Analysis Contraception

Plan B Becomes Available to Women of All Ages, But Everyone Should Have a Plan A

Martha Kempner

New decisions mean emergency contraception will soon be available over-the-counter to women of all ages.  While we celebrate this victory, we should also be using it as an opportunity to remind young people that there are much better ways to prevent pregnancy.

In the last few weeks, emergency contraception (EC) has gotten a lot of attention as the courts, the Food and Drug Administration (FDA), and the Obama administration worked out their differences (or put them aside) and agreed that one version of EC, Plan B One-Step, would be made available over-the-counter to women of all ages. This is a big step forward in efforts to expand access to contraception and, in turn, to prevent unintended pregnancies. Still, we have to remember that emergency contraception is not meant to be anyone’s primary method of birth control—it is taken after an act of sexual intercourse in which the couple forgot to use another method or used a method incorrectly, or in which the method failed. Here’s a quick review of methods that can be used effectively to prevent pregnancy.

Hormonal Methods

The birth control pill revolutionized contraception (and perhaps sexual relations) when it was introduced in the 1960s. Birth control pills were the first kinds of hormonal contraception. They work primarily by preventing ovulation (if there is no egg, there can be no fertilization and no pregnancy). Birth control pills and subsequent hormonal methods also thicken cervical mucus in order to prevent sperm from getting into the uterus.

Today, young women have numerous hormonal methods to choose from. The pill remains hugely popular, and there are many different kinds available; some run on a 21/7 cycle (meaning women take hormones for 21 days and then break for seven, during which time they get their period), others 24/4, and still others limit menstruation to just four times a year.

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For women who don’t want to swallow a pill every day or think they’ll have trouble remembering to do it, there are other hormonal methods that do not require daily action. The contraceptive patch, for example, which is sold under the brand name Ortho-Evra, is a bandage-like sticker that a woman wears on her upper arm, buttocks, back, or abdomen. It releases hormones through the skin. Women using the patch change it every week for three weeks. During the fourth week, they wear no patch and then get their periods.

Women can also choose the contraceptive ring. Sold as NuvaRing, this is a flexible piece of plastic that looks a little like a bracelet and is inserted into the vagina (the exact position isn’t important). It is left in for three weeks while it releases hormones. The user can then remove it, get their period, and put in a new one a week later. If inserted properly to begin with, most users don’t even feel it.

One of the older and more well-known hormonal methods is Depro-Provera, sometimes called the contraceptive shot. Women get an injection from their health-care provider every three months and are protected from pregnancy during that time.

If used perfectly, hormonal methods are all over 99 percent effective. People do make mistakes, however: they may forget to take a pill, forget to pick up a prescription for the patch, or forget to make an appointment to get a shot in time. For these reasons, the typical use failure rates are a little higher—they are between 91 and 94 percent effective. This means that out of every 100 couples who use hormonal methods, six to nine will experience an unintended pregnancy during their first year of use. Continuing users have lower rates of contraceptive failure than first-year users, as they become more accustomed to use.

Long-Acting Reversible Contraception (LARC) Methods

Contraceptive implants, which are now sold under the brand names Implanon and Nexplanon, are also hormonal methods, but last much longer. A single rod—about the size of a matchstick—is implanted by a health-care professional under the skin on the inside of a woman’s upper arm. It steadily releases hormones into a woman’s body for three years. These long-acting reversible contraception (LARC) methods last a long time but can be removed at any time and fertility will return quickly.

Implants were developed in the early 1980s and first approved by the FDA in 1990 under the brand name Norplant, which worked well but was taken off the market in 2002. At the time, the manufacturer cited “limitations on component supplies,” but difficulties with the removal process and negative public opinion were also clearly a factor in the decision. 

The new generation of implants was approved by the FDA in 2006. These single-rod implants are much easier for health-care providers to insert and remove. 

