Emergency Contraception: Dispelling Media Myths and Misperceptions

Elizabeth Westley and Anna Glasier

Emergency contraceptive pills (ECPs) are now available in many countries, but have failed to have the desired impact on unwanted pregnancy rates. Why is this? Earlier barriers to access are becoming less and less prevalent. A market for ECPs has been demonstrated and numerous manufacturers and distributors are keen to supply ECPs products; in many countries they are starting to be mainstreamed into norms, pre-service training, and services.

This article is a collaboration between the World Health Organization (WHO), the International Federation of Obstetrics and Gynecology, the International Planned Parenthood Federation, and the International Consortium for Emergency Contraception and is republished with permisson from the WHO. Please scroll down for a fact sheet on EC’s safety at the bottom of the post.

Emergency contraceptive pills (ECPs) are now available in many countries, but have failed to have the desired impact on unwanted pregnancy rates. Why is this? Earlier barriers to access are becoming less and less prevalent. A market for ECPs has been demonstrated and numerous manufacturers and distributors are keen to supply products; in many countries they are starting to be mainstreamed into norms, pre-service training, and services.

Yet knowledge continues to be an important barrier in much of the world. This post-coital contraceptive method is still relatively unknown in many countries, according to DHS data and other country level surveys. A 2007 survey of adolescents in New York City schools revealed that fewer than half of these young people had heard about ECPs, despite extensive public outreach and media publicity surrounding their over-the-counter status in the US.

Even when knowledge of this type of contraceptive is higher, use often remains fairly low, as in the UK, where 91 percent of women had heard of “the morning after pill” but only seven percent had used it in the past year.  One reason for low correct use of ECPs is the very poor basic understanding of fertility, contraception, and pregnancy risk that seems widespread in both developed and developing countries. In France, a survey of women seeking abortion indicated that more than half were unaware of their pregnancy risk at the time that they became pregnant or could not identify specific act that led to the pregnancy; only a minority of women used ECPs. In the UK, a study of abortion and pre-natal care clients showed that ECPs were used by only one in ten women who definitely did not wish to become pregnant, and even fewer used the method every time they were at risk of pregnancy.

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Unfortunately, the already substantial misinformation that women have about pregnancy risk and ECPs (along with other contraceptive methods) is being compounded by recent media coverage of ECPs. “Besides side effects, like nausea, heavy bleeding, and cramps, regular use of the emergency contraception may cause infertility and in some instances increase the risk of cancer” declared one BBC story on emergency contraceptive pills in Kenya.  “EC [emergency contraception] comes with an increased risk for things like blood clots and hormone-related cancers, like many traditional forms of birth control,” stated a mainstream newspaper in the United States. These statements are factually incorrect, but unfortunately are widespread. Such negative and sometimes inflammatory media coverage only alarms women and may keep some from using the method when they most need it.

Indeed, media and public health can be a volatile mix. The potential association between childhood vaccination and autism proposed in one article in the Lancet in 1998 (and officially retracted in 2010) was picked up by media around the world, and led to resistance to vaccination, millions spent on studies and many years of research to refute the claim. The effects have persisted: a 2009 survey found that fully one quarter of American parents agreed that “some vaccines cause autism in healthy children” and more than one in ten had refused a vaccine for their child.

Today, the echo chamber that is the internet can quickly spread and amplify media stories, particularly if they are sensational. An email circulating for several years describes a “true story” of a woman who died of a stroke while on hormonal birth control; recently, this story morphed and now states “the cause of death–continuously taking the morning after pill.” The fear-mongering media coverage around ECPs is likely driven by concerns about “irresponsible” sexuality hiding behind false “scientific” justification for such concerns.

Public health and medical professionals cannot afford to ignore the role of today’s media. Accurate media coverage has played an important role in spreading the news about health risks, healthy behaviors, and new products; sensationalist and frightening coverage can have the opposite effect. In the case of levonorgestrel-alone ECPs, safety has been clearly demonstrated through countless studies and many decades of use: no new research needs to be conducted. The urgent question is how we can explain and disseminate the science in simple terms.

