and those in our movements to take time off do so to combat the productivity anxiety embedded in our work. We’re underpaid and overworked, but still feel guilty taking a break or, worse, spending money on ourselves when it could go to something movement- or bill-related.

The guilt is intensified by our capitalist system having infected the self-care philosophy, much as it seems to have infected everything else. Our bootstrap, do-it-yourself culture demands we work to the point of exhaustion—some of us because it’s the only way to almost make ends meet and others because putting work/career first is expected and applauded. Our previous president called it “uniquely American” that someone at his Omaha, Nebraska, event promoting “reform” of (aka cuts to) Social Security worked three jobs.

“Uniquely American, isn’t it?” he said. “I mean, that is fantastic that you’re doing that. (Applause.) Get any sleep? (Laughter.)”

The audience was applauding working hours that are disastrous for health and well-being, laughing at sleep as though our bodies don’t require it to function properly. Bush actually nailed it: Throughout our country, we hold Who Worked the Most Hours This Week competitions and attempt to one-up the people at the coffee shop, bar, gym, or book club with what we accomplished. We have reached a point where we consider getting more than five or six hours of sleep a night to be “self-care” even though it should simply be part of regular care.

Most of us know intuitively that, in general, we don’t take good enough care of ourselves on a day-to-day basis. This isn’t something that just happened; it’s a function of our work culture. Don’t let the statistic that we work on average 34.4 hours per week fool you—that includes people working part time by choice or necessity, which distorts the reality for those of us who work full time. (Full time is defined by the Internal Revenue Service as 30 or more hours per week.) Gallup’s annual Work and Education Survey conducted in 2014 found that 39 percent of us work 50 or more hours per week. Only 8 percent of us on average work less than 40 hours per week. Millennials are projected to enjoy a lifetime of multiple jobs or a full-time job with one or more side hustles via the “gig economy.”

Despite worker productivity skyrocketing during the past 40 years, we don’t work fewer hours or make more money once cost of living is factored in. As Gillian White outlined at the Atlantic last year, despite politicians and “job creators” blaming financial crises for wage stagnation, it’s more about priorities:

Though productivity (defined as the output of goods and services per hours worked) grew by about 74 percent between 1973 and 2013, compensation for workers grew at a much slower rate of only 9 percent during the same time period, according to data from the Economic Policy Institute.

It’s no wonder we don’t sleep. The Centers for Disease Control and Prevention (CDC) has been sounding the alarm for some time. The American Academy of Sleep Medicine and the Sleep Research Society recommend people between 18 and 60 years old get seven or more hours sleep each night “to promote optimal health and well-being.” The CDC website has an entire section under the heading “Insufficient Sleep Is a Public Health Problem,” outlining statistics and negative outcomes from our inability to find time to tend to this most basic need.

We also don’t get to the doctor when we should for preventive care. Roughly half of us, according to the CDC, never visit a primary care or family physician for an annual check-up. We go in when we are sick, but not to have screenings and discuss a basic wellness plan. And rarely do those of us who do go tell our doctors about all of our symptoms.

I recently had my first really wonderful check-up with a new primary care physician who made a point of asking about all the “little things” leading her to encourage me to consider further diagnosis for fibromyalgia. I started crying in her office, relieved that someone had finally listened and at the idea that my headaches, difficulty sleeping, recovering from illness, exhaustion, and pain might have an actual source.

Considering our deeply-ingrained priority problems, it’s no wonder that when I post on social media that I’ve taken a sick day—a concept I’ve struggled with after 20 years of working multiple jobs, often more than 80 hours a week trying to make ends meet—people applaud me for “doing self-care.” Calling my sick day “self-care” tells me that the commenter sees my post-traumatic stress disorder or depression as something I could work through if I so chose, amplifying the stigma I’m pushing back on by owning that a mental illness is an appropriate reason to take off work. And it’s not the commenter’s fault; the notion that working constantly is a virtue is so pervasive, it affects all of us.

Things in addition to sick days and sleep that I’ve had to learn are not engaging in self-care: going to the doctor, eating, taking my meds, going to therapy, turning off my computer after a 12-hour day, drinking enough water, writing, and traveling for work. Because it’s so important, I’m going to say it separately: Preventive health care—Pap smears, check-ups, cancer screenings, follow-ups—is not self-care. We do extras and nice things for ourselves to prevent burnout, not as bandaids to put ourselves back together when we break down. You can’t bandaid over skipping doctors appointments, not sleeping, and working your body until it’s a breath away from collapsing. If you’re already at that point, you need straight-up care.

Plenty of activities are self-care! My absolutely not comprehensive personal list includes: brunch with friends, adult coloring (especially the swear word books and glitter pens), soy wax with essential oils, painting my toenails, reading a book that’s not for review, a glass of wine with dinner, ice cream, spending time outside, last-minute dinner with my boyfriend, the puzzle app on my iPad, Netflix, participating in Caturday, and alone time.

My someday self-care wish list includes things like vacation, concerts, the theater, regular massages, visiting my nieces, decent wine, the occasional dinner out, and so very, very many books. A lot of what constitutes self-care is rather expensive (think weekly pedicures, spa days, and hobbies with gear and/or outfit requirements)—which leads to the privilege of getting to call any part of one’s routine self-care in the first place.

