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Emergency contraception is still a mystery in D.C. Just try finding it on a weekend.
Accidents happen. But when they involve unprotected sexa condom breaks, a diaphragm slips, or a pill is missedthe possibility of an unintended pregnancy looms large. Just one sexual encounter during the second or third week of a woman’s menstrual cycle, according to a preponderance of medical evidence, yields an 8 percent chance of conception.
Odenton, Md., resident Nikki Hayes found herself in such a quandary. Birth control pills gave her headaches, so she decided to begin using a diaphragm. One Friday night, Hayes found that something was wrong with her new contraceptive method: After sex, she discovered that her diaphragm had not been inserted correctly.
“I had done everything I was supposed to do, but there was a human error,” Hayes says. “Your body is not a machine. It’s not as easy as putting in a cassette and ejecting the cassette.”
Hayes is, however, among the 20 percent of American women who know about and can obtain the “morning-after pill.” More correctly referred to as “emergency contraception” or “EC,” it is often confused with its rancorously contested cousinthe “abortion pill,” or RU-486.
Though Hayes knew she needed to use EC and that she had only 72 hours to start taking the necessary pills, she still ran into difficulties when she made an appointment the next day with her gynecologist.
“The nurse there proceeded to berate me about how I was using my contraceptive method,” Hayes says. “I thought, ‘Wow,
I’m a young professional woman here and she’s doing that to me. What if I was a 16-year-old?’”
Her doctor’s office didn’t have EC. After calling four or five pharmacies that also didn’t carry it, the gynecologist sent Hayes packing with “a prescription and a little chastisement.”
After trying a few other pharmacies on her own, she finally hit pay dirt at a Giant in Glen Burnie, Md. “It was truly a relief to finally get those pills,” Hayes says. “I think I took them in the car while leaving Giant. It was a long, panicking, nerve-racking day. I can’t believe that anyone has to go through that, especially for something that’s legal.”
Emergency contraception is a simple concept that’s been around since 1974, when Professor A. Albert Yuzpe of Canada first outlined a regimen that consisted of taking two ordinary oral contraceptive pills (containing both synthetic estrogen and progestin hormones) within 72 hours of unprotected sex and then taking two more pills 12 hours later.
Unlike the much better known RU-486, which induces abortion, the EC regimen, when executed properly, works by preventing pregnancy. It has been proved to reduce a woman’s risk of becoming pregnant by 75 percent when an accident occurs during a woman’s fertile period, according to the Food and Drug Administration (FDA). The Yuzpe regimen has been prescribed by emergency rooms, health clinics, and university health centers in the United States for the past 25 years.
Research suggests that EC can prevent pregnancy in three different ways. Depending on when the pills are taken during the menstrual cycle, EC can inhibit or delay the egg’s release from the ovaries (ovulation), prevent the union of egg and sperm (fertilization), or chemically alter the lining of the uterus, thereby preventing the implantation of a fertilized egg.
EC has raised less of a ruckus than RU-486, but the method’s lower profile is not the only hurdle facing its wider public acceptance. Acquiring EC in the District is a challenge, particularly on weekends, when unprotected sex seems likelier to occur.
In the last three years, two companies have introduced specifically labeled brands of EC, erasing any confusion over what dose of standard birth control pills to take. New Jersey-based Gynetics Inc. markets Preven, a package containing the four tablets of the Yuzpe regimen, and Women’s Capital Corp., headquartered in D.C., sells Plan B, a progestin-only form of EC that the World Health Organization (WHO) has found to be up to 95 percent effective and less likely than Preven to cause side effects such as nausea and headaches.
A Web site hosted by the Office of Population Research at Princeton University (http://ec.princeton.edu/) sorts and lists EC providers by ZIP code, area code, and city and state. That site lists phone numbers for 10 private physicians and clinics that carry EC in the District.
Phone calls to the listed D.C. sites on a Saturday revealed how difficult obtaining EC can be over the weekend. A call to the local chapter of Planned Parenthood was routed to an automated switchboard, which eventually coughed up contact info for six area clinicsfour of which are open on Saturdays. On this particular day in the District, only Planned Parenthood and the George Washington University Health Services Center (open from 9 a.m. to 1 p.m. on Saturday) were doing business. Kaiser Permanente also has a hot line, but members must wait until Monday to get an appointment for EC.
