In Our Control (32 page)

How many doctors object to providing certain kinds of care? A study published in 2007 in the
New England Journal of Medicine
suggests that the number is substantial: 52 percent of surveyed doctors objected to abortion as a response to botched birth control, and 42 percent felt that parents should be involved in deciding whether to prescribe teenagers contraceptives.
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The article’s authors estimate that as many as 14 million Americans may be going to doctors who don’t believe they have an ethical obligation to provide a patient with all their medical options if they find some of those possibilities objectionable, and 100 million Americans have doctors who don’t think they should be required to provide referrals for pills, procedures, or surgeries to which they object. These statistics offer a snapshot of how far-reaching the Bush-style conscience rule could be. On a practical level it is clear that patients need to be proactive in educating themselves about their medical conditions and calling doctor’s offices in advance of appointments to insure that their chosen practitioner provides all the services—or referrals—they might need.

For young, uninsured, and low-income women, this poses particular challenges. Women who struggle to afford a single doctor’s visit find that refusal of services at one office may mean an inability to receive desired care. Indeed, while advocates of sexual education often rightly point a finger at abstinence-only programs (which received $1.3 billion of federal money under Bush
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) when looking at teen pregnancy statistics, it is worth asking how free and open access to birth control services might impact these numbers. As one doctor notes, refusal of services “represents the latest struggle with regard to religion in America,” noting that doctors who insist on conscientious objection want “an unfettered right to personal autonomy while holding monopolistic control over a public good.”
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Several pharmacies also claim the right not to dispense Plan B or conventional contraceptives. So-called pro-life drugstores, such as the one that opened in Chantilly, Virginia, in 2008 and became the subject of a
Washington Post
article, are springing up around the country in states that allow druggists to refuse to provide products to which they object.
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The group Pharmacists for Life provides a national list of pharmacies that don’t stock contraceptive products. While some bioethicists feel that this sort of movement accurately represents the diversity of American opinions about these drugs, others worry that, particularly in rural areas, the new policies might create large geographic regions where birth control services are simply unavailable. At the very least, women’s health advocates argue, pharmacies that refuse to stock contraceptives should disclose this fact in some overt way, perhaps by noting their policies in store windows or by posting them on their Web site.

Few would argue that opponents of abortion should be forced to perform or assist in the procedure. Also at issue, though, is the right to refuse to provide patients with complete information about their medical options as well as the right to refuse to provide referrals. While the first issue is understandable, already legally protected under the Civil Rights Act of 1964, and largely uncontested, the second and third are more controversial.

One of the least compassionate aspects of the Bush administration’s conscience clause was the singling out of policies aimed at ensuring that hospitals, even religiously affiliated ones, offer EC to rape victims. Research prior to OTC status indicates that when it came to providing
resources for rape victims, emergency rooms and hospitals were falling down on the job. A 2002 report found that only 21 percent of rape victims received emergency contraception between 1992 and 1999.
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While these numbers have steadily improved over the last decade, they still remain strikingly low.
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Many states have taken steps to mandate that the drug be offered to women who come to emergency rooms after sexual assaults. Because the efficacy of EC declines rapidly with delayed administration, hospital refusal to provide the drug could be particularly devastating for rape victims. In some cases conservative lawmakers, such as Connecticut governor Jodi Rell, have contributed to legal compromises to ensure that women who need the drug receive it.
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The Connecticut rule dispensed with earlier requirements that women take both an ovulation and a pregnancy test before the drug could be administered, and state bishops decided not to fight the change. In Pennsylvania a similar bill stirred controversy and resistance from Catholic groups and other religious organizations who believed that EC amounted to abortion and opposed it even for rape victims. Amy Beisel of the Pennsylvania Catholic Conference explained, “If we believe that life begins at conception, then we are talking about treating two patients.”
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Representative Dan Frankel countered, “This is not an issue about abortion … this is about protecting women who have been victimized.”
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These state skirmishes were hard-won, and the new rule threatened to undo the fragile peace that had begun to grow on former battlegrounds. Lawyer and historian Dorothy Roberts singles out the tendency to “pit a mother’s welfare against that of her unborn child” as a particular feature of a society that tries to withhold reproductive autonomy from female populations.
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Here we see this strategy of control taken to the next level: the psychological and physical well-being of women at their most vulnerable—after a rape—is pitted against the
idea
of an unborn child.

By late February 2009, the Obama administration moved to discard the Bush conscience rule. By that point seven states and two family planning groups had filed lawsuits to contest the policy.
⁴⁰
One official noted that problems with “the Bush provider-refusal regulation” included the fact that it was worded so vaguely that “some have argued it could limit counseling, family planning, even blood transfusions and end-of-life
care.”
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The decision followed other reproductive health actions taken in Obama’s first thirty days where women’s rights figured prominently. In addition to removing the conscience rule, Obama laid the groundwork for dispensing with the so-called global gag rule, a Reagan-era policy that refused American funds to international family planning groups that offered or even just referred women for abortions.
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Lest women feel too optimistic about the new administration’s efforts to increase their reproductive rights, let it be known that the Obama administration capitulated with record speed when Republican lawmakers singled out contraceptive spending as an example of pork in the giant economic package. Commentator Ellen Goodman noted, “Searching through the economic stimulus plan for a villain, the balky Republican leadership jumped on a provision to allow states to expand family planning under Medicaid.”
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In defending his fledgling health care plan in the early fall of 2009, Obama said unequivocally that he did not plan to use public dollars to fund abortions, despite the fact that they are legal medical procedures. Women’s health provisions have again been singled out, treated differently, used as political currency, and made into an example. It is a reminder that post-Bush optimism needs to be tempered by the realities of reproductive struggles that will no doubt continue to endure.

