tag:theconversation.com,2011:/global/topics/emergency-contraception-5020/articlesEmergency contraception – The Conversation2023-08-31T13:41:56Ztag:theconversation.com,2011:article/2121402023-08-31T13:41:56Z2023-08-31T13:41:56ZEmergency contraception: here’s what you probably don’t know but should<figure><img src="https://images.theconversation.com/files/545250/original/file-20230829-21-sw8ysk.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5607%2C3741&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The 'morning after pill' can actually be taken up to five days after unprotected sex.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/morningafter-pill-174171692">Image Point Fr/ Shutterstock</a></span></figcaption></figure><p>Things don’t always go to plan when it comes to sex. Sometimes condoms break (or are even forgotten altogether) and daily contraceptive pills can be missed. Whatever the reason, if you need to prevent an unplanned pregnancy you might decide to use <a href="https://www.nhs.uk/conditions/contraception/emergency-contraception/">emergency contraception</a>.</p>
<p>There are three main options for emergency contraception: levonorgestrel tablets (known as Levonelle in the UK and <a href="https://www.plannedparenthood.org/learn/morning-after-pill-emergency-contraception/whats-plan-b-morning-after-pill">Plan B</a> in the US), ulipristal tablets (<a href="https://www.ellaone.co.uk/magazine/ask-ella/what-is-ulipristal-acetate/">EllaOne</a> in the UK and Ella in the US) and having a copper intra-uterine device (IUD – sometimes called the coil) fitted.</p>
<p>In the UK and US, you can get levonorgestrel and ulipristal from pharmacies. In UK pharmacies, there’s typically no charge if it’s offered as part of an NHS service. In other parts of the world, levonorgestrel is often <a href="https://en.wikipedia.org/wiki/Emergency_contraceptive_availability_by_country">easier to access</a> than ulipristal. For emergency IUD fittings, you need to go to a contraceptive and sexual health clinic, or your GP or gynaecologist.</p>
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<p><em><strong><a href="https://theconversation.com/uk/topics/quarter-life-117947?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">This article is part of Quarter Life</a></strong>, a series about issues affecting those of us in our twenties and thirties. From the challenges of beginning a career and taking care of our mental health, to the excitement of starting a family, adopting a pet or just making friends as an adult. The articles in this series explore the questions and bring answers as we navigate this turbulent period of life.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/period-delay-tablets-can-help-you-temporarily-skip-your-period-heres-how-they-work-184991?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">Period delay tablets can help you temporarily skip your period – here’s how they work</a></em></p>
<p><em><a href="https://theconversation.com/stis-are-on-the-rise-heres-how-to-navigate-telling-a-partner-if-youve-got-one-208267?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">STIs are on the rise – here’s how to navigate telling a partner if you’ve got one</a></em></p>
<p><em><a href="https://theconversation.com/five-important-things-you-should-have-learned-in-sex-ed-but-probably-didnt-202177?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">Five important things you should have learned in sex ed – but probably didn’t</a></em></p>
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<h2>How does it work?</h2>
<p>Although we often call emergency contraceptives “the morning-after pill”, the hormonal pill options can be taken up to five days after unprotected sex. The IUD can sometimes be used even later.</p>
<p>Levonorgestrel and ulipristal both work by delaying ovulation. This means that if there are sperm inside the fallopian tubes, there won’t be an egg for them to meet and fertilise. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/20116841/">Ulipristal is more effective</a> when ovulation is expected within a day, as it can still delay the release of an egg even after the ovulation process has started (when levels of a hormone called luteinising hormone start to rise). Levonorgestrel can’t delay ovulation once this starts.</p>
<p>In a typical menstrual cycle, you’re most at risk of pregnancy on <a href="https://doi.org/10.1136/bmj.321.7271.1259">days nine to 14</a>. But even if you’re more than halfway through your typical monthly cycle, these tablets can still work. This is because you can’t actually calculate when precisely <a href="https://www.bishuk.com/bodies/female-fertility-explained/">ovulation has occurred</a> until the next time your period arrives – so it’s better to get help than spend time stressing at home.</p>
<p><a href="https://www.brook.org.uk/your-life/emergency-contraception/">The IUD works</a> by making the environment within the uterus unfriendly to sperm, and so prevents the sperm fertilising an egg that may have been released. It can be inserted up to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3619968/#DES140C11">five days</a> after the earliest date you could have ovulated. For example, if you usually have 28 day cycles, you could use this up to day 19 (18 days after the day your last period started).</p>
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<img alt="A clinician wearing blue surgical gloves holds the copper IUD in their hands." src="https://images.theconversation.com/files/545251/original/file-20230829-23-gwd4hy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545251/original/file-20230829-23-gwd4hy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545251/original/file-20230829-23-gwd4hy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545251/original/file-20230829-23-gwd4hy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545251/original/file-20230829-23-gwd4hy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545251/original/file-20230829-23-gwd4hy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545251/original/file-20230829-23-gwd4hy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The copper IUD can be kept in and used as a regular form of contraception.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-holding-tshaped-intrauterine-birth-control-2075766613">New Africa/ Shutterstock</a></span>
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<p>It’s important to note that all of these methods are contraceptives, and don’t cause abortions. If you’re already pregnant, these won’t stop a pregnancy.</p>
<p>Emergency contraceptives also cannot protect against <a href="https://www.tht.org.uk/hiv-and-sexual-health/sexual-health/stis">sexually transmitted infections</a> (STIs) – so if you think you’ve been exposed to one, it’s important to visit a <a href="https://www.tht.org.uk/hiv-and-sexual-health/pep-post-exposure-prophylaxis-hiv">sexual health service</a> or your doctor.</p>
<h2>How effective is it?</h2>
<p>The <a href="https://www.nhs.uk/conditions/contraception/iud-coil/">IUD</a> is over 99% effective at preventing pregnancy, even when used as an emergency contraceptive. The coil can also be left in as a regular method of contraception afterwards.</p>
<p>While it’s the most effective form of emergency contraception, it can be uncomfortable or even painful to have an IUD fitted. It’s also somewhat less convenient than popping to a local pharmacy for a pill or using GP or online doctor services.</p>
<p>Ulipristal can be taken up to five days after unprotected sex. It’s at least <a href="https://www.sciencedirect.com/science/article/pii/S0140673610601018">95% effective</a> at stopping pregnancies when taken within this time frame. </p>
