Mandatory EC provision raises debate in Alabama

Is providing emergency contraception (EC) a problem for clinicians in your facility? Since January 2004, eight nurses within the Alabama Department of Public Health system have retired or resigned with letters of resignation that listed dispensing EC as at least one of their reasons for leaving.

According a statement issued by Tom Miller, MD, director of the bureau of family health services at the Alabama agency, the employees left without seeking an accommodation or without allowing the department time to resolve their request for accommodation.1 Five employees have requests pending for accommodations. The agency is working with them to find appropriate assignments, according to Miller’s statement.

The Alabama health department began providing EC as a routine service in April 2004. The state is the last in the Southeast to implement EC as a standard service, according to the statement issued by Miller. Some county clinics already were offering EC if patients asked for it, but not all clinics provided the service.2 In April, the state health department mandated that EC be available, as are all other forms of contraception, at all health departments.2

EC is recognized as a method of contraception; according to a 1997 Department of Health and Human Services memorandum issued to all Title X regional health administrators, "grantees should consider the availability of emergency contraception the same as any other method which has been established as safe and effective."3 The Alabama health department receives $4.9 million in federal family planning funds.4

The need for EC in Alabama exists. Planned Parenthood of Alabama provided the method to 770 women in 2003 at its four health centers in Birmingham, Huntsville, Mobile, and Montgomery, according to Larry Rodick, president and chief executive officer.

"It remains to be seen if we will see that many this year with the Health Department getting into it," he says. "We don’t have a problem with that; emergency contraception needs to be out there."

Refusal clauses rise 

The last two years have seen a revival of refusal clause legislation on the state level, says Erica Smock, a legislative analyst with the New York City-based Center for Reproductive Rights. Such legislation allows health care providers to refuse provision of medical services on religious or ethical grounds. Refusal clauses are rooted in the struggle over abortion rights. Because some of those opposed to abortion consider EC an abortifacient, the situation in Alabama may be an example of clinicians refusing to provide services on religious or ethical grounds, she notes.

According to the New York City-based Alan Guttmacher Institute, at least one state, Mississippi, has passed refusal-clause legislation in 2004. Gov. Haley Barbour signed legislation in May, allowing health care providers, including pharmacists or other pharmacy employees, counselors, social workers, health insurers, and health care facilities, to refuse to provide medical services, including counseling and referral, on religious or ethical grounds.5 The new law also prohibits the denial of public benefits because of a refusal to provide or pay for services.5

The Michigan House in April approved a measure to allow individual medical providers, including pharmacists, to refuse to provide health care services because of a moral, ethical, or religious objection.5 Although the measure would prohibit a provider from refusing to provide contraceptive services, it would limit that protection to services provided "in advance of sexual intercourse," which would allow a provider to refuse to provide EC. The measure is awaiting consideration in the Senate.5

Check WA record

Providing EC hasn’t proven to be a problem for many state agencies. Check the experience of Washington State’s Department of Social and Health Services Medical Assistance Administration and Department of Health Office of Family Planning and Reproductive Health. These agencies have had a successful experience, reports Jane Hutchings, senior program officer with the Seattle-based Program for Appropriate Technology in Health (PATH).

In 1999, the agencies decided to incorporate EC pills (ECPs) into family planning services and other programs serving women at risk of unintended pregnancy. Working with PATH, the departments collaborated in integrating EC in their efforts to reduce unintended pregnancy. By working with all involved, the agencies have implemented the following progressive steps:

  • The First Steps program for pregnant women and new mothers now provides EC information and supplies as part of its family planning services.
  • Clients in the Take Charge family planning waiver program, which reaches Washington State residents lacking full family planning insurance coverage, can obtain ECPs free of charge from participating clinics and participating pharmacies, which are reimbursed by the medical assistance administration.
  • The Drug and Alcohol Substance Abuse program, which includes a program for pregnant and parenting women, automatically includes ECPs with other family planning methods.6

"All participants — from policy-makers to local communities — must view family planning as a norm and promote EC within the context of family planning," say state officials in a report on the subject. "EC is an addition to the mix of family planning methods, not an end in itself."6


1. Miller T. Health Department issues statement on emergency contraception. June 25, 2004. Accessed at:

2. Velasco A. Group fights morning-after pill availability. Birmingham Post-Herald. June 17, 2004. Accessed at:

3. Department of Health and Human Services (DHHS), Office of Population Affairs, Memorandum: OPA program instruction series, OPA 97-2: Emergency contraception, Washington, DC; April 23, 1997.

4. Witt E. Path of logic has political pitfalls for Giles. Birmingham Post-Herald. June 26, 2004. Accessed at:

5. Alan Guttmacher Institute. Monthly State Update: Major Developments in 2004. July 1, 2004. Accessed at

6. Weldin M, Hutchings J, Kelly K, et al. Expanding Access to Emergency Contraception Through State Systems: The Washington State Experience. Seattle; June 2004.