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 V.14 No.22 | June 2 - 8, 2005 

Feature

What's Plan B?

Access to emergency contraception has become a national issue—one that asks whether pharmacists have the right to dispense morality.

Lorrie Latham

No one ever said parenting was easy. But at 16, the word parent takes on a whole new meaning.

Angel Duran learned she was pregnant when she was 15. The news came just days before she was scheduled to take the birth control pills burning a hole in her purse. Shortly after her sweet sixteen, she gave birth to a baby girl.

“Having a baby changes everything,” she says, one ear cocked to the side, tuned to the soft chirps of her daughter in the next room. “Most teenagers spend their money on anything. Me, it goes to diapers, clothes and toys.”

Duran is one of six teens that belong to the local group Get Loud, which focuses on providing education to other teens (and whoever else will listen) on topics such as drugs, alcohol and sex. The Planned Parenthood-sponsored group, based out of the South Valley, was initiated by some of its members a couple years ago after they attended an event by the similarly motivated group Get Real, which focuses on teen pregnancy. Get Loud was finally turned into an official school club this year at Rio Grande High School, the school its members attend.

The group is active in the community and tries to educate by visiting classrooms, other schools and attending local events such as South Valley Pride Day and health fairs. An issue of primary importance, says Duran, is that of emergency contraception and in particular Plan B (a.k.a. the morning-after pill), which is now the safest and most widely used form of emergency contraception. Different from regular contraception in that it is used after sex, emergency contraception works in the same way as birth control pills, preventing pregnancy primarily by delaying or stopping ovulation, as well as potentially helping to prevent fertilization and implantation (although it has never been proven to affect the latter).

“Most of the girls I talk to don't know what [Plan B] is, or they think it's an abortion pill,” says Duran. “Before I got pregnant, I thought that's what it was, too. I didn't learn about what it really was until after I had my daughter.” Duran's observations seem to be representative of the common opinion among her peers. It's an opinion that also seems to mirror the nation's understanding of emergency contraception. According to a 2003 California study by the Kaiser Family Foundation with the Princeton Survey Research Associates, only 65 percent of the population has heard about emergency contraception, and 49 percent of women confuse it with the actual abortion pill, mifepristone (a.k.a. RU-486).

“If girls knew what it was, it could really help their lives,” says Duran, stressing that education is about understanding all of the medical choices tested and readily available. “It would give them options.”

Jasmin Hendrickson of Planned Parenthood believes that teen pregnancy in New Mexico could be reduced if Plan B was made more widely available.
Lorrie Latham
Jasmin Hendrickson of Planned Parenthood believes that teen pregnancy in New Mexico could be reduced if Plan B was made more widely available.

Currently, all over the United States, access to options is driving the fight over women's reproductive rights. A new legislative interest, both federally and statewide, has recently emerged in emergency contraception. While some states are working to make it more accessible, others are working to limit its access. Meanwhile, the federal government is fiddling back and forth between the two. The one certain thing is that, right now, nothing is stable.

Sex and Politics

Nine years ago, a woman walked into a Kmart in Indiana and handed over her prescription for birth control pills to the pharmacist. She was refused. The pharmacist, citing moral objections as her reason for lying to the woman, told her that the requested brand was out of stock when it wasn't. The pharmacist was promptly fired. Around the same time, a similar thing happened at a pharmacy in Portland, Ore., when the pharmacist refused to fill a prescription for Plan B and failed to refer the patient to someone else. Parallel incidents also occurred in California and New Mexico. In one Wisconsin case, a pharmacist not only refused to fill a woman's prescription for birth control pills, but he physically took the prescription from her.

According to Dr. Eve Espey, Associate Professor with the Department of Obstetrics and Gynecology at the University of New Mexico, within the last six months over 180 cases of women being refused oral contraceptives by pharmacists have been cited around the country, and that's just the women who've reported their experiences. Over the last few years, this rather sudden and unexpected series of events has sparked a chain of legislation all around the country.

