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On-line awareness campaign ad sponsored by 100 medical and women's health advocacy groups.
By Kari Huus Reporter
msnbc.com
updated 3/4/2004 1:56:36 PM ET 2004-03-04T18:56:36

Unprotected sex. It may seem like a good idea at the time, but with dawn can come the creeping dread of an unintended pregnancy. For some women, this is where the "morning after" pill comes in.

The drug, now available only by prescription, offers a woman who has had unprotected sex in the previous three days a good chance of averting an unintended pregnancy.

In theory, the Food and Drug Administration's approval of the pill for over-the-counter sales without the OK of doctors, pharmacists or parents would make the drug no more difficult to buy than aspirin. But even if it is approved, widespread availability of emergency contraception is anything but guaranteed.

The two sides in the long-running, high-stakes battle over reproductive rights are split over the definition of life, even when intervention occurs almost immediately. If anything, the morning after pill, which would be sold under the brand name Plan B, could expand their public battle ground to include not only clinics that perform abortions, but drug store chains and hospitals that offer emergency contraception.

“This is not the end of the story,” Evelyn Becker, deputy director of communications for NARAL Pro-choice America, says of the pill. “There is still a lot of legislation that we’re working on around the country. ... There’s still the huge issue of women being aware of it.”

Ditto for opponents of the drug, such as Concerned Women for America, a non-profit group that promotes biblical principles in public policy. “I’m sure there will be groups that will work on a grass-roots level” to limit access to the drug, says Wendy Wright, senior policy adviser to the group. She adds: “There’s one group that will be very interested, and that will be trial lawyers, because there will be women who are hurt by (the drug).”

The pill is actually two concentrated doses of levonorgestrel, a hormone commonly found in birth control pills, that are taken within 72 hours of sexual activity. While it has been available by prescription in most states, a handful have made it legal for drug stores to sell the pill without a prescription after a pharmacist has counseled the customer.

The devil’s in the definitions
The battle over the morning after pill centers on definitions. The American College of Obstetricians and Gynecologists defines the start of pregnancy as the successful implantation of a fertilized egg in the wall of the uterus, a process that can take a week and a half from ovulation.

Plan B, and a product available through prescription called Preven, is believed to work in three ways: by delaying the release of the woman’s egg, by preventing sperm from fertilizing the egg or by inhibiting implantation of the fertilized egg. The drug has no effect on an egg successfully implanted in the wall of the uterus, distinguishing it from RU-486, a drug designed to induce miscarriage. So from a pro-choice point of view, the morning after pill is a means of preventing pregnancy, thus a contraceptive.

But anti-abortion groups, such as the National Right to Life Movement, the American Life League, the Family Research Council and Concerned Women for America, argue that life begins at fertilization, not implantation, and that using the morning after pill is tantamount to abortion because it could prevent a fertilized egg from being implanted. Another powerful opponent is the U.S. Conference of Catholic Bishops, which opposes contraception as well as abortion.

Debate over the debate
Right-to-life groups have subtly shifted their definition of abortion, says Jean Reith Schroedel, professor of politics and policy at Claremont Graduate University. "Most right-to-life groups are now defining abortion as anything that interrupts or halts a fertilized egg," she says. But, she also notes, "just by natural processes, two-thirds of fertilized eggs don't attach."

Some on the other side of the debate say it is the pro-choice groups that have shifted ground, out of expediency. "When birth control became available in 1960s ... the medical community suddenly said the beginning of life begins at implantation, not conception," says Wright. She and others argue that Plan B should be labeled as an abortion agent since it has the capacity to determine the fate of a fertilized egg.

Asked about its position on the morning after pill, the National Right to Life Committee issued a statement, but declined further comment. NRLC "is opposed to abortion, infanticide, euthanasia and assisted suicide," the statement read. "NRLC takes no position on the prevention of the uniting of sperm and egg. Once fertilization, i.e., the uniting of sperm and egg, has occurred, a new life has begun and NRLC is opposed to the destruction of that new human life."

Gauging the impact on abortion rates
According to Plan B’s supporters, making the drug widely available could result in a dramatic dent in abortion rates. “Increased access has the potential to avert half of the approximately 3 million unintended pregnancies each year,” says Becker. Some studies cited by these groups contend the morning after pill also could avert up to 800,000 abortions per year.