While countering every health-related rumor on the internet and inaccurate story in local newspapers and magazines is surely a fool’s errand, it is increasingly important to be ready with the facts when reporters, community members, and patients voice concerns. A team of experts from around the world has produced a short, simple statement on the safety of levonorgestrel-alone emergency contraceptive pills, responding directly to articles that appeared in mainstream media in 2009 and written for non-scientists.

Fact sheet on the safety of levonorgestrel-alone emergency contraceptive pills

Commentary Contraception

Cost, Inequality, and Misinformation: Why Generic Emergency Contraception Is Still Inaccessible for Many

Jazmine Walker

Though the FDA decision to permit generic EC pill manufacturers to sell their products over the counter represents a gain for those with the most access to resources, ultimately the decision reflects pharmaceutical manufacturing companies’ interests, rather than the lives of those most adversely affected by lack of access to EC.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

Recently, the U.S. Food and Drug Administration (FDA) permitted generic emergency contraceptive pill manufacturers to sell their products over the counter. This is seemingly great news for increasing the variety of emergency contraceptives accessible to people who need them and making them relatively affordable, but there are still barriers to access specifically for women and teens of color who disproportionately live in poor and segregated neighborhoods that are routinely vulnerable to reproductive rights and justice violations.

After years of litigation, in 2013 drug manufacturer Teva was granted a three-year exclusivity agreement that would allow its product, Plan B One-Step, to be the only emergency contraceptive (EC) sold over the counter without age restrictions. However, that changed in February when the FDA sent a letter to generic emergency contraceptive pill manufacturers that permitted them to sell their products over the counter because Plan B’s exclusivity agreement was deemed “too broad.”

To compensate for reversing its prior agreement with Teva, the FDA requires manufacturers of generics, such as My Way and Next Choice One Dose, to have a label that says “for ages 17 and up,” though people will not be required to show proof of age. Plan B will be the only emergency contraceptive pill without a “17 and up” label.

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Though the FDA decision represents a gain for those with the most access to resources, ultimately the decision largely reflects pharmaceutical manufacturing companies’ interests, rather than the lives of those most adversely affected by lack of access to EC. For example, following the FDA’s letter, Teva announced it would release its own generic called Take Action. It can do this because Teva still has exclusivity on the clinical trials that removed the age requirement from the label of its drug, and a U.S. appeals court ruled that drug companies can create and sell cheaper FDA-approved versions of their branded products, or generics, in 2005.

Despite not having to show proof of age to purchase, the age-restriction labels on My Way and Next Choice One Dose are confusing and misleading. A study released in December 2013, in which female researchers posing as 17-year-olds called more than 940 pharmacies, found that some 20 percent of pharmacy staff told callers that teens could not access emergency contraceptives at all. “That’s completely incorrect,” said the study’s lead author, Tracy Wilkinson. Of the remaining 80 percent of respondents, only about half of them got the exact age requirements for Plan B correct.

To test whether pharmacists were still spreading misinformation almost a year after Plan B was approved to sell over the counter without an age requirement, I called my own local pharmacy, which is less than a half of a mile from my apartment in Asheville, North Carolina. Unfortunately, the pharmacist told me it was sold behind the pharmacy counter, that I needed to show proof that I was 18 years old, and that my boyfriend could not purchase it for me—she said I had to come to the pharmacy and buy it myself. All of these assertions are false. In fact, Plan B is available in the “feminine hygiene” aisle at that particular pharmacy, without an age requirement—not to mention no gender requirement. My small “study” is not nearly as systematic as the one mentioned above, but it is an example of how pharmacists can spread misinformation that limits access to emergency contraception.