<p>Levonorgestrel is <a href="https://www.tht.org.uk/hiv-and-sexual-health/sexual-health/improving-your-sexual-health/contraception/emergency">95% effective</a> at preventing pregnancy if taken within 24 hours of unprotected sex. But this drops to 58% effectiveness if taken between two and three days after unprotected sex.</p>
<p>Depending on the point in your cycle when you had unprotected sex, ulipristal is often a better option. But both tablets are up to 95% effective at stopping pregnancies when taken soon after unprotected sex.</p>
<p>Levonorgestrel and ulipristal are preferably only taken once in each monthly cycle, as they are possibly less effective if used <a href="https://www.brook.org.uk/your-life/morning-after-pill/">more than once</a>. It’s also important to continue with other forms of contraception, such as condoms or the contraceptive pill, until your next period arrives – ulipristal can reduce the effectiveness of some contraceptive pills, so speak to your healthcare provider about taking it.</p>
<p>In my practice as a community pharmacist, I always prefer to recommend ulipristal because of its longer period of effectiveness. It is more expensive though, and so sometimes it isn’t always available as part of a free service. Both levonorgestrel and ulipristal are available without prescription in the UK.</p>
<p>Certain medical conditions (especially those affecting your gastrointestinal system, <a href="https://www.nhs.uk/conditions/crohns-disease/">such as Crohn’s</a>) and medications (such as antiepileptic drugs) can affect how well the pills work. In this circumstance, it’s worth speaking with a doctor about your options as an IUD may work better for you. </p>
<h2>What should you expect?</h2>
<p>Nausea and vomiting are the most common side effects from taking the morning-after pill. It may also cause your next period to begin earlier or later than normal. Some people have also reported headaches or dizziness.</p>
<p>The IUD can make periods heavier or more painful. This often subsides after three to six months if you have chosen to keep it in.</p>
<p><a href="https://www.nhs.uk/conditions/ectopic-pregnancy/">Ectopic pregnancy</a> (when a fertilised egg implants in a fallopian tube) may be possible if emergency contraception fails. If you have lower stomach pain (even if your period arrives), it’s important to seek immediate help as this can be very serious.</p>
<p>If your period is more than seven days late or is shorter or lighter than normal, you should take a pregnancy test to check the emergency contraception has worked.</p>
<p>There’s zero shame in using an emergency contraceptive if you need it. Just remember it’s less effective than regular forms of contraceptives, so only use it as a backup plan. It’s also worth noting that emergency contraceptives have no effect on long-term fertility and can be used even if you plan to have children later on.</p><img src="https://counter.theconversation.com/content/212140/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cathryn Brown does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Whatever your reason for using it, emergency contraceptives can help prevent unplanned pregnancies.Cathryn Brown, Lecturer in Pharmacy Practice, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1913102023-04-19T12:44:30Z2023-04-19T12:44:30ZEmergency contraception is often confused with abortion pills – here’s how Plan B and other generic versions work to prevent pregnancy<figure><img src="https://images.theconversation.com/files/520092/original/file-20230410-26-r8dpzm.jpg?ixlib=rb-1.1.0&rect=46%2C0%2C5200%2C3440&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Morning-after pills are most effective when taken within three days after sex.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-taking-contraceptive-pill-royalty-free-image/91558808?phrase=Morning%20after%20pill&adppopup=true">Ian Hooton/Science Photo Library via Getty Images</a></span></figcaption></figure><p>Since the overturning of Roe v. Wade in June 2022 and the <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">end of constitutional protection for abortion</a>, emergency contraception has become more difficult to obtain and – more than ever – shrouded in misinformation. </p>
<p>Attempting to control inventory, Amazon, Rite Aid and Walmart have <a href="https://www.theguardian.com/society/2022/jun/28/emergency-contraception-pills-pharmacies">imposed purchase limits on the emergency contraception known as Plan B</a> since the Supreme Court’s ruling. Panicked buyers have been trying to stock up on the drug in case it becomes unavailable. </p>
<p>Several legislators and proposed bills have <a href="https://nwlc.org/resource/dont-be-fooled-birth-control-is-already-at-risk/">conflated emergency contraception with abortion</a> and are trying to limit access to it. The <a href="https://theconversation.com/anti-mifepristone-court-decisions-rely-on-medical-misinformation-about-abortion-and-questionable-legal-reasoning-203742">recent court ruling</a> <a href="https://www.washingtonpost.com/politics/2023/04/07/texas-abortion-pill-ruling-mifepristone/">blocking access to mifepristone</a> – which has been approved by the FDA since 2000 – is an ominous sign to many that emergency contraception could be the next target. </p>
<p>Regardless of one’s stance on abortion, it is important to understand why emergency contraception should be a basic component of women’s reproductive health care and family planning services. As a researcher of <a href="https://www.researchgate.net/profile/Amie-Ashcraft">women’s sexual and reproductive health and decision-making</a>, I have extensively researched access to emergency contraception.</p>
<h2>What is emergency contraception?</h2>
<p>Emergency contraception is the only way to prevent pregnancy after sex has already occurred. It can be used when no contraception was used or it was used incorrectly, such as with missed birth control pills or broken condoms. Emergency contraception is also used to prevent pregnancy after sexual assault or rape. </p>
<p>Emergency contraception can take the form of pills – sometimes called the morning-after pill – or <a href="https://www.acog.org/womens-health/faqs/long-acting-reversible-contraception-iud-and-implant">an intrauterine device, or IUD</a> that delays ovulation. </p>
<p>There are two types of emergency contraception pills. The most widely known is <a href="https://medlineplus.gov/druginfo/meds/a610021.html">levonorgestrel</a>, which is sold in the U.S. under the brand name <a href="https://www.planbonestep.com/">Plan B</a>, along with numerous generic versions. </p>
<p>Levonorgestrel was <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/plan-b-one-step-15-mg-levonorgestrel-information#:%7E">first approved for over-the-counter sale</a> to women 18 and older in 2006, and in 2013 age restrictions were removed. </p>
<p>The second type of emergency contraception pill is ulipristal acetate, which is sold under the brand name ella. Both Plan B and ella work by delaying ovulation. In addition, ella <a href="https://doi.org/10.3109/09513590.2014.950648">also thins the uterus lining</a> so that even if an egg were fertilized, it is harder for it to implant in the uterus to start a pregnancy. </p>
<p>Both types of pills are effective at preventing pregnancy. Plan B is most effective if taken within three days of sex, with some declining effectiveness on days four and five. Ella is effective if taken within five days of sex and, unlike Plan B, is equally effective all five days.</p>