It is an issue that most folks feel passionate about—albeit for very different reasons. Some pharmacists and reproductive rights groups are angry that all pharmacists aren't fulfilling their job descriptions, while passing judgment on those that come before their counters.

Other pharmacists and some pro-life groups are riled that employees, who are only stepping in sway with their values, are being punished for doing what they believe to be morally right. Groups such as Pharmacists for Life International (PFLI), for instance, which has 1,600 members around the country, believes that pharmacists shouldn't be forced to dispense a medication they find morally wrong. The organization is against emergency contraception, as it believes that if the drug ever prevents a fertilized egg from implanting in the uterine wall (although, again, it has never been proven that Plan B has this capability) the contraceptive could be considered tantamount to abortion.

Dr. Eve Espey discusses the impact that pharmaceutical legislation could have on women in rural communities.
Lorrie Latham
Dr. Eve Espey discusses the impact that pharmaceutical legislation could have on women in rural communities.

And so the issue has become not only one of whether pharmacists should be obligated to fill prescriptions, but also one of pro-choice versus pro-life, or between those who believe that pregnancy begins at implantation versus those who believe it begins at fertilization.

To date, at least 23 states have passed laws or are contemplating measures concerning access to emergency contraception. Some states are pushing “conscience clauses,” which allow pharmacists the right to refuse to dispense contraceptives. Others are interested in legislation that would require all pharmacies to stock Plan B (which, nationally, they aren't obligated to do), and which would also force pharmacists to fill contraception-related prescriptions. Still other states are concerned with providing access to Plan B in hospitals, requiring that doctors and nurses offer it to rape victims. And some states, like New Mexico, have enacted legislation that allows pharmacists, with the proper voluntary training, to prescribe and dispense Plan B independently.

New Mexico is actually one of the most liberal states when it comes to emergency contraception. In 2001, the Legislature passed a law that allowed pharmacists in the state (after taking the appropriate training) to prescribe and dispense Plan B without the collaboration of any other healthcare provider. There are five other states that have similar laws, called “collaborative practice” measures, which allow pharmacists to prescribe emergency contraception in-house, although they all require that the pharmacist get the consent of a doctor. New Mexico also enacted a law two years ago, which requires that all hospitals inform rape victims about the emergency contraception option.

Giovanna Rossi, Executive Director of NARAL Pro-Choice New Mexico, says that before this law was passed, only one-half of all hospitals in the state had policies regarding Plan B. Beyond hospital care, our state takes the middle ground on whether or not pharmacists should be able to refuse prescriptions. Currently, it's acceptable for pharmacists to decline to fill a prescription, although they are required to refer the patient to someone who will fill it.

Contraception has also become a federal issue. A bill sponsored by Sen. Frank Lautenberg (D-NJ) proposes to make it illegal for pharmacists to refuse to fill prescriptions because of moral objections. The bill would still allow pharmacists to decline to fill a prescription themselves, but would oblige them to find another pharmacist who was easily accessible who would be willing to fill it. If the bill passes, pharmacists could be fined up to $5,000 a day or $500,000 total for violations.

“With this administration that [bill] will never fly—but at least it's been proposed,” says Dr. Espey, who's hopeful that the bill is a sign of mounting national awareness. “I think there's increasing consciousness that pharmacists, in some ways, are becoming the moral arbiters of who gets what in the pharmacy.”

Yet all of the debated legislation could become immaterial if Plan B is approved by the Food and Drug Administration (FDA) to be sold over-the-counter without prescription, an effort that's been underway on the part of reproductive rights organizations for years. In fact, in December of 2003 the FDA advisory panel on women's health and nonprescription drugs voted 23 to 4 to approve Plan B for over-the-counter sale. Yet, in what has been deemed a highly political move by many reproductive rights groups, in May of last year the FDA rejected the advice of the panel, and refused to change Plan B's status.

