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.

Commentary Contraception

Hillary Clinton Played a Critical Role in Making Emergency Contraception More Accessible

Susan Wood

Today, women are able to access emergency contraception, a safe, second-chance option for preventing unintended pregnancy in a timely manner without a prescription. Clinton helped make this happen, and I can tell the story from having watched it unfold.

In the midst of election-year talk and debates about political controversies, we often forget examples of candidates’ past leadership. But we must not overlook the ways in which Hillary Clinton demonstrated her commitment to women’s health before she became the Democratic presidential nominee. In early 2008, I wrote the following article for Rewirewhich has been lightly edited—from my perspective as a former official at the U.S. Food and Drug Administration (FDA) about the critical role that Clinton, then a senator, had played in making the emergency contraception method Plan B available over the counter. She demanded that reproductive health benefits and the best available science drive decisions at the FDA, not politics. She challenged the Bush administration and pushed the Democratic-controlled Senate to protect the FDA’s decision making from political interference in order to help women get access to EC.

Since that time, Plan B and other emergency contraception pills have become fully over the counter with no age or ID requirements. Despite all the controversy, women at risk of unintended pregnancy finally can get timely access to another method of contraception if they need it—such as in cases of condom failure or sexual assault. By 2010, according to National Center for Health Statistics data, 11 percent of all sexually experienced women ages 15 to 44 had ever used EC, compared with only 4 percent in 2002. Indeed, nearly one-quarter of all women ages 20 to 24 had used emergency contraception by 2010.

As I stated in 2008, “All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.”

Now, there are new emergency contraceptive pills (Ella) available by prescription, women have access to insurance coverage of contraception without cost-sharing, and there is progress in making some regular contraceptive pills available over the counter, without prescription. Yet extreme calls for defunding Planned Parenthood, the costs and lack of coverage of over-the-counter EC, and refusals by some pharmacies to stock emergency contraception clearly demonstrate that politicization of science and limits to our access to contraception remain a serious problem.

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Today, women are able to access emergency contraception, a safe, second chance option for preventing unintended pregnancy in a timely manner without a prescription. Sen. Hillary Clinton (D-NY) helped make this happen, and I can tell the story from having watched it unfold.

Although stories about reproductive health and politicization of science have made headlines recently, stories of how these problems are solved are less often told. On August 31, 2005 I resigned my position as assistant commissioner for women’s health at the Food and Drug Administration (FDA) because the agency was not allowed to make its decisions based on the science or in the best interests of the public’s health. While my resignation was widely covered by the media, it would have been a hollow gesture were there not leaders in Congress who stepped in and demanded more accountability from the FDA.

I have been working to improve health care for women and families in the United States for nearly 20 years. In 2000, I became the director of women’s health for the FDA. I was rather quietly doing my job when the debate began in 2003 over whether or not emergency contraception should be provided over the counter (OTC). As a scientist, I knew the facts showed that this medication, which can be used after a rape or other emergency situations, prevents an unwanted pregnancy. It does not cause an abortion, but can help prevent the need for one. But it only works if used within 72 hours, and sooner is even better. Since it is completely safe, and many women find it impossible to get a doctor’s appointment within two to three days, making emergency contraception available to women without a prescription was simply the right thing to do. As an FDA employee, I knew it should have been a routine approval within the agency.

Plan B emergency contraception is just like birth control pills—it is not the “abortion pill,” RU-486, and most people in the United States don’t think access to safe and effective contraception is controversial. Sadly, in Congress and in the White House, there are many people who do oppose birth control. And although this may surprise you, this false “controversy” not only has affected emergency contraception, but also caused the recent dramatic increase in the cost of birth control pills on college campuses, and limited family planning services across the country.  The reality is that having more options for contraception helps each of us make our own decisions in planning our families and preventing unwanted pregnancies. This is something we can all agree on.

Meanwhile, inside the walls of the FDA in 2003 and 2004, the Bush administration continued to throw roadblocks at efforts to approve emergency contraception over the counter. When this struggle became public, I was struck by the leadership that Hillary Clinton displayed. She used the tools of a U.S. senator and fought ardently to preserve the FDA’s independent scientific decision-making authority. Many other senators and congressmen agreed, but she was the one who took the lead, saying she simply wanted the FDA to be able to make decisions based on its public health mission and on the medical evidence.

When it became clear that FDA scientists would continue to be overruled for non-scientific reasons, I resigned in protest in late 2005. I was interviewed by news media for months and traveled around the country hoping that many would stand up and demand that FDA do its job properly. But, although it can help, all the media in the world can’t make Congress or a president do the right thing.

Sen. Clinton made the difference. The FDA suddenly announced it would approve emergency contraception for use without a prescription for women ages 18 and older—one day before FDA officials were to face a determined Sen. Clinton and her colleague Sen. Murray (D-WA) at a Senate hearing in 2006. No one was more surprised than I was. All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.

Sometimes these success stories get lost in the “horse-race stories” about political campaigns and the exposes of taxpayer-funded bridges to nowhere, and who said what to whom. This story of emergency contraception at the FDA is just one story of many. Sen. Clinton saw a problem that affected people’s lives. She then stood up to the challenge and worked to solve it.

The challenges we face in health care, our economy, global climate change, and issues of war and peace, need to be tackled with experience, skills and the commitment to using the best available science and evidence to make the best possible policy.  This will benefit us all.