Intrauterine devices (IUDs), which are also considered to be LARCs, are flexible plastic devices that are inserted into the uterus to prevent pregnancy. IUDs prevent pregnancy by interfering with the movement of sperm toward eggs, thereby inhibiting fertilization. They may also change the lining of the uterus, preventing implantation of a fertilized egg (though this theory has not been proven) and thicken cervical mucus.

There are currently three IUDs on the market in the United States. ParaGard (also known as the Copper-T) releases a small amount of copper into the uterus and lasts ten years. Mirena releases a hormone similar to that in some birth control pills, which means it may also prevent ovulation in some women; it lasts for five years. The newest introduction to the market is called Skyla. It is also a hormonal IUD; it has been designed to be smaller and is specifically meant for younger women. Skyla lasts for three years. 

IUDs have a bit of a sordid history in the United States. They were first introduced in the 1960s and became quite popular. In fact, by the next decade there were over 17 models in development by 15 different companies. One model, the Dalkon Shield, had serious design flaws which resulted in higher rates of pelvic inflammatory disease (PID) in users, causing scarring in the uterus and fallopian tubes and, for many of these women, increased infertility. The Dalkon Shield also had a higher failure rate than expected, and women who became pregnant while using it risked spontaneous septic abortions (miscarriages followed by infection). Eighteen deaths were attributed to the Dalkon Shield, and more than 400,000 lawsuits were brought against the manufacturer. Though the design flaws were unique to the Dalkon Shield, public opinion of all IUDs soured, and by 1986 there was only one model of IUD on the market in the United States, and few women were using it.

ParaGard and Mirena became available in the early 2000s, but the FDA initially only approved them for use in women who had already had children. Research has shown, however, that they are safe for women of all ages, regardless of whether they’ve had children. Last summer, the American College of Obstetrics and Gynecology recommended that IUDs be among the first line of contraceptives offered to adolescents.

LARC methods are highly effective in part because user error is essentially taken out of the equation. The “get it and forget it” aspect of these methods means that perfect use and typical use rates are the same—IUDs are more than 99 percent effective.

For this reason, some in the public health world have started to see LARCs as the magic bullet for teen pregnancy—put one in at 15 and without changing her behavior or managing any medicines a girl can make it out of her teen years pregnancy-free. Though there has been an increase in the number of teens using both IUDs and implants over the past few years, these methods are not yet extremely popular with teens. Between 2008 and 2010, for example, only 4.4 percent of teens who were using contraception were using an IUD.

Don’t Forget the Condom

Condoms may be the original “plan B” for many teenagers, because unlike all the other methods they require almost no forethought. For those teens who find themselves hot and heavy but are not on the pill and don’t have an IUD, there is always the condom. Even if she doesn’t already have one in her purse and he doesn’t have one in his wallet, a teen is never far from a condom because this inexpensive form of birth control, which works by going over the penis and preventing sperm from entering the vagina, can often be purchased at a drug store, convenience store, or even a gas station.

If used perfectly, condoms are 98 percent effective, which is similar to hormonal methods. Typical failure rates are higher than those of other methods (about 18 of 100 couples using condoms as their primary method will experience a pregnancy in the first year of use) because people make mistakes—like putting it on too late, taking it off too soon, or opening the package with something sharp. Typical use rates for condoms also include those couples who say condoms are their primary method of contraception but weren’t actually using a condom when they got pregnant.

Using a condom correctly is not difficult, so instead of waiting until the next day to go to the drug store for emergency contraception, couples can hit the RiteAid or CVS for condoms before sex (even if it means taking a quick break from all the kissing and groping).

In fact, even those people who are on other birth control methods should consider hitting the condom aisle before a big date because—other than not having sex—condoms are the only way to prevent sexually transmitted infections (STIs). None of the other methods we talked about here prevent STIs.    

The ideal situation, of course, is dual use, where couples who want to avoid pregnancy use LARC methods for birth control and continue to rely on condoms to prevent STIs, including HIV. The good news is that more young couples are doing so; according to a recent National Survey of Family Growth 23 percent of teens reported dual use between 2008 and 2010 (up from 16 percent between 2006 and 2008).