Plan B was again considered for over-the-counter status by the FDA at the end of last year and a decision was due this January. Still, any motions on the matter have been stalled, and as of yet no decision has been made. Dr. Lester Crawford, the FDA acting director throughout the controversy last year, and who is believed to have a primary role in rejecting the panel's recommendation, was nominated by President Bush this year to return as a permanent director. But Sen. Hillary Clinton (D-NY) and Sen. Patty Murray (D-WA) are holding up his nomination in committee until the FDA makes a final decision on Plan B.

Sex and Science

Sex and science are two words that most of us rarely string together, but when it comes to the world of contraceptive medicine, the two are inextricably linked. Dr. Diana Koster, Medical Director at Planned Parenthood of New Mexico, says that much of the debate surrounding emergency contraception is based on a misconception of science. Koster, who has practiced women's healthcare for over 30 years, is a strong supporter of Plan B, and believes that if it was more widely available, it would dramatically help to lower rates of abortion and unintended pregnancy.

Emergency contraception has been around for over 25 years. In the '70s and into the '90s, higher doses of ordinary birth control pills were used. Plan B, which came onto the market in the late '90s, is the only product designed and marketed only for emergency contraception. Packaged in the form of two pills (both can be taken at once or 12 hours apart), it's shown to have practically no physical ill-effect. Safer than birth control pills, it is only taken once (or once in a while) versus every day. In fact, Dr. Julie Johnson, who has served for four years on the FDA advisory board on women's health and nonprescription medicine, is quoted as saying that “I would take [Plan B] to be the safest product that we have seen brought before us.”

The function of Plan B, as stated earlier, is to prevent pregnancy. Hence the name, Plan B acts as a backup method, and is most often used after condom breakage. Often confused with mifepristone, a pill which causes abortions, Plan B, contrary to popular belief, is not itself an abortion pill, at least not based on the scientific definition of pregnancy.

Yet it is that very definition that seems to be causing all the commotion. Scientific journals and associations, such as the FDA, the National Institutes of Health (NIH) and the American College of Obstetrics-Gynecology all define pregnancy as beginning when a fertilized egg implants in the uterine wall. But other groups such as PFLI define pregnancy as beginning with fertilization. A definition that, if you accept it, means that if Plan B actually can prevent fertilized eggs from becoming implanted, then it has the potential to terminate a pregnancy by not allowing the egg to attach.

“Pharmacists for Life isn't a religious organization; we don't have to be religious,” says Manuel Rodriguez, a counselor with the New Mexico branch of PFLI. “We know that at the moment of conception there is a human being that has started the life process ... that is a scientific view.”

When asked to provide scientific resources that support his view, Rodriguez, a semi-retired pharmacist who has been in the field for 35 years, answers: “The PFLI website has many other websites that they will refer you to—not necessarily medical, and not necessarily scientific, but websites that are pro-life—and they also recognize that a child is a child at the moment of fertilization.” He adds that any research he does on the subject he does through PFLI.

The PFLI website links to sites such as the American Life League, Children of God for Life, and Pilltruth.org, a personal site run by a high-school religion teacher which discusses the Bible's view on abortion and contraception.

Yet Planned Parenthood's Dr. Koster is emphatic when explaining the scientific definition of pregnancy. She says that all available research shows that overwhelmingly, emergency contraception stops or delays ovulation, which occurs before fertilization, so implantation isn't an issue. Fertilization happens five to seven days before implantation, and fertilization doesn't happen right at intercourse. “I think a lot of people think you have sex and you're pregnant, immediately, or within hours. And there's actually approximately a week delay between intercourse and implantation, the true beginning of a pregnancy. So if you take Plan B within 12 hours, you can see that the idea that it's doing anything to a pregnancy is not logical.”

Rodriguez, however, argues that Plan B and birth control pills can have long-term side-effects that harm women, but that don't show up for 15 years or more. “There have been studies that show that these drugs can cause death ... but the death is not attributed to the use of birth control medication. And so the information is being kept from the public.” Rodriguez has been advising women to stop taking the pill for years, he says.

Yet Koster, whose practice specializes in women's reproductive health, argues that not only is Plan B one of the safest medicines available on the market today, it is much safer for a properly medically screened woman to take birth control pills or Plan B than to be pregnant.