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<figcaption><span class="caption">Studies show emergency contraception prevents pregnancy only before the egg is fertilized, not after.</span></figcaption>
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<p>The most effective types of emergency contraception are IUDs that are inserted by a health care provider. Copper IUDs – also referred to as nonhormonal IUDs – are sold under the brand name Paragard. They release into the uterus copper ions that are <a href="https://www.mayoclinic.org/tests-procedures/paragard/about/pac-20391270">toxic to both eggs and sperm</a>. This allows them to be used as emergency contraception if inserted within five days after sex, and as ongoing contraception for up to 10 years. </p>
<p>Levonorgestrel IUDs – referred to as hormonal IUDs – are sold under the brand names Mirena, Liletta, Kyleena and Skyla. The levonorgestrel released into the uterus makes the mucus around the cervix thicker so that a sperm cannot penetrate to fertilize the egg, and it is as effective as the copper IUD when inserted as emergency contraception <a href="https://doi.org/10.1056/NEJMoa2022141">for up to five days after sex</a>. Both Paragard and Mirena IUDs have been approved by the FDA for use as contraception, but they are <a href="https://www.contemporaryobgyn.net/view/updates-on-emergency-contraception">not yet approved specifically for use as emergency contraception</a>.</p>
<h2>How is emergency contraception different from the abortion pill?</h2>
<p>For many years, the way that emergency contraception works has been misunderstood. There has been confusion about whether emergency contraception is an abortifacient – that is, a medication that triggers an abortion. The key difference is that the abortion pill works only when a woman is pregnant, and emergency contraception works only when she is not.</p>
<p>The so-called abortion pill is used for a medication abortion and actually consists of <a href="https://www.bedsider.org/abortion/abortion-pill">two separate pills that do different things</a>. </p>
<p>The <a href="https://theconversation.com/what-the-fdas-rule-changes-allowing-the-abortion-pill-mifepristone-to-be-dispensed-by-pharmacies-mean-in-practice-5-questions-answered-197339">first of these pills is mifepristone</a>, which functions to block production of the pregnancy hormone progesterone so that the uterus lining thins and the embryo detaches from it. This is the pill that is receiving national attention because of clashing court rulings over access, a battle that is headed to <a href="https://www.statnews.com/2023/04/13/abortion-mifepristone-texas-appeals-court-restores-access-access/">the Supreme Court</a>.</p>
<p>The second pill, misoprostol, stimulates contractions in the uterus to eject the embryo and gestational sac. Emergency contraception prevents a pregnancy before it occurs, whereas the abortion pill ends a pregnancy once it’s begun.</p>
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<figcaption><span class="caption">Some observers say there’s a possibility of an eventual ban on Plan B and other contraceptives.</span></figcaption>
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<h2>How do abortion restrictions jeopardize emergency contraception?</h2>
<p>With the increase in abortion restrictions, access to a full range of contraceptive options – including emergency contraception – is more critical than ever. </p>
<p>There are already numerous barriers to obtaining emergency contraception in a timely manner. The most effective types of emergency contraception, ulipristal acetate and both hormonal and nonhormonal IUDs, must be obtained from a health care provider. This means a woman needs an appointment – usually available only on a weekday during business hours – as well as transportation and the means to pay for the appointment, either through health insurance or self-pay. She may need to take time off of work to attend the appointment, or she may need to obtain child care.</p>
<p>For many women in poor, rural or geographically isolated neighborhoods, these barriers are difficult to surmount. This is particularly true given the short window of time in which emergency contraception is effective.</p>
<p>Levonorgestrel emergency contraception pills are available over the counter and should be easily accessible, but individuals trying to purchase them run into numerous obstacles. These include <a href="https://doi.org/10.1016/j.japh.2020.07.027">low stocks in pharmacies</a> – especially independent pharmacies – and <a href="https://doi.org/10.1016/j.srhc.2022.100765">point-of-sale restrictions</a>, such as requirements that purchasers be a certain age, show identification or have parental consent. People also encounter high rates of misinformation about when to take levonorgestrel for maximum effectiveness and about sales restrictions. Finally, they encounter pharmacy staff who object to selling it because they <a href="https://doi.org/10.1177/0969733020918926">misunderstand how it works</a>.</p>
<p>The surge in demand for emergency contraception since the reversal of Roe v. Wade and the <a href="https://www.theguardian.com/society/2022/jun/28/emergency-contraception-pills-pharmacies">purchase limits put on it by retailers</a> have exacerbated these access challenges. </p>
<h2>What are the benefits of emergency contraception?</h2>
<p>Access to emergency contraception promotes women’s health in several ways. <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">Nearly half of pregnancies in the U.S. are unintended</a>, and emergency contraception can prevent about <a href="https://www.who.int/news-room/fact-sheets/detail/emergency-contraception">95% of unwanted or mistimed pregnancies</a> when used within five days of sex. It can also be used as a backup option when another form of contraception fails. And it can be given to survivors of sexual assault. Emergency contraception also <a href="https://www.guttmacher.org/news-release/2005/emergency-contraception-ec-played-key-role-abortion-rate-declines">reduces the need for abortions</a>.</p>
<p>Overall, access to a full range of contraceptive options – including emergency contraception – gives women greater control over their reproductive choices. The ability to control the number and spacing of their pregnancies improves the health, social and <a href="https://iwpr.org/iwpr-issues/reproductive-health/the-economic-effects-of-contraceptive-access-a-review-of-the-evidence/">economic outcomes</a> of both women and their families.</p><img src="https://counter.theconversation.com/content/191310/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amie Ashcraft does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The increase in abortion restrictions may also lead to a decline in access to emergency contraceptives.Amie Ashcraft, Service Assistant Professor in Family Medicine, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1862782022-08-11T12:15:09Z2022-08-11T12:15:09ZHow primary care is poised to support reproductive health and abortion in the post-Roe era<figure><img src="https://images.theconversation.com/files/478117/original/file-20220808-17-4g635q.jpg?ixlib=rb-1.1.0&rect=69%2C53%2C5048%2C3283&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Primary care providers comprise nearly a third of the U.S. clinician workforce.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/new-jersey-jersey-city-doctor-with-patient-in-royalty-free-image/140193309?adppopup=true">Tetra Images/via Getty Images </a></span></figcaption></figure><p>Just over a month after the <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">Supreme Court struck down 50 years of federal protection of abortion rights</a> in the U.S., at least <a href="https://www.guttmacher.org/article/2022/07/one-month-post-roe-least-43-abortion-clinics-across-11-states-have-stopped-offering">43 abortion clinics in 11 states</a> have stopped offering abortion services. In states where abortion remains legal, abortion clinics are experiencing <a href="https://www.nytimes.com/2022/07/23/upshot/abortion-interstate-travel-appointments.html">excessive wait times</a> due to the influx of out-of-state patients. </p>