EC pills remain broadly misunderstood in terms of who has the right to access them. This misinformation can be devastating for poor women, especially poor women of color living in racially segregated neighborhoods. Women in these neighborhoods are much more likely to have limited pharmacy options and lack the means to travel to access necessary reproductive health care. For them, one phone call to what may be the only pharmacy to which they have access may represent their only real option for acquiring EC. Being rebuffed by a misinformed staffer when it is already difficult to reach a pharmacy may deter them from going to the pharmacy to check the accuracy of the pharmacist’s report. If pharmacists, people who are literally paid to know these rules, are unsure of the specifics, it is unreasonable to assume that many women will know enough to challenge or question them. Some women may even assume that those incorrect rules apply universally and avoid further investigation altogether, all because the constant rule-shifting and general vagueness of the regulations complicate the learning process.

Though the age label is nothing more than a bureaucratic necessity, it can be used as a deterrent. The label is not based on science or safety concerns for women and girls; it is strictly for the benefit of Teva’s bottom line as part of its exclusivity agreement with the FDA. As attorney Andrea Costello told the Guardian in 2013, “The administration is basically saying only those women who can afford to pay the monopoly price that Teva is going to demand have access to the morning-after pill.”

The lack of an age requirement label on Teva’s Plan B, Plan B One-Step, and eventually its generic Take Action give the company a virtual monopoly on the under-17 market—if, of course, teenagers can even afford the expensive drugs.

EC generics are only about 10 to 15 percent cheaper than Plan B One-Step, whose price averages $48. At their cheapest, the generics My Way and Next Choice One Dose will cost about $41. And Teva’s Take Action, the only generic on shelves without an age restriction, will cost $40. EC pills are cheap to manufacture; the price seems to be driven largely by corporate financial interest. Similar levonorgestrel-based emergency contraceptive pills average €15 (about $20) in Europe. The FDA’s approval of emergency contraceptive generics may encourage other manufacturers to enter the market and drive down costs, but it is still unclear whether prices in the United States will ever be as low as those in Europe.

In the meantime, women and girls are not offered consistent financial assistance for emergency contraceptives, which means the financial burdens will fall disproportionately on low-income women and teens of color who cannot afford to pay out of pocket for the drugs (that’s if they can even reach a pharmacy). The Affordable Care Act does not require insurance companies to cover non-prescription emergency contraceptives, and state Medicaid programs have varying policies surrounding emergency contraceptive coverage. Only eight states cover non-prescription EC on Medicaid. The majority of state Medicaid policies require a prescription, but Medicaid in states like Florida, Texas, South Carolina, and Mississippi do not cover emergency contraceptives under any circumstances. This means that women who are not fortunate enough to have insurance that will pay for non-prescription emergency contraceptives must pay for it themselves, which can be difficult, especially for low-income teenagers, who may see a $40 price tag for a contraceptive as an insurmountable obstacle.

Emergency contraceptives may not accommodate all bodies, but the availability of generics is supposed to increase access for people who need them. Low-income women and teens of color need them. Unfortunately, maintaining profit margins again proves to be more important than the best interests of women and girls as they are left incapable of exercising their human rights to make healthy decisions about their reproductive lives.

Analysis Contraception

Clearing Up Confusion: Emergency Contraception and Weight

Martha Kempner

Rewire takes a look at the recent media storm around emergency contraception and weight and explains what readers need to know about the research.

Recently, there has been a lot of discussion in the news about emergency contraception pills and whether they are effective for women over a certain weight. Below is Rewire‘s explanation of why this story came to light, and what women who may need emergency contraception now or the future should know. 

Why is everyone talking about weight and emergency contraception right now?

A few weeks ago, a European manufacturer of emergency contraceptive pills identical to some of those on the market in the United States announced it was changing its labeling to add a caution that the product is less effective in women with a higher body mass index (BMI). This decision was based, at least in part, on the company’s own research, but there is other published research that has found the same thing. The media picked up the story and questioned whether the Food and Drug Administration (FDA) was going to ask or require U.S. manufacturers to make the same labeling change.

Remind me: What is emergency contraception?

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Emergency contraception is birth control that is used to prevent pregnancy after a couple has unprotected vaginal intercourse. In order to be effective, emergency contraception has to be used within 120 hours of unprotected sex.