“The use of birth control pills for a healthy woman is safer than riding a motorcycle; it's safer than playing touch football,” she says.

Let's Talk About Sex

“What aren't we talking about?” asks Jasmin Hendrickson, health educator at Planned Parenthood and coordinator of Get Loud, implying that high teen birth rates in New Mexico are directly related to a lack of education about contraception among adolescents. “We're number four in the nation [for teenage pregnancy]—that blows me out of the water.”

Hendrickson believes that if emergency contraception was more readily available, unintended pregnancies would be dramatically reduced, and, subsequently, so would the rate of abortion.

According to The Alan Guttmacher Institute, as much as 43 percent of the decline in abortions in the United States between 1994 and 2000 can be attributed to Plan B and other forms of oral emergency contraception. Considering that 49 percent of the 6.3 million pregnancies that occur in the country every year are unplanned, and that in 2000, over 1.3 million abortions took place, the niche for Plan B could be significant. To put things in even greater perspective, there are an estimated 46 million abortions that take place every year worldwide, 20 million of which are done illegally (which often means dangerously).

Much of the unintended pregnancy rate comes from rural areas, and because of this, rural women have become a primary concern for many health professionals. Some doctors, such as Koster and Espey, worry that rural women are especially at risk in the current political climate and fear that if rural pharmacists refuse to stock or to dispense birth control pills or Plan B, unintended pregnancies and abortions could be on the rise.

One motivator for their concern is that Wal-Mart has a corporate policy not to stock Plan B, although they do carry birth control pills. “Wal-Mart is a company that tends to drive out other pharmacies. It's far more of an access issue rurally, where Wal-Mart blows out the competitors, and it can be a huge barrier to access for those women,” says Espey.

Sue Baker, a pharmacist in northern, rural New Mexico who wishes that her real name be withheld, agrees with Espey. Baker, who works at a single-pharmacist clinic, reports that even though it's required in the state for pharmacists to refer patients to someone who will fill a prescription if they are unwilling to, she has heard complaints that in some cases, that isn't happening. “Our job is to dispense the medicine they're taking,” she says. “We're not here to judge why they're taking their medication,” adding: “We're here to educate them about it.”

Baker also worries that if legislation is passed that makes it acceptable for pharmacists to refuse to fill prescriptions, the concept may transfer over to other forms of medication such as those that serve HIV patients.

Baker is one of the 10 percent of New Mexico pharmacists licensed to prescribe Plan B, because it requires special voluntary training. Dale Tinker, Executive Director of the New Mexico Pharmaceutical Association, says that an effort is underway to increase the number of pharmacists in the state who have the license. “The point is to provide access to the patient,” he says, “so if they come in late at night, the pharmacist would write the prescription, as opposed to sending the patient back to the physician or to the emergency room.”

Yet there are still other issues that threaten access to Plan B. Opponents, for instance, fear that it will lead to increased promiscuity among teens and un-wed women in general if it is made more readily available, be it through easier access from pharmacists with prescriptive authority or through it being made available over-the-counter. Even Baker, who is a supporter of patient access to Plan B, worries that if it is made over-the-counter proper education won't be given with it and women will use it as a regular form of birth control, which it is not intended to be.

But other Plan B advocates argue that such speculation is unfounded. Diana Koster compares this to a similar fear that was spread with the advent of seatbelts—people claimed that having seatbelts in cars would increase the likelihood for reckless driving. Additionally, considering that Plan B costs a minimum of $25, many health professionals scoff at the idea that people would choose it as a means of regular birth control—versus using condoms (which are free at Planned Parenthood and public health clinics throughout Albuquerque).

The future of emergency contraception isn't easy to predict. Despite scientific evidence that suggests that Plan B is safe and effective, there are still many opponents throughout the country (and in Congress and the White House) who are concerned with its moral implications. It is a scenario that begs the question, as Espey puts it, “Do pharmacists have the right to dispense morality?”

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