Contact Name
Barbara Dietsch
562-799-5126
bdietsc@WestEd.org

By Cassandra E. Henderson, M.D.

Several surveys provide comprehensive reports on pregnancies and pregnancy rates in the United States. The 1995 National Survey of Family Growth and the Alan Guttmacher Institute’s survey of abortion providers indicated that nearly one half (48%) of all pregnancies in the United States are unplanned. American women choose to abort 47% of these unplanned pregnancies. Furthermore, unplanned pregnancies that are continued and are at increased risk for adverse perinatal outcome, are selectively aborted. A 1995 report on the National Survey of Family Growth indicated that small for gestational age infants occurred in 10.3% and 6.7% of unplanned and planned pregnancies, respectively. In the same report, data from the National Maternal and Infant Health Survey found that unplanned pregnancies compared to planned pregnancies had higher rates of premature labor (10.2% vs. 6.8%) and small for gestational age infants (11.3% vs. 9.5%).

To reduce the incidence of unplanned pregnancies in the United States it is important to provide all women of reproductive age with greater contraceptive options. However, for adolescents, facilitating greater access to effective and safe contraceptive methods is a greater challenge. Indeed the increased risk that adolescent women will be exposed to unanticipated intercourse, either consensual or non-consensual, makes hormonal emergency contraception (ECP) an important family planning tool for adolescents. Emergency contraception uses routine contraceptive methods to prevent pregnancy after sexual intercourse has occurred. It is not an appropriate method for regular contraceptive needs as it is less effective than all available methods of contraception. When used as the only method of contraception, ECP has an annual failure rate of 24%. Furthermore, the most common side effects, nausea and vomiting, make regular use of ECP undesirable for most women.

In 1967, Morris published the first report of post-coital contraception using the hormonal preparation, Diethylstilbestrol (DES). It was not until 1974 that Yuzpe introduced the method of low dose combination OCS that is currently recommended. Since these early reports, a plethora of literature has documented the use of hormonal contraceptives or intrauterine devices as safe and effective methods of preventing pregnancy after an episode of unprotected intercourse. During the midmenstrual cycle, 24 to 48 hours before ovulation, the chance of pregnancy resulting from one episode of unprotected intercourse is 15 to 30%. The protection provided by ECP is reported in various studies to be approximately 75% (range 55 to 94%).

Despite the undisputed benefits of preventing unplanned pregnancies, numerous barriers continue to limit access to ECP. A rather simple barrier is the misnomer of "morning-after pill". Hormonal preparations for ECP can be effective anytime within the 72 hour period following unprotected intercourse. The availability of the product Preven in 1998 surmounted a critical barrier of not having a dedicated hormonal emergency contraceptive product. In 1998 Gynetics marketed Preven as the first product indicated for Emergency Contraception. Subsequently, the Women’s Capital Corporation has marketed the Emergency Contraceptive Plan B. Unlike Preven, which is composed of a combination of oral contraceptives, Plan B contains only levonorgestrel. Plan B is more effective than Preven and has a lower incidence of nausea. Prior to the availability of these dedicated ECP products, women needed to receive written or oral instruction on using combination oral contraceptives for emergency contraceptive regimens. These treatment regimens vary depending on the brand of contraceptive. For specific regimens see: J. Trussell, F. Stewart, F. Guest, R.A. Hatcher, "Emergency Contraceptive Pills: A Simple Proposal to Reduce Unintended Pregnancies." Family Planning Perspectives, 24:269-273,1992.

A 1999 Guttmacher report (Vol. 2, No. 3, June 1999) has recently documented an unanticipated obstacle to widespread access to emergency contraception. Individual pharmacists have refused to fill emergency contraception prescriptions. Their refusals are often on the grounds of not wanting to facilitate abortions. The use of emergency contraception will not abort an established pregnancy. Emergency contraception prevents pregnancy by delaying ovulation or preventing implantation. Medical science defines the beginning of pregnancy as the implantation of a fertilized egg in the lining of a woman’s uterus. Implantation occurs 5 to 7 days after fertilization.

Despite the recent difficulties of obtaining ECP specific products, the greatest barrier to using ECP is the paucity of prospective information provided to reproductive age women. The need for ECP often arises during evening or weekend hours. As a result, the 72 hour time constraint is exceeded by the time one is able to arrange a visit to a health care professional. A review of the risk and benefits of ECP should become a component of the routine annual health care visits for reproductive age women. If the women and health care provider deem it appropriate, women should be provided with ECP prescriptions or emergency contraceptive products to be used when needed.

The low dose of hormones given over 24 hours makes contraindications to hormonal ECP practically non-existent. The only absolute contraindication is pregnancy. A large amount of data indicate that maternal use of exogenous hormones is unlikely to cause fetal harm. Therefore, women who are not obviously pregnant should not be denied access to emergency contraception.

To improve access to ECP, professional and activist groups have established a 24-hour national and local Emergency Contraceptive Hotline, 1888-NOT-2-LATE, and an Emergency Contraception Web site, www.princeton.edu/ec, as a means of distributing information. Providers who are willing to prescribe ECP can list themselves in these information resources. Initially, while supplies are limited, Plan B is available only to Planned Parenthood Clinics and other health care providers listed on the 24-Hour Emergency Contraception Hotline.

Unintended pregnancy is an economic and social burden. The primary cost is human cost in lost opportunities for parents. This is particularly true for adolescent parents. The 1995 Institute of Medicine report "The Best Intentions" identifies the immense consequences associated with unintended pregnancies. Providing a method to decrease the incidence of unplanned pregnancies is a valuable public health tool. The public health benefit of reducing unplanned pregnancies is a reduction in abortion rates and for continuing pregnancies, lower rates of preterm and intrauterine growth retarded infants.

Dr. Cassandra E. Henderson is Medical Director, MIC Women’s Health Services; Associate Professor, Albert Einstein College of Medicine; Practicing Maternal-Fetal Medicine Specialist, Montifiore Medical Center; Guest Scientist, National Institute for Child Health & Development.