Emergency contraceptive pills (ECPs) are taken orally and work by preventing ovulation and therefore pregnancy. There are two types of ECPs on the market in the United States. The first type is referred to as LNG pills because they rely on a synthetic version of the hormone progesterone called Levonorgestrel. LNG pills are sold under the brand name Plan-B One Step as well as the generic versions Next Choice One Dose and My Way. This is the type of ECP that is available over-the-counter to women of all ages in the United States. This is also the type for which the label was changed in Europe. The other type of ECP relies on a chemical called Ulipristal acetate (UPA) and is sold under the brand name Ella. This is not available over-the-counter.

It is also possible for a woman to have a copper intrauterine device (IUD) inserted into her uterus after unprotected sex, which can prevent pregnancy and also continue to act as a birth control method for up to ten years. Copper IUDs are more than 99 percent effective at preventing a pregnancy when inserted on an emergency basis. IUDs, however, can be very expensive and must be inserted by a health-care provider, which makes it difficult, if not impossible, for many women to access this method, especially within the 120-hour window.

What is the research on ECPs and weight?

In 2011, researchers analyzed two randomized controlled trials on the efficacy of LNG and UPA pills to try to understand why emergency contraception does not always work. They found timing to be the most important predictor of whether ECPs would work—how close a woman was to ovulation when she took the pills. However, they also found that ECPs were significantly less effective in women who were overweight or obese. Specifically, they found that women with a BMI of 30 or greater who used either kind of ECP became pregnant more than three times more often than women who were not obese.

The analysis found differences between the two types of pills. UPA pills were effective in women with a BMI of up to 35 but LNG pills lost efficacy at a much a lower BMI. In fact, pregnancy rates among women with a BMI of 26 or higher who took LNG pills were no different than would have been expected had they not used EC at all.

Body mass index is a way to determine obesity based on an individual’s height and weight. A BMI of under 25 is considered healthy, between 25 and 29 overweight, and 30 and over obese. As an example, a woman who is 5′ 6″ and 160 pounds would typically have a BMI around 26, whereas a woman who is 5′ 2″ and 160 pounds would have a BMI of over 30. The average weight for U.S. women is 166 pounds, and 35 percent of people in the United States are obese. Though BMI remains the most common tool used to measure obesity, there is an ongoing debate as to whether it is a reliable measure or a good indicator of overall health.

To put the research in terms of weight, which can be easier to understand, LNG pills seem to lose efficacy beginning at 165 pounds and become ineffective in women above 176 pounds.

Can’t women over a certain weight just take a higher dose?

As of now, there is no research to suggest that taking a higher dose of ECP pills would increase their efficacy, and it is not recommended that women do so.

Should women who are over a certain weight not use emergency contraception at all?

No. Health-care providers are still figuring out what the research really means and whether it should change what women do. Many think there isn’t enough research to recommend such a change yet. That said, it’s important that women know the research and discuss it with their provider, ideally before they need emergency contraception.

Women over 165 pounds who need emergency contraception may want to consider using UPA pills like Ella or getting a copper IUD inserted instead. As mentioned above, however, access to these methods, especially within the 120-hour window, can be difficult because they require a health-care provider either to write the prescription or to insert the IUD. They may also be cost prohibitive.

Women who cannot access these other methods quickly may want to considered using the LNG pills, as they may work and the side effects are minimal.

Will the FDA require label changes in the United States as well?

That remains to be seen. After the news of the label change in Europe, many people questioned whether the FDA would require a similar label change for Plan-B One Step and its generic equivalents. The FDA has told media outlets that it is reviewing the information and research and will make that determination in the near future.

Does this research apply to birth control pills as well?

Though some monthly oral contraceptives do rely on LNG, there is no research to suggest that birth control pills are ineffective in women over a certain weight or BMI. However, there is some research to suggest that the contraceptive patch may be ineffective in women over a certain weight; women using or considering the patch may want to talk to their health-care provider about that.