Expanded access to emergency contraception is critical and represents a huge step forward in preventing unintended pregnancies. Still, we have to remember that, in the ideal world, emergency contraception would hardly ever be needed, because everyone would have the information and access they needed to use other reliable methods correctly and would be able to protect themselves against pregnancy and STIs in the moment every time they had sex.

Analysis Abortion

Legislators Have Introduced 445 Provisions to Restrict Abortion So Far This Year

Elizabeth Nash & Rachel Benson Gold

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. Of these, 35 percent (445 provisions) sought to restrict access to abortion services. By midyear, 17 states had passed 46 new abortion restrictions.

Including these new restrictions, states have adopted 334 abortion restrictions since 2010, constituting 30 percent of all abortion restrictions enacted by states since the U.S. Supreme Court decision in Roe v. Wade in 1973. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

Mid year state restrictions

 

Signs of Progress

The first half of the year ended on a high note, with the U.S. Supreme Court handing down the most significant abortion decision in a generation. The Court’s ruling in Whole Woman’s Health v. Hellerstedt struck down abortion restrictions in Texas requiring abortion facilities in the state to convert to the equivalent of ambulatory surgical centers and mandating that abortion providers have admitting privileges at a local hospital; these two restrictions had greatly diminished access to services throughout the state (see Lessons from Texas: Widespread Consequences of Assaults on Abortion Access). Five other states (Michigan, Missouri, Pennsylvania, Tennessee, and Virginia) have similar facility requirements, and the Texas decision makes it less likely that these laws would be able to withstand judicial scrutiny (see Targeted Regulation of Abortion Providers). Nineteen other states have abortion facility requirements that are less onerous than the ones in Texas; the fate of these laws in the wake of the Court’s decision remains unclear. 

Ten states in addition to Texas had adopted hospital admitting privileges requirements. The day after handing down the Texas decision, the Court declined to review lower court decisions that have kept such requirements in Mississippi and Wisconsin from going into effect, and Alabama Gov. Robert Bentley (R) announced that he would not enforce the state’s law. As a result of separate litigation, enforcement of admitting privileges requirements in Kansas, Louisiana, and Oklahoma is currently blocked. That leaves admitting privileges in effect in Missouri, North Dakota, Tennessee and Utah; as with facility requirements, the Texas decision will clearly make it harder for these laws to survive if challenged.

More broadly, the Court’s decision clarified the legal standard for evaluating abortion restrictions. In its 1992 decision in Planned Parenthood of Southeastern Pennsylvania v. Casey, the Court had said that abortion restrictions could not impose an undue burden on a woman seeking to terminate her pregnancy. In Whole Woman’s Health, the Court stressed the importance of using evidence to evaluate the extent to which an abortion restriction imposes a burden on women, and made clear that a restriction’s burdens cannot outweigh its benefits, an analysis that will give the Texas decision a reach well beyond the specific restrictions at issue in the case.

As important as the Whole Woman’s Health decision is and will be going forward, it is far from the only good news so far this year. Legislators in 19 states introduced a bevy of measures aimed at expanding insurance coverage for contraceptive services. In 13 of these states, the proposed measures seek to bolster the existing federal contraceptive coverage requirement by, for example, requiring coverage of all U.S. Food and Drug Administration approved methods and banning the use of techniques such as medical management and prior authorization, through which insurers may limit coverage. But some proposals go further and plow new ground by mandating coverage of sterilization (generally for both men and women), allowing a woman to obtain an extended supply of her contraceptive method (generally up to 12 months), and/or requiring that insurance cover over-the-counter contraceptive methods. By July 1, both Maryland and Vermont had enacted comprehensive measures, and similar legislation was pending before Illinois Gov. Bruce Rauner (R). And, in early July, Hawaii Gov. David Ige (D) signed a measure into law allowing women to obtain a year’s supply of their contraceptive method.