Commentary Contraception

The Promotion of Long-Acting Contraceptives Must Confront History and Center Patient Autonomy

Jamila Taylor

While some long-acting reversible contraceptive methods were used to undermine women of color's reproductive freedom, those methods still hold the promise of reducing unintended pregnancy among those most at risk.

Since long-acting reversible contraceptives (LARCs), including intrauterine devices and hormonal contraceptive implants, are among the most effective means of pregnancy prevention, many family planning and reproductive health providers are increasingly promoting them, especially among low-income populations.

But the promotion of LARCs must come with an acknowledgment of historical discriminatory practices and public policy related to birth control. To improve contraceptive access for low-income women and girls of color—who bear the disproportionate effects of unplanned pregnancy—providers and advocates must work to ensure that the reproductive autonomy of this population is respected now, precisely because it hasn’t been in the past.

For Black women particularly, the reproductive coercion that began during slavery took a different form with the development of modern contraceptive methods. According to Dorothy Roberts, author of Killing the Black Body, “The movement to expand women’s reproductive options was marked with racism from its very inception in the early part of [the 20th] century.” Decades later, government-funded family planning programs encouraged Black women to use birth control; in some cases, Black women were coerced into being sterilized.

In the 1990s, the contraceptive implant Norplant was marketed specifically to low-income women, especially Black adults and teenage girls. After a series of public statements about the benefits of Norplant in reducing pregnancy among this population, policy proposals soon focused on ensuring usage of the contraceptive method. Federal and state governments began paying for Norplant and incentivizing its use among low-income women while budgets for social support programs were cut. Without assistance, Norplant was not an affordable option, with the capsules costing more than $300 and separate, expensive costs for implantation and removal.

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Soon, Norplant was available through the Medicaid program. Some states introduced (ultimately unsuccessful) bills that would give cash rewards to entice low-income women on public assistance into using it; a few, such as Tennessee and Washington state, required that women receiving various forms of public assistance get information about Norplant. After proposing a bill to promote the use of Norplant in his state in 1994, a Connecticut legislator made the comment, “It’s far cheaper to give you money not to have kids than to give you money to have kids.” By that year, as Roberts writes, states had spent $34 million on Norplant-related care, much of it for women on Medicaid. Policymakers thought it was completely legitimate and cost-effective to control the reproduction of low-income women.

However, promoting this method among low-income Black women and adolescents was problematic. Racist, classist ideology dictating that this particular population of women shouldn’t have children became the basis for public policy. Even though coercive practices in reproductive health were later condemned, these practices still went on to shape cultural norms around race and gender, as well as medical practice.

This history has made it difficult to move beyond negative perceptions, and even fear, of LARCs, health care, and the medical establishment among some women of color. And that’s why it’s so important to ensure informed consent when advocating for effective contraceptive methods, with choice always at the center.

But how can policies and health-care facilities promote reproductive autonomy?

Health-care providers must deal head on with the fact that many contemporary women have concerns about LARCs being recommended specifically to low-income women and women of color. And while this is part of the broader effort to make LARCs more affordable and increasingly available to communities that don’t have access to them, mechanisms should be put in place to address this underlying issue. Requiring cultural competency training that includes information on the history of coercive practices affecting women of color could help family planning providers understand this concern for their patients.

Then, providers and health systems must address other barriers that make it difficult for women to access LARCs in particular. LARCs can be expensive in the short term, and complicated billing and reimbursement practices in both public and private insurance confuse women and providers. Also, the full cost associated with LARC usage isn’t always covered by insurance.

But the process shouldn’t end at eliminating barriers. Low-income Black women and teens must receive comprehensive counseling for contraception to ensure informed choice—meaning they should be given information on the full array of methods. This will help them choose the method that best meets their needs, while also promoting reproductive autonomy—not a specific contraceptive method.

Clinical guidelines for contraception must include detailed information on informed consent, and choice and reproductive autonomy should be clearly outlined when family planning providers are trained.

It’s crucial we implement these changes now because recent investments and advocacy are expanding access to LARCs. States are thinking creatively about how to reduce unintended pregnancy and in turn reduce Medicaid costs through use of LARCs. The Colorado Family Planning Initiative has been heralded as one of the most effective in helping women access LARCs. Since 2008, more than 30,000 women in Colorado have chosen LARCs as the result of the program. Provider education, training, and contraceptive counseling have also been increased, and women can access LARCs at reduced costs.

The commitment to LARCs has apparently yielded major returns for Colorado. Between 2009 and 2013, the abortion rate among teenagers older than 15 in Colorado dropped by 42 percent. Additionally, the birth rate for young women eligible for Medicaid dropped—resulting in cost savings of up to an estimated $111 million in Medicaid-covered births. LARCs have been critical to these successes. Public-private partnerships have helped keep the program going since 2015, and states including Delaware and Iowa have followed suit in efforts to experience the same outcomes.

Recognizing that prevention is a key component to any strategy addressing a public health concern, those strategies must be rooted in ensuring access to education and comprehensive counseling so that women and teens can make the informed choices that are best for them. When women and girls are given the tools to empower themselves in decision making, the results are positive—not just for what the government spends or does not spend on social programs, but also for the greater good of all of us.

The history of coercion undermining reproductive freedom among women and girls of color in this country is an ugly one. But this certainly doesn’t have to dictate how we move forward.

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