It would serve us well to consciously add an intersectional view to our enthusiasm for self-care when encouraging others to engage in activities that may be out of reach financially, may disregard disability, or may not be right for them for a variety of other reasons, including compounded oppression and violence, which affects women of color differently.

Over the past year I’ve noticed a spike in articles on how much of the emotional labor burden women carry—at the Toast, the Atlantic, Slate, the Guardian, and the Huffington Post. This category of labor disproportionately affects women of color. As Minaa B described at the Huffington Post last month:

I hear the term self-care a lot and often it is defined as practicing yoga, journaling, speaking positive affirmations and meditation. I agree that those are successful and inspiring forms of self-care, but what we often don’t hear people talking about is self-care at the intersection of race and trauma, social justice and most importantly, the unawareness of repressed emotional issues that make us victims of our past.

The often-quoted Audre Lorde wrote in A Burst of Light: “Caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.”

While her words ring true for me, they are certainly more weighted and applicable for those who don’t share my white and cisgender privilege. As covered at Ravishly, the Feminist Wire, Blavity, the Root, and the Crunk Feminist Collective recently, self-care for Black women will always have different expressions and roots than for white women.

But as we continue to talk about self-care, we need to be clear about the difference between self-care and actual care and work to bring the necessities of life within reach for everyone. Actual care should not have to be optional. It should be a priority in our culture so that it can be a priority in all our lives.

News Politics

Debbie Wasserman Schultz Resigns as Chair of DNC, Will Not Gavel in Convention

Ally Boguhn

Donna Brazile, vice chair of the DNC, will step in as interim replacement for Wasserman Schultz as committee chair.

On the eve of the Democratic National Convention in Philadelphia, Rep. Debbie Wasserman Schultz (D-FL) resigned her position as chair of the Democratic National Committee (DNC), effective after the convention, amid controversy over leaked internal party emails and months of criticism over her handling of the Democratic primary races.

Wasserman Schultz told the Sun Sentinel on Monday that she would not gavel in this week’s convention, according to Politico.

“I know that electing Hillary Clinton as our next president is critical for America’s future,” Wasserman Schultz said in a Sunday statement announcing her decision. “Going forward, the best way for me to accomplish those goals is to step down as Party Chair at the end of this convention.”

“We have planned a great and unified Convention this week and I hope and expect that the DNC team that has worked so hard to get us to this point will have the strong support of all Democrats in making sure this is the best convention we have ever had,” Wasserman Schultz continued.

Just prior to news that Wasserman Schultz would step down, it was announced that Rep. Marcia Fudge (D-OH) would chair the DNC convention.

Donna Brazile, vice chair of the DNC, will step in as interim replacement for Wasserman Schultz as committee chair.

Wasserman Schultz’s resignation comes after WikiLeaks released more than 19,000 internal emails from the DNC, breathing new life into arguments that the Democratic Party—and Wasserman Schultz in particular—had “rigged” the primary in favor of nominating Hillary Clinton. As Vox‘s Timothy B. Lee pointed out, there seems to be “no bombshells” in the released emails, though one email does show that Brad Marshall, chief financial officer of the DNC, emailed asking whether an unnamed person could be questioned about “his” religious beliefs. Many believe the email was referencing Sen. Bernie Sanders’ (I-VT).

Another email from Wasserman Schultz revealed the DNC chair had referred to Sanders’ campaign manager, Jeff Weaver, as a “damn liar.”

As previously reported by Rewire before the emails’ release, “Wasserman Schultz has been at the center of a string of heated criticisms directed at her handling of the DNC as well as allegations that she initially limited the number of the party’s primary debates, steadfastly refusing to add more until she came under pressure.” She also sparked controversy in January after suggesting that young women aren’t supporting Clinton because there is “a complacency among the generation” who were born after Roe v. Wade was decided.

“Debbie Wasserman Schultz has made the right decision for the future of the Democratic Party,” said Sanders in a Sunday statement. “While she deserves thanks for her years of service, the party now needs new leadership that will open the doors of the party and welcome in working people and young people. The party leadership must also always remain impartial in the presidential nominating process, something which did not occur in the 2016 race.”

Sanders had previously demanded Wasserman Schultz’s resignation in light of the leaked emails during an appearance earlier that day on ABC’s This Week.

Clinton nevertheless stood by Wasserman Schultz in a Sunday statement responding to news of the resignation. “I am grateful to Debbie for getting the Democratic Party to this year’s historic convention in Philadelphia, and I know that this week’s events will be a success thanks to her hard work and leadership,” said Clinton. “There’s simply no one better at taking the fight to the Republicans than Debbie—which is why I am glad that she has agreed to serve as honorary chair of my campaign’s 50-state program to gain ground and elect Democrats in every part of the country, and will continue to serve as a surrogate for my campaign nationally, in Florida, and in other key states.”

Clinton added that she still looks “forward to campaigning with Debbie in Florida and helping her in her re-election bid.” Wasserman Schultz faces a primary challenger, Tim Canova, for her congressional seat in Florida’s 23rd district for the first time this year.