EXECUTIVE SUMMARY

In 2013, the Food and Drug Administration removed age restrictions on emergency contraception (EC), allowing it to be sold over the counter to all consumers. However, results of a new study indicate that barriers to and disparities in access for adolescents still exist.

  • Despite policy changes that were intended to improve access to EC, there still are persistent barriers to access that are more prominent in low-income neighborhoods, research indicates.
  • While over-the-counter access to levonorgestrel-only pills does provide women a chance to prevent unintended pregnancy, family planning clinicians now advocate for the use of the copper intrauterine device and ulipristal acetate pills as more effective methods of emergency contraception.

In 2013, the Food and Drug Administration removed age restrictions on emergency contraception (EC), allowing it to be sold over the counter to all consumers. However, results of a new study indicate that barriers to and disparities in access for adolescents still exist.1

Same-day access to emergency contraception is an important piece of effective pregnancy prevention for adolescents. Despite policy changes that started in 2013 that were intended to improve access to EC, there still are persistent barriers to access that are more prominent in low-income neighborhoods.

Reproductive health access advocates were heartened in 2014 when restrictions on generic forms of EC were removed. However, packaging still had to include a “use recommendation” that mentioned the intended users were limited to women 17 years of age or older. The use recommendation, while not enforceable, was related to Frazer, PA-based Teva Women’s Health’s patent on Plan B One-Step, the initial levonorgestrel EC pill. This recommendation was removed in 2016 when the market exclusivity for Plan B One-Step expired.

Tracey Wilkinson, MD, MPH, assistant professor of pediatrics at Indiana University in Indianapolis, conducted an initial investigation into pharmacy access, which was published in 2012.2 Wilkinson, whose research focuses on access to reproductive health services for adolescents, says she is not surprised by the current results. “Given the history of EC in the U.S. and all the changing regulations, the fact that misinformation exists isn’t shocking; however, it is disappointing because the point of removing all the restrictions (which occurred in 2013) was to help decrease this misinformation and improve access,” Wilkinson says.

“Our study shows that there are still persistent barriers for adolescents, and so there is still work to be done to assure that everyone (especially adolescents) can have guaranteed access to EC when it is needed,” she says.

Review the Research

To perform the study, female mystery callers posing as 17-year-old teens in need of EC used standardized scripts to call 979 pharmacies in Nashville, Philadelphia, Cleveland, Austin, and Portland. Researchers used 2015 estimated census data and the federal poverty level to characterize pharmacy neighborhood income levels.

Of the 979 pharmacies contacted, 827 (83%) indicated that EC was available. The proportion did not vary by pharmacy neighborhood income level, nor was it significantly different from the 2012 study (P = 0.78). When examining access, 8.3% of the pharmacies reported it was impossible to obtain EC under any circumstances, which occurred more often in low-income neighborhoods (10.3% vs. 6.3%, adjusted odds ratio [OR] 1.5; 95% confidence interval [CI], 1.20-1.94). This number was not significantly different from 2012 (P = 0.66).

Correct information regarding over-the-counter access was conveyed only 51.6% of the time; accuracy did not differ by the pharmacy’s neighborhood income (47.9% vs. 55.3%, adjusted OR 0.89; 95% CI, 0.71-1.11) and was not significantly different from 2012 (P = 0.37).

New Recommendations Issued

While over-the-counter access to levonorgestrel-only pills does provide women a chance to prevent unintended pregnancy, family planning clinicians now advocate for the use of the copper intrauterine device (IUD) and ulipristal acetate pills as more effective methods of emergency contraception. The IUD represents the most effective method of emergency contraception, with a failure rate of less than one per thousand.3 Ulipristal acetate pills have an approximate 1.4% failure rate.3

The American College of Obstetricians and Gynecologists has just issued a new Committee Opinion on the subject, with the following recommendations:

  • Clinicians should counsel patients that a copper IUD is the most effective form of emergency contraception. Providers should consider integrating copper IUD emergency contraception provision into their practices and allowing same-day provision of IUDs, the opinion states.
  • Providers should prescribe ulipristal acetate when possible because it is more effective than levonorgestrel at all times up to five days after unprotected intercourse, and in women of all weights.
  • Clinicians should write advance prescriptions for emergency contraception, particularly for ulipristal acetate, to increase awareness and reduce barriers to immediate access.4

Compared to EC users who choose oral levonorgestrel, those who select the copper IUD have lower rates of pregnancy in the next year, results of a 2014 study indicate.5 

REFERENCES

  1. Wilkinson TA, Clark P, Rafie S, et al. Access to emergency contraception after removal of age restrictions. Pediatrics 2017; doi:10.1542/peds.2016-4262.
  2. Wilkinson TA, Fahey N, Suther E, et al. Access to emergency contraception for adolescents. JAMA 2012;307:362-363.
  3. Cleland K, Zhu H, Goldstuck N, et al. The efficacy of intrauterine devices for emergency contraception: A systematic review of 35 years of experience. Hum Reprod 2012;27:1994-2000.
  4. Committee on Health Care for Underserved Women. Committee Opinion No. 707: Access to Emergency Contraception. Obstet Gynecol 2017;130:e48-e52.
  5. Turok DK, Jacobson JC, Dermish AI, et al. Emergency contraception with a copper IUD or oral levonorgestrel: An observational study of 1-year pregnancy rates. Contraception 2014;89:222-228.