<p>Wait times are only expected to grow as <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">more states restrict abortion with regulations</a> such as gestational age limits, waiting periods and requirements for in-person visits, unnecessary clinical tests and required parental consent for minors. Abortion bans and restrictions are associated with higher rates of complications and are <a href="https://www.colorado.edu/today/2021/09/08/study-banning-abortion-would-boost-maternal-mortality-double-digits">harmful to the health of women</a> because they delay necessary care. </p>
<p>Although primary care doctors and clinicians are not typically associated with the abortion debate, they are a critical, untapped resource to help offset the abortion care crisis. Primary care is a key access point for patients, especially for adolescent, low-income and rural women. </p>
<p>And because almost all Americans <a href="https://www.fiercehealthcare.com/practices/89-americans-value-relationship-primary-care-doctor">value their relationship</a> with their primary care provider, primary care has a responsibility to ensure patients <a href="https://doi.org/10.1007/s11606-020-06245-8">maintain personal bodily autonomy</a>, including deciding when and how many children to have. </p>
<p>In the post-Roe era, primary care providers can help their patients prevent unintended pregnancy and avoid delays in abortion care by providing comprehensive contraceptive and family planning services, knowing how to counsel and refer individuals seeking pregnancy termination and providing post-abortion care. Due to various state restrictions, providers should <a href="https://states.guttmacher.org/policies/">familiarize themselves with their specific state regulations</a> to determine what is permissible in their current practice environment.</p>
<p>We are practicing <a href="https://www.uwmedicine.org/bios/emily-godfrey">primary care</a> <a href="https://www.uwmedicine.org/bios/adelaide-hearst">physicians</a> who include comprehensive family planning as part of our practices. We have written extensively about the feasibility of <a href="https://doi.org/10.1007/s11606-021-06863-w">including full-spectrum birth control</a> and first-trimester <a href="https://doi.org/10.1016/j.pop.2018.07.010">abortion services</a> in primary care.</p>
<p>Primary care providers make up 30% of the <a href="https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/PrimaryCareChartbook2021.pdf">entire U.S. clinician workforce</a>. They include family physicians, general internists, pediatricians and advanced practice clinicians such as nurse practitioners, midwives and physician assistants, who are often the only source of care in <a href="https://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.html">underserved and rural areas</a>. </p>
<h2>Primary care’s role in preventing abortion</h2>
<p>One of the top reasons why patients go to their primary care provider is for birth control. Primary care clinics that provide all-inclusive birth control services <a href="https://upstream.org/results/">reduce unintended pregnancy</a> rates in their communities, which can help alleviate the demand for abortion services. </p>
<p>Primary care providers can talk with their patients about becoming <a href="https://beforeandbeyond.org/toolkit/reproductive-life-plan-assessment">pregnant now or in the future</a>, using <a href="https://powertodecide.org/one-key-question">clinical tools</a> that help patients decide <a href="https://www.mypathtool.org/en/intro_mp">which birth control method</a> to use. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Graphic depiction of the variety of contraception and family planning methods." src="https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478177/original/file-20220809-20-qqm53q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Contraceptive methods range from IUDs and birth control pills to permanent sterilization.</span>
<span class="attribution"><span class="source">Centers for Disease Control and Prevention</span></span>
</figcaption>
</figure>
<p>Nationally based <a href="https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm">birth control clinical guidelines</a> empower clinicians to prescribe even the most effective birth control methods, such as an implant or intrauterine device – IUD – to patients with serious and chronic medical conditions. Primary care can also help patients with emergency contraception, either in the form of a pill or IUD, within five days after unprotected sex. </p>
<p><a href="https://acrobat.adobe.com/link/track?uri=urn:aaid:scds:US:750761d8-2138-3bd7-bcda-af1b07cc8404">Emergency contraceptive pills</a> are considered safe and effective. They are high-dose birth control pills that work by <a href="https://www.webmd.com/sex/birth-control/faq-questions-emergency-contraception#">interfering with the process of ovulation</a>, and thus will not affect a pregnancy if already pregnant. Emergency contraception is a last chance to prevent unplanned pregnancy.</p>
<h2>Abortion pill prescription falls within primary care</h2>
<p><a href="https://theconversation.com/how-to-navigate-self-managed-abortion-issues-such-as-access-wait-times-and-complications-a-family-physician-explains-186186">Abortion with medications can be safely and effectively used</a> up to the 11th week of pregnancy, with low rates of complications. Of the approximately 1 million legal abortions provided each year in the U.S., 90% occur in the first trimester, or through the 12th week of pregnancy. Thus, it’s no surprise that <a href="https://www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortions">more than half</a> of abortions are now managed with <a href="https://doi.org/10.1007%2Fs11606-020-05836-9">medicines that can be prescribed by a primary care provider</a>. </p>
<p>The <a href="https://nap.nationalacademies.org/catalog/24950/the-safety-and-quality-of-abortion-care-in-the-united-states">National Academies of Sciences, Engineering and Medicine</a> have issued evidence-based guidelines reiterating that trained, licensed primary care clinicians can safely and effectively provide medication abortion. Patients who have received abortions from primary care providers report that they are <a href="https://pubmed.ncbi.nlm.nih.gov/25646981/#">satisfied with the experience</a>. Studies show that patients <a href="https://doi.org/10.1007/s10995-010-0722-4">prefer abortion services in primary care</a> <a href="https://doi.org/10.1016/j.contraception.2009.01.017">because of the privacy</a>, convenience and <a href="https://pubmed.ncbi.nlm.nih.gov/26950663/">continuity of care</a>. </p>
<h2>How abortion care can be integrated into telehealth</h2>
<p>Despite the fact that first-trimester abortion care <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2012.301119?">fits well within primary care medical services</a>, it has not been widely offered in this setting. This is <a href="https://doi.org/10.3122/jabfm.2022.03.210266">due to roadblocks</a>, including lack of provider training, federal and state legislation, institutional barriers and administrative resistance. </p>