071midyearstatecoveragetable

But the Assault Continues

Even as these positive developments unfolded, the long-standing assault on sexual and reproductive health and rights continued apace. Much of this attention focused on the release a year ago of a string of deceptively edited videos designed to discredit Planned Parenthood. The campaign these videos spawned initially focused on defunding Planned Parenthood and has grown into an effort to defund family planning providers more broadly, especially those who have any connection to abortion services. Since last July, 24 states have moved to restrict eligibility for funding in several ways:

  • Seventeen states have moved to limit family planning providers’ eligibility for reimbursement under Medicaid, the program that accounts for about three-fourths of all public dollars spent on family planning. In some cases, states have tried to exclude Planned Parenthood entirely from such funding. These attacks have come via both administrative and legislative means. For instance, the Florida legislature included a defunding provision in an omnibus abortion bill passed in March. As the controversy grew, the Centers for Medicare and Medicaid Services, the federal agency that administers Medicaid, sent a letter to state officials reiterating that federal law prohibits them from discriminating against family planning providers because they either offer abortion services or are affiliated with an abortion provider (see CMS Provides New Clarity For Family Planning Under Medicaid). Most of these state attempts have been blocked through legal challenges. However, a funding ban went into effect in Mississippi on July 1, and similar measures are awaiting implementation in three other states.
  • Fourteen states have moved to restrict family planning funds controlled by the state, with laws enacted in four states. The law in Kansas limits funding to publicly run programs, while the law in Louisiana bars funding to providers who are associated with abortion services. A law enacted in Wisconsin directs the state to apply for federal Title X funding and specifies that if this funding is obtained, it may not be distributed to family planning providers affiliated with abortion services. (In 2015, New Hampshire moved to deny Title X funds to Planned Parenthood affiliates; the state reversed the decision in 2016.) Finally, the budget adopted in Michigan reenacts a provision that bars the allocation of family planning funds to organizations associated with abortion. Notably, however, Virginia Gov. Terry McAuliffe (D) vetoed a similar measure.
  • Ten states have attempted to bar family planning providers’ eligibility for related funding, including monies for sexually transmitted infection testing and treatment, prevention of interpersonal violence, and prevention of breast and cervical cancer. In three of these states, the bans are the result of legislative action; in Utah, the ban resulted from action by the governor. Such a ban is in effect in North Carolina; the Louisiana measure is set to go into effect in August. Implementation of bans in Ohio and Utah has been blocked as a result of legal action.

071midyearstateeligibilitytable

The first half of 2016 was also noteworthy for a raft of attempts to ban some or all abortions. These measures fell into four distinct categories:

  • By the end of June, four states enacted legislation to ban the most common method used to perform abortions during the second trimester. The Mississippi and West Virginia laws are in effect; the other two have been challenged in court. (Similar provisions enacted last year in Kansas and Oklahoma are also blocked pending legal action.)
  • South Carolina and North Dakota both enacted measures banning abortion at or beyond 20 weeks post-fertilization, which is equivalent to 22 weeks after the woman’s last menstrual period. This brings to 16 the number of states with these laws in effect (see State Policies on Later Abortions).
  • Indiana and Louisiana adopted provisions banning abortions under specific circumstances. The Louisiana law banned abortions at or after 20 weeks post-fertilization in cases of diagnosed genetic anomaly; the law is slated to go into effect on August 1. Indiana adopted a groundbreaking measure to ban abortion for purposes of race or sex selection, in cases of a genetic anomaly, or because of the fetus’ “color, national origin, or ancestry”; enforcement of the measure is blocked pending the outcome of a legal challenge.
  • Oklahoma Gov. Mary Fallin (R) vetoed a sweeping measure that would have banned all abortions except those necessary to protect the woman’s life.

071midyearstateabortionstable

In addition, 14 states (Alaska, Arizona, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Maryland, South Carolina, South Dakota, Tennessee and Utah) enacted other types of abortion restrictions during the first half of the year, including measures to impose or extend waiting periods, restrict access to medication abortion, and establish regulations on abortion clinics.

Zohra Ansari-Thomas, Olivia Cappello, and Lizamarie Mohammed all contributed to this analysis.

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.