Dr. Ellen Whitaker, an OB-GYN in the District, returned an EC-seeking call on Monday morning. Whitaker prescribes EC for patients, but she notes that “you have to know about it to seek out a prescription.” She adds that “Plan B is hard to get in local pharmacies.”
Indeed, the 24-hour CVS in Dupont Circle had no EC on a recent Sunday visit. A staffer claimed that it “usually” carries Preven and suggested trying Rite Aid. Several Rite Aid branches in the District, as well as Safeway’s pharmacies, are closed on Sundays, but the Rite Aid in the Universal Building, at 1825 Connecticut Ave. NW, did stock Preven on that Sunday.
James Trussell, associate dean of the Woodrow Wilson School of Public and International Affairs at Princeton University, is a leader in the effort to broaden the use of EC. He cites a general lack of information about the regimen as the cause of its limited public acceptance.
“The clinical bottleneck is really very clear,” observes Trussell. “Only 20 percent of clinicians are routinely counseling about EC in advance.” In his attempt to spread the word, Trussell created the Princeton EC Web site and a toll-free hot line (1-888-NOT-2-LATE).
Sharon Camp, the president and founder of Women’s Capital Corp., says that the lack of awareness about EC has made it “the best-kept secret in contraceptive technology, despite 30 years of medical knowledge.” Only 1 percent of American women in their childbearing years have used EC, according to statistics cited by both Women’s Capital Corp. and the American College of Obstetricians and Gynecologists (ACOG).
Women in urban areas like the District have a better chance of finding EC than their less cosmopolitan counterparts. In the vast stretches of America where Wal-Mart is the only game in town, EC is much harder to obtain. The world’s largest retailer decided not to carry the regimen in 1998, citing “business considerations.”
Jessica Moser, a spokesperson in Wal-Mart’s Arkansas-based corporate headquarters, characterizes the policy as a business decision that was made for “a variety of reasons, including customer demand.”
Virginia Martin, vice president for external affairs at Planned Parenthood of Metropolitan Washington, D.C., is skeptical about Wal-Mart’s reasons for nixing EC. “I’m not sure [Wal-Mart’s decision] was based on financial issues,” she says. “I think it’s political, frankly.”
Martin acknowledges that EC is difficult to find in D.C. pharmacies as well, and she argues that awareness and availability problems with EC are symptomatic of typical resistance to contraceptive methods and the low priority placed on women’s health and reproductive issues.
Outright opposition to EC has also been a factor in the lack of public support for the regimen. Trussell calls EC “a real dividing line” between anti-abortion groups, some of which object to the possibility that EC blocks pregnancy by preventing a fertilized egg from implanting in the uterus.
To date, the largest anti-abortion groupthe National Right to Life Committeehas offered only a muted statement opposing the termination of a fertilized egg. More vociferous attacks on EC by other powerful anti-abortion groups are part of the public record, however.
Jason Campbell, director of media for the Christian Coalition, labels the use of EC a “chemically induced abortion.” He argues that its wider acceptance “will promote promiscuity, redefine what it means to be pregnant, and yes, [be] just another unsafe and immoral way to kill the unwanted.”
Even subterfuge has become a tactic in the battle against EC by some anti-abortion groups.
One of the most prominent Web sites dedicated to EC can be found at www.morningafterpill.org. (It is, in fact, the first Web site listed in answer to a search for “morning after pill” on the Yahoo! search engine.)
The site’s home page features a photograph of a young woman with the text”The Morning After Pillwhat you need to know about emergency contraception” and links to pages labeled “How Does It Work?” and “Medical Statements.”
Up until May 2001, the Web site lacked any identification of its host organization. The site’s material, however, echoed arguments made by the anti-abortion American Life League, including statements such as: “If in fact the woman is pregnant when she takes these birth control pills, the high dosage could act to kill her pre-born childa living human being. The only ’emergency’ in this case is the woman’s fear of being pregnant.”