<p>However, there are now new, <a href="https://doi.org/10.1016/j.contraception.2017.11.005">more simplified medication abortion protocols</a> that allow primary care to safely offer abortion care remotely with a <a href="https://doi.org/10.1001/jamainternmed.2022.0217">history screening tool</a> that doesn’t require unnecessary clinical laboratory and ultrasound testing. Primary care’s expansion of telehealth abortion services has the potential to significantly reduce delays in care. This could help reduce abortions at more advanced gestational ages and the complications that come with them. Our study from 2021 conducted among primary care physicians providing telemedicine abortion <a href="https://doi.org/10.1016/j.contraception.2021.04.026">found that more than 85% of patients</a> were less than seven weeks pregnant when they sought care. </p>
<h2>Post-abortion ‘primary’ care</h2>
<p>In states with restricted abortion access, it is inevitable that patients will seek abortions on their own. Given the current legal landscape, clinicians are often confused about how to treat patients with pregnancy complications, including miscarriage. The World Health Organization stresses that even in settings where abortion may be outlawed, it is incumbent for clinicians to provide <a href="https://srhr.org/abortioncare/chapter-3/post-abortion-3-5/">compassionate, nonjudgmental post-abortion care</a>. </p>
<p>Post-abortion care includes managing residual side effects or complications of abortion, as well as the provision of comprehensive birth control services without discrimination or coercion. Complications from abortion or miscarriage are rare. However, complications like retained pregnancy tissue in the uterus, bleeding or infection can occur, most of which can be managed by primary care providers in the clinical setting. </p>
<p>Primary care providers who don’t offer abortion care can still counsel patients about <a href="https://www.abortionfinder.org/">where to seek</a> reliable, high-quality abortion services. The U.S. Department of Health and Human Services provides information about <a href="https://reproductiverights.gov/">Americans’ rights to reproductive health care</a>. </p>
<p>The short-term implications of the Supreme Court decision remain uncertain as state legislators weigh public opinion among their constituents. </p>
<p>What remains certain in the post-Roe era, however, is that primary care continues to be among the most reliable resources in the U.S. for accurate information and safe reproductive health care services.</p><img src="https://counter.theconversation.com/content/186278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily M. Godfrey receives funding from Cystic Fibrosis Foundation and Society of Family Planning Research Fund. She is a Nexplanon Trainer for Organon</span></em></p><p class="fine-print"><em><span>Adelaide H. McClintock is the named institutional PI for a grant from the Society of Family Planning. This grant was officially awarded to Nina Tan. </span></em></p>Primary care doctors have long played an important role in providing birth control. Now, with the fall of Roe, they could help fill a critical need for comprehensive family planning services.Emily M. Godfrey, Associate Professor of Family Medicine and Obstetrics & Gynecology, School of Medicine, University of WashingtonAdelaide H. McClintock, Professor of Internal Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1828622022-05-24T14:19:25Z2022-05-24T14:19:25ZWe tested plants used for contraception in South Africa. Here’s what we found<figure><img src="https://images.theconversation.com/files/463584/original/file-20220517-16-zqkwzc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>In <a href="https://theconversation.com/unintended-pregnancy-rates-are-highest-in-africa-a-look-at-the-complex-reasons-180454">sub-Saharan Africa</a>, 91 per 1,000 pregnancies are unwanted. This is around three times the rates of unintended pregnancies recorded in Europe and North America. </p>
<p>There are many reasons for this, from the individual to the household and community and policy levels. For instance, a young woman may want to terminate a pregnancy so she can finish her <a href="https://theconversation.com/unintended-pregnancy-rates-are-highest-in-africa-a-look-at-the-complex-reasons-180454">education</a> or get the skills to improve her socio-economic prospects. These pregnancies may end in unsafe abortions. Breaking the cycle of unwanted pregnancy is therefore critical to realising <a href="https://theconversation.com/unintended-pregnancy-rates-are-highest-in-africa-a-look-at-the-complex-reasons-180454">socio-economic development</a> in Africa. </p>
<p><a href="https://www.ajrh.info/index.php/ajrh/article/view/2515">Indigenous contraception</a> methods, including medicinal plants, have long been used in various African societies to prevent unwanted pregnancy. Medicinal plants used for contraception vary widely in composition and can be used as single species or herbal mixtures (concoctions). In most cases they are used as a tea. In the past, our research group has identified <a href="https://www.sciencedirect.com/science/article/pii/S0378874118323857">23 medicinal plants</a> reported to be used for contraception in South Africa. </p>
<p>But concerns have been raised about the safety, efficacy and quality of indigenous contraception methods.</p>
<p>In a recently published <a href="https://www.mdpi.com/2223-7747/11/2/193">study</a>, we tested a plant-based concoction used for contraception by health practitioners in the Batswana tradition, in South Africa’s North West province. We collaborated with practitioners to investigate the phytochemical composition and likely mechanism of the plants. Using rats as test subjects, we tested whether the plants were safe to use and whether they prevented pregnancy in the rodents. </p>
<p>Studies like ours that evaluate the safety and efficacy of medicinal plants using rodents as models are necessary before such studies can be performed on humans. </p>
<p>Our study supports the idea that herbal contraceptives can assist in the development of safe and effective hormonal contraceptives. </p>
<h2>Key findings</h2>
<p>Our <a href="https://natural-sciences.nwu.ac.za/indigenous-knowledge-systems-centre/home">research and teaching centre</a> in South Africa aims to create bridges between indigenous and modern scientific knowledge. Part of our work is to explore concerns relating to the use of plants in traditional medicine. </p>
<p>We found a herbal mixture that was commonly used for contraception by traditional practitioners. <a href="https://www.mdpi.com/2223-7747/11/2/193">The mixture</a> consisted of three medicinal plants and was taken orally by women for contraception. A traditional health practitioner with knowledge and experience of medicinal plants used for contraception in the study area assisted with the collection of the three plant species (<em>Bulbine frutescens</em>, <em>Helichrysum caespititium</em> and <em>Teucrium trifidum</em>). The preparation of the herbal mixture for scientific evaluation was based on the recipe provided by the traditional health practitioners.</p>
<p>First, we profiled the phytochemicals in the herbal mixture using modern analytical techniques. This told us the types and quantity of compounds that were in the herbal mixture.</p>
