Commentary Contraception

With Reproductive Rights in Great Jeopardy, ‘Plan C’ Is More Important Than Ever

Francine Coeytaux, Victoria Nichols & Elisa Wells

Plan C—making "missed period pills" widely available—would give users the power to decide whether or not they wished to test for or confirm pregnancy before taking pills to bring on their period.

Four years ago, we argued for an important new family planning option. We envisioned a method that could be used at home when a period was late to induce menstruation and thus reassure individuals that they were not pregnant. Plan C, we posited, was not only possible—the technology already existed in the form of mifepristone and misoprostol—but could be the answer to the age-old question asked by women around the world, “What do I do if my period is late and I don’t want to be pregnant?” With the recent news of Justice Anthony Kennedy’s resignation and the rising concern about a likely shift in the balance of the U.S. Supreme Court, the need to ensure timely and affordable access to innovative reproductive health options like Plan C is even more urgent.

Women know what is best for them when it comes to their own reproductive health and pregnancy decisions. Our proposal for Plan C would give users the power to decide whether or not they wished to test for or confirm pregnancy before taking pills to bring on their period. And it could be positioned between emergency contraception and abortion (which is the termination of a confirmed pregnancy), filling the gaping hole in the continuum of options available to those trying to manage their fertility.

Since we envisioned Plan C, the concept of delivering pills by mail to people wishing to induce menstruation or terminate an unconfirmed early pregnancy at home has been widely discussed. There is strong interest from the public, many activists, and some researchers in the concept of having a period management or “missed period” product for individuals in the United States. This model would offer convenience, confidentiality, and control to the user. It would eliminate many of the existing barriers to care and reduce stigma and harassment.

We conducted a study two years ago to understand key stakeholder views about a missed period pill and found that numerous informants expressed excitement about positioning misoprostol as a menses inducer. Comments included: “[It’s] a fantastic idea that’s really in sync with how lots of women think about their periods. Women don’t necessarily want to know if they are pregnant; they just want their period back. This is a powerful strategy—women would embrace it.”

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Yet little progress has been made in developing it. This is likely in part due to the relatively slow adoption of mifepristone and misoprostol in the United States: Medication abortion is used in only 31 percent of nonhospital abortions in this country as compared to 80 to 91 percent in some Western European countries, 81 percent in India, and 74 percent in Mexico City. The slow progress in developing a “missed period pill” may also be explained by our country’s general ambivalence toward self-use of medication abortion and the politics that prevent these pills from being available in pharmacies and by mail-order. And progress may even be stymied by concerns within the reproductive health provider community about the fact that a missed period pill blurs the lines between contraception and abortion, lines of distinction that have been painstakingly drawn for decades. We think the distinction should be left to the individual: While some who choose to use a missed period pill will definitely want to know their pregnancy status before making the decision, others might embrace the opportunity for ambiguity and choose not to do a pregnancy test.

Meanwhile, many countries are much further ahead in exploring a market for such an option. Bangladesh took the lead decades ago: Despite abortion being illegal except to save a woman’s life, menstrual regulation has been a part of the country’s national family planning program since 1979. For decades, the government program used vacuum aspiration to provide millions of women a safe and effective method to manage a missed period. Recently, the program has been exploring the use of mifepristone and misoprostol as an alternative to aspiration, and studies show that “medical menstrual regulation” can be safely administered and is highly acceptable to women. In Cuba, where abortion is legal, a woman whose period is two weeks late is offered menstrual regulation without a pregnancy test. And, in Mexico and numerous African countries, women are being creative with the use of misoprostol and mifepristone, reframing their use to “bajar la regla” or bring down the period.

Many questions need to be addressed to bring the Plan C concept to fruition in the United States. The first will be to determine what is the best product to use for this purpose. Can we repurpose or reframe the use of misoprostol and/or mifepristone, two drugs that have already been proven to be safe and effective for menstrual regulation? Or will we have to develop a dedicated product that will require FDA approval? The latter, we know from experience, will require years and millions of dollars and may result in reduced accessibility for many. For instance, when a dedicated product for emergency contraception (Plan B) was approved, the price was out of reach for many, and the FDA approval of Mifeprex came with restrictions on its distribution, making it largely inaccessible.

As we begin the work to evaluate what it would take to make this new method available as a family planning option, there is much we could do to better understand, from users’ points of view, the pluses and minuses of the method. For instance, what are user perspectives about the ability to act faster/sooner to resolve a missed period, the amount of cramping and bleeding (less than an abortion done later in pregnancy), and the similarity of this approach to a natural period? Users should be the ones to decide how best to frame, describe, and talk about it; what words would they use to make it an inclusive product for a wide variety of communities that may include people who speak different languages, identify along the gender spectrum, and have different abilities? Finally, potential users could shed light on who and how big the market might be. Similarly, we need to hear from medical providers and reproductive rights and justice advocates about their concerns, which might include how to ensure informed consent, how to measure and evaluate use, the impact on use of other methods, and how users will access follow-up care, if needed.

We have the tools to begin answering these questions. We have pills in hand that we know are effective for menstrual regulation, whose application in this form we could test. And we have qualitative research methods, including human-centered design, that could be applied to better understand the needs of individuals who experience a late period and do not wish to be pregnant. All of these resources could be used to develop and test an innovative product that would effectively meet user needs and expand the range of options available to manage fertility.

We are calling once again on the family planning and reproductive and sexual health communities to develop a “missed period pill.” There is no doubt that such an option would fill a unique niche—one that addresses immediate needs that arise after a missed period if one does not wish to be pregnant. And it is equally clear that adding such a unique, self-empowering, and practical option to the continuum of methods of fertility control would fill a significant unmet need. The use of misoprostol for self-managed abortion was imagined, realized, and inspired by women whose needs were not being met. Had we been listening to our “target audience,” people whose Plan A (contraception) and Plan B (emergency contraception) has failed, we would by now have developed a Plan C—a safe, convenient, and effective method that could be taken to relieve the anxiety and anguish associated with an unexpected missed period.

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