Scott Weinberg, director of media relations for the American Life League, admitted in a phone interview with the Washington City Paper that his organization does produce the Web site. He asserted that the site was a link from the league’s home page and that it is listed on the index of its home page.
Asked about the ethical concerns arising from the Web site’s lack of host identification, Weinberg was dismissive. “I’ll describe that concern as laughable,” he said, “because on AOL, it’s listed on the site index. The site has the backing of scientists, and the facts speak for themselves.”
A week after that interview, however, the Web site did add a tag that identifies the American Life League as its host organization.
Trussell scoffs at anti-abortion groups’ claims that EC is equivalent to abortion. He points out that the National Institutes of Health and the FDA have defined pregnancy as when the egg implants in the uterus.
“I really don’t think the general public in the U.S. is all that concerned about fertilized eggs,” Trussell argues. “If we are, we need to be paying closer attention to panties and discarded tamponsbecause most fertilized eggs never implant. We should also outlaw all other methods that could work toward inhibiting implantation. That includes other contraceptives and even breast-feeding.”
EC supporters received a boost in late April from the ACOG, when the group’s incoming president urged
OB-GYNs to offer advance prescriptions for EC during routine gynecological visits.
An ACOG statement asserted that half of the 3 million unintended pregnancies in the United States end in abortion. The statement says, “Widespread availability of emergency contraception could potentially prevent over one million of these unplanned pregnancies a year.” The American Medical Association recently gave EC its public backing as well.
To judge by anecdotal evidence, the use of EC in the District is on the rise.
Sharon Zalewski, executive director of the Washington Free Clinic in Mount Pleasant, says that the three to five walk-ins seeking EC at her clinic each week are usually young womencollege students or sometimes adolescents with their parents. The clinic asks for a donation when dispensing ECusually $10 to $25.
The six Planned Parenthood clinics in the D.C. area have seen a 30 percent increase in EC use in the past six months. The cost of EC at Planned Parenthood is based on a sliding scale, with the highest price being $20.
Maxine Klane, vice president for patient services at Planned Parenthood of Metropolitan Washington, D.C., says that in addition to giving EC to women who come looking for it, her clinics offer more comprehensive services. “Our patients come in for other care, and we educate them about EC,” she says. “We’re trying very hard to educate our patients.”
As to the anti-abortion movement’s claims that counseling teenagers about EC will lead to more unprotected sex, Planned Parenthood’s Martin says, “When you’re talking to a teenager who has already begun having sex, why is it appropriate to discuss the dangers of smoking or drug use but not sexual issues? If [anti-abortion groups] are interested in preventing abortion, they would be distributing this pill to every sexually active woman.”
Both Klane and Zalewski say the volume of walk-ins looking for EC at their clinics is highest on Mondays, and the problem of simply finding the regimen in the District is exacerbated by the knowledge that EC’s efficacy diminishes over the 72-hour window in which it should be taken.
Roderick McKenzie, chairman of Gynetics, says, “Wisdom would say that the sooner you use [EC], the better. Women should try to get it as soon as possible.”
This view is supported by recent research from the WHO, which found that the efficacy of Plan B drops 34 percent from the first 24 hours after sex to the third day. Preven has an efficacy reduction of 39 percent in the same time period.
Pending the results from ongoing studies, Women’s Capital Corp. has petitioned the FDA for approval of over-the-counter status for Plan B. If the FDA gives its approval, women may one day find EC on the pharmacy shelves with aspirin.
Camp’s company still faces an uphill battle in getting the regimen into drugstores, however. “Pharmacies say they don’t carry it because they haven’t seen prescriptions,” she explains. “Doctors are waiting for pharmacies. It’s kind of a disconnect. We just don’t have the money to get the word to every OB-GYN….We’re the world’s tiniest pharmaceutical [company].”
The massive number of unwanted pregnancies in the District and elsewhere speaks loudly about a potential demand for EC. “I think we could do a lot more with EC,” says Whitaker.
For now, EC remains a mystery to many local women. When Hayes describes her experience using the regimen to friends, their reaction is usually surprise at its existence.
“They’re shocked every time I explain this to them,” says Hayes. “They think emergency contraception is something they do over there in Europe.” CP