<p>Then we evaluated the safety and efficacy of the herbal mixture with rodents as animal models. This work was done at the preclinical drug development facility of our <a href="https://health-sciences.nwu.ac.za/pcddp">research partners</a>. The safety of the herbal mixture was evaluated using the <a href="https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/acute-toxic-class-method">acute toxic class method</a>. This procedure follows certain steps to establish whether further testing is needed or not. </p>
<p>During the efficacy study, female rats were randomly divided into four groups, each consisting of seven rats. We gave female rats the herbal mixture for three days, then put them with male rats for three days. Three groups received different doses of the mixture. A control group did not receive the mixture. </p>
<p>Overall, the herbal mixture extract was found to be safe. It had no toxic effects on cells and <a href="https://www.mdpi.com/2223-7747/11/2/193">no rat got sick or died</a>. </p>
<p>Our investigations showed that the herbal mixture contained <a href="https://www.mdpi.com/2223-7747/11/2/193">bioactive compounds</a> with contraceptive activity. Two of the doses showed no contraceptive efficacy. A dose of 50 mg/kg showed a low rate of contraceptive efficacy (14%) – only one rat out of seven did not fall pregnant.</p>
<p>The results suggest that there is potential for developing safe and efficacious herbal contraceptives from natural extracts of local plants. Medicinal plants and the associated indigenous knowledge could offer alternatives for women who have health problems with or lack access to modern contraceptives. </p>
<h2>Moving forward</h2>
<p>In future we would like to know more about medicinal plants used for male contraception, female emergency contraception and termination of pregnancy (abortifacients). </p>
<p>We want to determine the effects these plants have on reproductive hormones and reproductive organs as guided by laboratory and animal experiments. We also want to determine the effect of storage and packaging on the quality of these plant-based concoctions and extracts. </p>
<p>Since some traditional practitioners cultivate wild medicinal plants in their home gardens, we would also like investigate whether that affects their safety, efficacy and quality.</p><img src="https://counter.theconversation.com/content/182862/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Molelekwa Moroole receives funding from National Research Foundation.</span></em></p><p class="fine-print"><em><span>Adeyemi Oladapo Aremu receives funding from the National Research Foundation, Pretoria, South Africa. He is a member of the Global Young Academy (GYA), Young Affiliate of the African Academy of Sciences (AAS) and South African Young Academy of Science (SAYAS). </span></em></p><p class="fine-print"><em><span>Professor Simeon Materechera is a researcher at the Indigenous Knowledge Systems Centre of the North-West University. </span></em></p>Medicinal plants and the associated indigenous knowledge could offer alternatives for women who lack access to modern contraceptives.Molelekwa Moroole, DSI/NRF Postdoc Research Fellow, North-West UniversityAdeyemi Oladapo Aremu, Associate professor, North-West UniversityMaterechera Simeon, Professor of Soil Science, North-West UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1015632018-08-22T11:03:54Z2018-08-22T11:03:54ZPopularity of apps like Natural Cycles highlights serious issues with contraceptives today<figure><img src="https://images.theconversation.com/files/232351/original/file-20180816-2903-ewmmvc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Natural Cycles</span></span></figcaption></figure><p>Many women have made a dramatic change in their use of contraceptives of late. Specifically, use of “contraceptive apps” such as <a href="https://www.naturalcycles.com/en?campaignid=1023659502&adgroupid=50744576537&adid=289266179911&gclid=EAIaIQobChMIiKSt06eA3QIV65XtCh2d0gCFEAAYASAAEgLHYfD_BwE">Natural Cycles</a>, a smartphone app that predicts the days on which a woman is fertile and can be used for contraception (as well as planning pregnancy), is on the rise. By closely tracking a woman’s cycle and temperature, such apps designate unprotected sex safe or unsafe each day. When unsafe, the use of barrier methods of protection is advised.</p>
<p>Natural Cycles was developed by CERN scientist Elina Berglund and her husband, Raoul Scherwitzl, whose scientific background has lent the app a certain kudos. And as “the only app certified for contraception” in Europe and, as of August 10, the US, women who might otherwise be suspicious of the method, which is at the end of the day simply jazzed up natural family planning, have taken the plunge.</p>
<p>The fact that many women are spurning more “medical” kinds of contraception, such as the pill or IUD, in favour of such apps, along with discussion in some cases of their <a href="https://www.theguardian.com/society/2018/jul/21/colossally-naive-backlash-birth-control-app">failures</a>, are once again drawing public attention to the hazards of being a pre-menopausal, heterosexual, sexually active woman. The risks of contraceptives range from milder side effects to rare but potentially serious complications. These, of course, come alongside the ever present risk of unintended pregnancy through contraceptive failure.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many women report side effects with the contraceptive pill, but often aren’t listened to.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/birth-control-pill-contraceptive-safe-sex-1140875126?src=GHbPGDZp7RDjsKYf-n8MFg-2-77">Suriyachan/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Understated side effects</h2>
<p>When choosing a method of contraception, women routinely have to balance the impacts of each method against its likely effectiveness. Most of <a href="https://www.tandfonline.com/doi/abs/10.1080/07399330600629468">the evidence</a> suggests that it is common for women to choose the least bad option in terms of side effects, rather than something they are really comfortable with. Consequently, it’s not surprising that a technology that promises to overcome many of these difficulties would prove to be popular.</p>
<p>Being able to control fertility is essential for women’s equality, yet the means to do this are currently all imperfect. Side effects are a common experience and are a major cause of women stopping using particular birth control methods. In contraceptive consultations, the frequency and severity of side effects and other more serious health risks are often understated. </p>
<p><a href="https://broadly.vice.com/en_us/article/kzeazz/the-racist-and-sexist-history-of-keeping-birth-control-side-effects-secret">Research</a> suggests that health professionals seek to avoid mentioning issues they believe would cause undue concerns. This reluctance to disclose may be linked to historic ideas that women are not fully capable of rational decision making. The assumption that women are not to be trusted with contraception is most clearly seen in the promotion of <a href="http://www.dchs.nhs.uk/our-services/find_services_by_topic/different_types_of_larc">long-acting reversible contraception</a> (LARC): the injection, implant, and hormonal and copper coils. The <a href="https://www.tandfonline.com/doi/abs/10.1016/S0968-8080(13)41688-9">evidence</a> shows that some women who encounter difficulties sometimes struggle to get health professionals to remove their LARC. Women are expected to put up with side effects rather than taking a bigger risk of unintended pregnancy.</p>
<h2>A perfect woman</h2>
