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LOS ANGELES TIMES - Monday, May 22, 2000
The 'Morning After' Pill Works Fine If You
Can Get It
Drugs * To reduce unplanned
pregnancies, advocates seek easier access to emergency contraceptives.
By SHARI ROAN, LA Times Health Writer
Complaining that
emergency contraceptives are still not within easy reach of many women,
health activists are trying to improve access to medication that they say
could reduce the nation's high rate of unplanned pregnancies.
In Los Angeles, Planned Parenthood's 11
clinics have begun offering most patients a dose of the so-called
morning-after pills to take home with them--for a fee of $5--just in case.
And the Los Angeles-based Pacific
Institute for Women's Health recently published two guides--one for
consumers and one for health practitioners--to promote awareness of the
pills.
"We need to very much keep the
pressure on and try to [make] this accessible to the man and woman on the
street," says Francine Coeytaux, an associate of the nonprofit institute.
"We do have a lot of barriers still."
Doctors had long known that certain
combinations of ordinary birth control pills can be safely taken within a
few days after unprotected intercourse to help prevent pregnancy. But the
first dedicated emergency contraceptive, called Preven, became available
in late 1998. A second product, called Plan B, arrived in 1999. (They are
not the same as the so-called abortion pill, which induces abortion once a
pregnancy is established and confirmed.)
The emergency contraceptives, which
cause nausea in some women, must be taken within 72 hours after
unprotected intercourse. Both are highly effective, giving rise to
expectations that the products could make a dent in the estimated 3
million unintended pregnancies and 800,000 abortions that occur each year
in the United States.
While surveys show
that awareness of emergency contraceptive pills is rising, Coeytaux says:
"I think that those who thought this would be the be-all and end-all and
would help us reduce abortions are probably realizing now that that's not
true."
It's no mystery why emergency
contraceptive pills remain more promising than practical.
The problem is time.
"Unlike other [contraceptive] methods,
this one has a window of time in which it has to happen, or it's not
effective," Coeytaux says.
* * * Women typically are
not offered the pills to have handy for future use and then do not have
enough time to obtain them in an emergency, say family planning experts.
Even individuals who call a national
hotline listing emergency contraceptive health practitioners often have
difficulty getting the pills. A survey of the hotline ([888] NOT-2-LATE)
found that 14% of the calls resulted in failure to obtain an appointment
or prescription within 72 hours of calling. The study was published in the
February issue of the journal Obstetrics & Gynecology.
"The vast majority of providers do a
good job. But we were certainly discouraged that people who self-selected
to provide emergency contraceptives didn't do a better job," says James
Trussell, an author of the study and professor of economics and public
affairs at Princeton University and a leading advocate of the method. "The
bottleneck [in the access process] is that physicians don't routinely
counsel women or prescribe it in advance."
The study found that some callers failed
to even make telephone contact with the provider, that doctors refused to
see women who were not established patients, or that appointments were
unavailable.
The survey was taken on
weekdays, Trussell notes, suggesting that women who try to call for
emergency contraceptives on a Saturday morning, when doctors' offices are
usually closed, will encounter even greater obstacles.
And there have been other snags in
bringing emergency contraceptives to the marketplace. Under some state
laws, pharmacists can refuse to dispense emergency contraceptives if doing
so would conflict with their moral or religious beliefs.
But even the majority of pharmacists who
are willing to fill prescriptions for Preven or Plan B sometimes don't
have the medication in stock, Coeytaux says. The sooner the medication is
taken, the more effective it is.
"The
pharmacists haven't ordered lots of them to have in stock," she says.
"That's a huge problem. Pharmacists are business people. They only stock a
product once they recognize there is a demand. It will take a while for
them to realize that people want this."
Another barrier is cost and insurance
coverage. Emergency contraceptives usually cost $20 to $25 (or less in
family planning clinics) plus the doctor's office fee.
Under California law, all contraceptives
must be covered by insurance. But emergency contraceptives require special
billing procedures in order for providers to be reimbursed--a problem that
has caused many rejected claims in California because of doctors'
unfamiliarity with the process, Coeytaux says.
Despite the growing pains, family
planning advocates say there are solutions to nearly all of the problems
thwarting access to emergency contraceptive pills.
For example, Planned Parenthood is
leading the charge to encourage all women of childbearing age to have a
dose on hand or to obtain a prescription to fill in an emergency.
The Los Angeles chapter's distribution
of the pills doubled from February to March (from 428 to 976), when the
campaign was launched.
"Studies have
shown that women are much more likely to use emergency contraception when
they need it if they already have it at home," says Nancy L. Sasaki,
president and chief executive of Planned Parenthood Los Angeles.
* * * The Pacific Institute
for Women's Health will distribute its physician's guide to all
state-funded family planning providers and 25,000 doctors nationwide to
encourage providers to "reduce the steps" that women must go through to
obtain the pills.
For example, some
doctors still require a woman to have a pelvic exam and pregnancy test
before writing a prescription for the pills, although no major medical
group mandates this.
Doctors are also
urged to issue the pills by telephone, without requiring an appointment,
Coeytaux says. The institute's guide describes how a doctor can conduct
safe, careful telephone screening and prescribing of emergency
contraceptives.
Doctors need to
establish a plan on how to provide fast service to patients at all times
of the day and week, Trussell says.
"Physicians haven't grappled with how to
change their practices to deal with this," he says. "They need to decide
how women will get it. Will they prescribe over the phone? Who do they
refer a woman to after hours? Providers need to figure out the logistics."
* * * There is also a
growing movement to convince state legislators to allow pharmacists to
dispense emergency contraceptives. Washington state has such a law. And,
in California, a law went into effect in January that allows pharmacists
to initiate and monitor drug therapy for individual patients in
collaboration with a doctor.
What this
means is that a doctor and pharmacist can agree in advance that the
pharmacist may treat a particular patient for a given condition, whether
it is diabetes or asthma or emergency contraceptive use.
"One of the most valuable aspects of
pharmacies is their long hours, weekend hours and the fact that no
appointment is necessary," says Elizabeth Johnson, senior vice president
of the California Pharmacists' Assn. In February, the CPA passed a
resolution urging voluntary participation in programs to expand the use of
emergency contraceptives, Johnson says.
Finally, Coeytaux says, there is hope
that emergency contraceptive pills, because of their safety, will someday
be sold over the counter.
That is not
expected to happen any time soon. But progress can be made to bring down
other barriers, Coeytaux says, "as long as we aim for a rapid response to
access."
* * *
Preven and
Plan B
Two emergency contraceptive
products are on the market. Preven contains the same hormones found in
birth control pills, estrogen and progestin. The pills cause nausea in
about half of women. Preven reduces the risk of pregnancy by 75%.
Generally, if 100 women have unprotected intercourse in the second or
third week of the menstrual cycle, about eight become pregnant. Preven
cuts that rate to about two, a 75% reduction.
Plan B contains the hormone
levonorgestrel and carries less risk of nausea and vomiting. If the same
100 women used Plan B, only 1 would become pregnant, an 89% reduction over
normal risk.
Another levonorgestrel
product is expected to come on the market later this year.
* * * The Pacific Institute
for Women's Health has two publications on emergency contraception: one
for health care providers called "A Clinician's Guide to Providing
Emergency Contraceptive Pills" and one for the general public called "From
Secret to Shelf: How Collaboration Is Bringing Emergency Contraception to
Women."
The publications are available
from the institute ($6 for "Clinicians Guide" and $10 for "Secret to
Shelf") or by calling (310) 842-6828. They are free on the Web at http://www.piwh.org/.
*
Copyright 2000 Los Angeles Times
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