A victory for emergency contraceptive advocates that was not tied to the new administration happened in March 2009, when the US District Court for the Eastern District of New York ordered the FDA to offer Plan B without prescription to seventeen-year-olds within thirty days, and gave the organization a mandate to reconsider the original decision for women of all ages. Judge Edward R. Korman noted that the FDA had “acted in bad faith and in response to political pressure.”
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It was a vindication for Susan Wood and the other health advocates who had fought to publicize the strange case of Plan B. For young women who are still barred from access, it is important to know that several states offer programs where patients can obtain the drug directly from pharmacists, usually for a small consultation fee. These programs were put in place in response to the initial rejection of OTC Plan B to make access easier for women who didn’t have the time or financial resources for doctor’s visits.
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Politics Aside: Safety and Efficacy of Emergency Contraception

Once we detach these little pills from the big rhetoric that surrounds them, what information do patients need in order to use them safely and wisely?

The single biggest misconception about emergency contraception is that it is equivalent to medication abortion. Many young women who could benefit from the drug are reluctant to use it because of this very common error. Emergency contraception will not induce abortion if a patient is already pregnant. Mifepristone and misoprostol, the drugs taken to cause an abortion, work in ways that are totally different from EC. Mifepristone is an antiprogestin that prevents progesterone from protecting a woman’s pregnancy and letting her body know that further ovulation isn’t necessary. As a result, the uterine lining begins to shed—as it does in a monthly period. The second drug, misoprostol, induces uterine contractions that cause bleeding and the expulsion of the embryo.

Plan B has the opposite effect on a woman’s hormones. It provides the body with a massive dose of progestin (levonorgestrel), helping to prevent ovulation by convincing the body that it is already pregnant. Despite being used after sex, EC is (as its name implies) contraception, meaning it
prevents
pregnancy—not abortion, which ends pregnancy.

There are several forms of postcoital birth control. The most famous, of course, is Plan B. For many reasons it is the simplest form of emergency contraception, consisting of only two small white levonorgestrel pills that may be taken together or twelve hours apart. In the summer of 2009, the FDA approved Plan B One-Step, a single 1500 μg dose of levonorgestrel.
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In addition, at least twenty-three approved brands of birth control pills can be used for emergency contraception,
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including combination (estrogen and progestin) and progestin-only pills; progestin-only pills are found to have fewer side effects and to be more effective. Patients who choose to use regular birth control pills must take the suggested dose in two installments spaced twelve hours apart. If you are considering this, be sure to speak with your doctor or consult a health care professional (clinics like Planned Parenthood can offer comprehensive information). Because you may experience severe nausea and vomiting, you might want to take an antinausea aid such as Dramamine or Bonine to settle your stomach.

In general, Plan B and hormonal emergency contraception have good safety profiles, and there are no long-term side effects. But because they offer a large dose of powerful chemicals, there are usually short-term side effects. These are generally painful but not dangerous, usually akin to bad menstrual symptoms. Common problems include cramping and abdominal pain, dizziness and headache, breast tenderness, spotting or bleeding, and tiredness. As with traditional oral contraceptives, EC can interact with certain drugs, particularly those that are metabolized through the liver such as St. John’s Wort, potentially decreasing its effectiveness.

Because EC disrupts the menstrual cycle, it is likely that those who take it will experience cycle irregularity. Your period may come earlier or later than you expect, or your flow might be different from your usual menses. Repeated use of the drug over a short period of time may cause a more serious disruption of periods and even menstrual chaos. Since the extent of this damage isn’t known, it is advisable to use emergency contraception only as a backup method, not as a primary form of birth control. One extremely rare but serious possible problem is ectopic pregnancy.
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Another highly effective type of birth control that can be employed after sex is the insertion of a Copper-T IUD. The IUD can be inserted up to five days after intercourse
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and is 99 percent effective at preventing pregnancy. The decision to have an IUD put in is a serious one and is far more complicated to reverse than taking a pill. IUDs generally remain in the uterus for years (three to ten) and are not a short-term solution to any problem. Still, this method may be more foolproof in terms of pregnancy prevention than chemical alternatives.

Many health experts recommend that women keep emergency contraception on hand as a precautionary measure. This advice comes in response to studies showing that women are more likely to use the pill if they already have it. Michael T. Mennuti of the American College of Obstetricians and Gynecologists (ACOG) explains, “We hope to make EC a forethought, not an afterthought.”
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The shelf life of Plan B is forty-eight months,
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long enough to make the fifty dollar investment worthwhile.

Access remains an issue for many patients. Estimates vary about how many pharmacies carry the drug. A study of Los Angeles–area stores found that 69 percent had the drug on their shelves, 19 percent referred
callers to other providers, and the remaining stores refused to provide information or hung up the phone.
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A survey in New York City is more encouraging:
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between 2002 and 2006 the percentage of stores stocking Plan B rose from 55 percent to 87 percent, and by the spring of 2007 the number was up to 94 percent, an accomplishment that Council Speaker Christine Quinn called a “major victory in the fight to protect the reproductive rights of all women.”
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In general, access to EC is better in cities than in small towns,
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and the number of stores that stock the products has improved since OTC status was granted.
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