<p>Culturally speaking, unintended pregnancies are usually frowned upon. This is particularly the case for younger women and those in marginalised circumstances. This denigration links to ideas about irresponsibility more generally. Popular stereotypes of “feckless” families who have babies for benefits are commonplace, but are rarely accurate. In the US for example, the idea of the “welfare queen” has been shown <a href="https://www.theatlantic.com/business/archive/2016/09/welfare-queen-myth/501470/">to be false</a>. </p>
<p>In the UK, it is <a href="https://theconversation.com/welcome-to-the-uk-land-of-the-two-child-policy-44756">government policy</a> to limit the number of children claimants can receive benefits for. As in-work poverty means increasing numbers of families are reliant on <a href="https://theconversation.com/state-of-the-nation-welfare-shifts-towards-the-working-poor-39194">benefits</a>, more and more women will have their fertility judged. </p>
<p>Stereotypes of who would be or not be a “good” mother can be seen in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055778/">healthcare providers’ assumptions</a> of who would particularly benefit from LARC. It is also important to remember that the stigma surrounding abortion builds on assumptions of irresponsible women failing to successfully control their fertility. This is despite the evidence that contraceptive failure is a significant reason for <a href="https://www.bpas.org/about-our-charity/press-office/press-releases/women-cannot-control-fertility-through-contraception-alone-bpas-data-shows-1-in-4-women-having-an-abortion-were-using-most-effective-contraception/">needing abortion</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Failed contraceptives are a major cause of unwanted pregnancy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-makes-pregnancy-test-waiting-result-1153289131?src=tN-Li7fOfp2dlUIKtYZTRA-2-8">Vadim Zakharishchev/Shutterstock</a></span>
</figcaption>
</figure>
<p>The cultural notions that women fail, rather than the fault being with contraceptive technologies, has even become standardised within health information. Many contraceptive information pages have institutionalised notions of women’s irresponsibility by including statistics on effectiveness reporting “perfect” and “typical” use. Given that “perfect” use for some methods is actually beyond women’s control (for example, the impact of a stomach upset on the pill), just showing “typical” use would ensure women were informed properly but without being judgemental. </p>
<p>Although women are largely held responsible for failure, that does not necessarily mean they are seen as responsible enough to make decisions over which birth control method to use. Although in other parts of the world, emergency hormonal contraception is available in <a href="https://www.mercurynews.com/2013/07/31/morning-after-pill-goes-on-sale-thursday-in-pharmacies-and-grocery-stores-available-to-anyone/">supermarkets</a> or even <a href="https://www.telegraph.co.uk/women/sex/should-have-morning-pill-vending-machines-every-street-corner/">vending machines</a>, in the UK and Australia, women wanting access need to have a consultation, even if this just takes place in a pharmacy. This is not necessarily to access them medically, but so they can be “advised” to avoid future “mistakes”.</p>
<h2>Gendered inequality</h2>
<p>In an age where relationships are supposed to be equal partnerships, contraception raises equality issues. To date, the “<a href="https://theconversation.com/heres-whats-on-the-horizon-for-a-male-contraceptive-pill-but-dont-hold-your-breath-92509">male pill</a>” still has not materialised, leaving men with few options. Condoms are often not seen as “proper” contraception for ongoing relationships. The protection they provide against sexually transmitted infections means that they are associated with casual partners. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Condoms tend not to be used by those in ongoing relationships.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bangkok-thailand-8-august-2018-various-1156815850?src=MTLGQYZvxdjVj35sPU75VQ-1-0">BORIMAT PRAOKAEW / Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Meanwhile the idea of vasectomy (which should obviously only be undertaken if a decision of no future children is made) is popular with women for equality reasons. It allows couples to take turns over contraceptive responsibility over time. But many men do not seem to be that <a href="https://www.telegraph.co.uk/men/thinking-man/having-vasectomy-dont-tell/">keen</a>. </p>
<p>It’s also important to remember that pregnancy carries some risks for women alone. Even if they are supportive partners, men do not face the same biological issues of either continuing or ending a pregnancy. While there are now challenges to the expectations that women should always be the primary carer of children, changes in attitude cannot overcome this biological reality of pregnancy. </p>
<p>So it’s unsurprising that such apps are popular. Avoiding the health difficulties that many women experience with other contraceptive methods is appealing. But women are still waiting for better contraceptive solutions. In the meantime, reducing the stigma and costs of unintended pregnancy and abortion would an extremely useful step in recalibrating the understanding of the difficult balance women make between embodied impacts and the effectiveness of the current options.</p><img src="https://counter.theconversation.com/content/101563/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pam Lowe has received research funding from the ESRC and Umbrella Partnership/University Hospitals Birmingham NHS Foundation Trust and Birmingham City Council for research on contraception. She is a member of Abortion Rights. </span></em></p>It’s unsurprising that such apps are popular. Contraceptives come with a slew of hazards.Pam Lowe, Senior Lecturer in Sociology, Aston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/591522016-06-29T02:55:13Z2016-06-29T02:55:13ZWeekly Dose: new morning after pill makes it difficult to choose which to take<figure><img src="https://images.theconversation.com/files/125310/original/image-20160606-25992-1k3fk45.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some data has found one pill is slightly more effective, but you need to visit your doctor to get it and it needs to be taken in a hurry.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/downloading_tips.mhtml?code=&id=232823290&size=huge&image_format=jpg&method=download&super_url=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTQ2NTIyMDYyNSwiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfMjMyODIzMjkwIiwiayI6InBob3RvLzIzMjgyMzI5MC9odWdlLmpwZyIsIm0iOiIxIiwiZCI6InNodXR0ZXJzdG9jay1tZWRpYSJ9LCJTZlNCQkF0cmZRQTJXOGgrdWNLOUcxMjZEdWMiXQ%2Fshutterstock_232823290.jpg&racksite_id=ny&chosen_subscription=163&license=standard&src=2J0-P0cm7hNcpDDb77nkJA-1-8">from www.shutterstock.com.au</a></span></figcaption></figure><p>Almost 200,000 unplanned pregnancies occur in Australia each year, though not all go full term. Safe and effective emergency contraception is necessary to help prevent unintended pregnancies in people who do not wish to fall pregnant.</p>