In 2000, even when the drug was almost exclusively available only by prescription, it was used to prevent some 50,000 potential abortions, according to a study by the Alan Guttmacher Institute, which tracks reproductive health issues.

Opponents counter that the drug would prompt women and teens to have unprotected sex, raising the risk of sexually transmitted diseases. They also cite research from other countries where abortion rates have not fallen, despite relatively easy access to the morning after pill.

U.S. abortion rates have declined since 1990, and both sides claim some credit for this. The rate hit a low of 23.1 per 1,000 women ages 15 to 44 in 2000, but it has ebbed and flowed throughout history, influenced by factors as varied as the weather and economy, and difficult to isolate.

Scholars say both sides are probably overplaying their predictions for the morning after pill.

Making the pill available over the counter would have “a significant impact,” says Schroedel, but probably not among teenagers, who are least likely to act within 72 hours.

“The younger the female is, the later she is to deal with the pregnancy," Schroedel says. "So a 14-, 15-year-old girl has sex for the first time … she may not be in a place emotionally or psychologically to deal with this until she is past that window.”

Adrienne Asch, the Henry R. Luce professor in biology, ethics and the politics of human reproduction at Wellesley College, says the pill would most likely be used by “people who tried to be responsible and on one occasion weren’t.”

But she also sees teens as problematic: "People who pretend to themselves that they’re not having sexual relations ... especially teenagers ... have no more reason to use the morning after pill than they were to buy contraception” beforehand.

Fight over public awareness
To a great extent, the impact of Plan B would depend on public awareness campaigns, pro and con. A Kaiser Family Foundation survey published in 2000 found that only about half of American women know the morning after pill is an option and understand how it is used — lagging far behind knowledge of the pill in Europe. Many American women also confused it with RU-486.

Women's Capital Corporation  /  Kaisernetwork.org
An advertisement for Plan B emergency contraception that was posted on college campuses. It reads: "Delta Delta Thi. 27 upstanding young men. 36 billion sneaky little sperm." The campaign was discontinued.
Opponents of Plan B would most certainly fight its inclusion in sex education curriculum. One-fourth of sex education teachers already are prohibited from teaching students about contraceptives of any kind. Pending in Congress is a bill introduced by Rep. Melissa Hart, R-Pa., to deny federal funding to public secondary or elementary schools that provide emergency contraception to students through school clinics.

Another controversy surrounds hospitals and whether they must give victims of sexual assault emergency contraception or provide information about it. Each year, an estimated 32,000 women become pregnant as a result of rape or incest, according to the Guttmacher Institute.

Although the American Medical Association recommends counseling on emergency contraception as a key part of treating sexual assault victims, a study conducted in Pennsylvania in 2000 and 2002 by the non-profit Clara Bell Duvall Reproductive Freedom Project showed that fewer than half of emergency rooms in that state offered the counseling, and 10 percent did not mention emergency contraceptives at all.

Five states have passed laws that require hospitals that receive public funding to offer information on emergency contraception. Two — California and Washington — require that both information on and access to the drug be provided. Similar legislation has been introduced in Congress.

Catholic hospitals are bound to fight any such requirements. About 75 percent of Catholic hospitals will not make the morning after pill available to sexual assault victims, and about half also refuse to tell victims where they can obtain the pills. Religious groups have fought for conscience clauses — provisions in laws that permit individual doctors, pharmacists, insurers and hospitals to refuse to provide services that they object to on moral, ethical or religious grounds.

Catholic hospitals control about 15 percent of the market and their influence is growing. “As hospitals shut down and Catholic hospitals merge with non-Catholic hospitals, then it becomes a real issue,” says Schroedel.

Drug stores a new battle ground?
Store policies also would determine Plan B's availability. The huge discount chain Wal-Mart has opted not to stock emergency contraception — a policy that the company says it has no plans to change if the drug is approved for over-the-counter sales. The company has said it would refer women seeking the drugs to other outlets, but some pro-choice advocates fear that Wal-Mart's policy may leave rural women in particular without a timely option. Many drug stores in small communities would be reluctant to carry the pill, fearful of negative publicity and protests, according to a Guttmacher Institute study.

Starting in the late 1990s, Washington state ran a trial allowing women to buy emergency contraceptives after talking with a pharmacist, but with no prescription. The expected protests and confrontation did not materialize, but the real test, say scholars, would be in American's conservative heartland.

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