<p>Until 2015, the levonorgestrel “morning after pill” (for example the common brand name Postinor®) was the only oral emergency contraception available in Australia. It comes as one 1.5mg tablet or two 0.75mg tablets and is available from a pharmacist without a prescription from A$14.99.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/128577/original/image-20160628-7836-zar7yp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/128577/original/image-20160628-7836-zar7yp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=700&fit=crop&dpr=1 600w, https://images.theconversation.com/files/128577/original/image-20160628-7836-zar7yp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=700&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/128577/original/image-20160628-7836-zar7yp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=700&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/128577/original/image-20160628-7836-zar7yp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=880&fit=crop&dpr=1 754w, https://images.theconversation.com/files/128577/original/image-20160628-7836-zar7yp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=880&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/128577/original/image-20160628-7836-zar7yp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=880&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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</figure>
<p>Now a new option, EllaOne® (ulipristal), is available in Australia with a doctor’s prescription. But how are they different, and which one should you choose?</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/128579/original/image-20160628-7842-z95iz5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/128579/original/image-20160628-7842-z95iz5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=700&fit=crop&dpr=1 600w, https://images.theconversation.com/files/128579/original/image-20160628-7842-z95iz5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=700&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/128579/original/image-20160628-7842-z95iz5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=700&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/128579/original/image-20160628-7842-z95iz5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=880&fit=crop&dpr=1 754w, https://images.theconversation.com/files/128579/original/image-20160628-7842-z95iz5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=880&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/128579/original/image-20160628-7842-z95iz5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=880&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
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<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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</figure>
<h2>How does it work?</h2>
<p>Levonorgestrel is a synthetic progestogen, which is a drug used to mimic the effects of the body’s own hormone, progesterone (a sex hormone involved in the menstrual cycle and pregnancy). It is thought to work by inhibiting or delaying ovulation, and impeding transport of sperm and/or egg to prevent fertilisation. It <a href="https://amhonline.amh.net.au/auth">may also change</a> the <a href="http://www.ncbi.nlm.nih.gov/pubmed/25740886">uterus environment</a> to make it more difficult for a fertilised egg to attach to it.</p>
<p>Last year the Therapeutic Goods Administration approved ulipristal (EllaOne), which has been used as emergency contraception in the European Union (EU) since 2009. Ulipristal was approved to treat uterine fibroids (common benign growths) in Canada in 2013 and the EU in 2015. However this was a 5mg dose, much lower than the 30mg emergency contraception dose.</p>
<p>EllaOne is an oral tablet (30 mg) that is taken as a single dose and is currently only available on prescription in Australia. EllaOne does not yet have a recommended retail price (RRP) in Australia, however, its RRP in the United Kingdom is £34.95, or almost A$70. </p>
<p>Ulipristal was developed from a molecule similar to progesterone and binds more strongly and more specifically to the progesterone receptor compared to levonorgestrel. Ulipristal blocks the effect of the body’s progesterone, inhibiting or delaying ovulation. It may also make it more difficult for a fertilised egg to attach to the uterus.</p>
<p>For emergency contraception, both levonorgestrel and ulipristal should be taken as soon as possible. However, while levonorgestrel should be taken within 72 hours, ulipristal should be taken up to 120 hours (five days) after unprotected sex or contraceptive failure. Contraceptive failure can be missing a regular active contraceptive pill, or having used a broken condom.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/125313/original/image-20160606-25999-mhv97h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/125313/original/image-20160606-25999-mhv97h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/125313/original/image-20160606-25999-mhv97h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/125313/original/image-20160606-25999-mhv97h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/125313/original/image-20160606-25999-mhv97h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/125313/original/image-20160606-25999-mhv97h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/125313/original/image-20160606-25999-mhv97h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/125313/original/image-20160606-25999-mhv97h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Whichever you choose, both should be taken as soon as possible.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/downloading_tips.mhtml?code=&id=171524915&size=huge&image_format=jpg&method=download&super_url=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTQ2NTIyMTQyOCwiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfMTcxNTI0OTE1IiwiayI6InBob3RvLzE3MTUyNDkxNS9odWdlLmpwZyIsIm0iOiIxIiwiZCI6InNodXR0ZXJzdG9jay1tZWRpYSJ9LCJCOUdSUXQvK1dRcWl0M2hhMnJpQk1tb3RES3ciXQ%2Fshutterstock_171524915.jpg&racksite_id=ny&chosen_subscription=163&license=standard&src=2J0-P0cm7hNcpDDb77nkJA-1-33">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Side effects</h2>
<p><a href="https://www.tga.gov.au/auspar/auspar-ulipristal-acetate">Clinical trials</a> found levonorgestrel and ulipristal had comparable side effects. These were mild to moderate in nature, short-lived and resolved on their own. The most common side effects reported were stomach aches, nausea, and headaches. </p>
<p>Both levonorgestrel and ulipristal are metabolised and broken down by a specific liver enzyme called cytochrome P450 3A4. The effectiveness of these medications may be reduced when taken with other medicines that increase the activity of this liver enzyme (such as St Johns Wort and some epilepsy medicines).</p>
<p>Women who require emergency contraception because they missed a regular active contraceptive pill should resume taking their normal pill within 12 hours after taking levonorgestrel. However, ulipristal may reduce the effect of any contraceptive pill that contains a progestogen (synthetic progesterone).</p>
<p>Consequently, EllaOne’s manufacturer recommends waiting at least five days before the regular contraceptive pill is restarted. During this time, barrier methods of contraception (such as condoms) are recommended until cover from the regular contraceptive pill is achieved, so this can be up to one week after recommencing, or almost two weeks after taking EllaOne.</p>
<h2>So which is more effective?</h2>
<p>Levonorgestrel is most effective when taken within 24 hours after unprotected sex as it prevents 95% of expected pregnancies. After 24-48 hours, the effectiveness decreases to 85%, then 58% after 48-72 hours. Ideally it is taken within three days as the benefits after 96-120 hours are uncertain. </p>
<p>When used within 72 hours, ulipristal is linked to lower pregnancy rates compared to levonorgestrel. This effect is maintained up to 120 hours after intercourse. However, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216625/">neither is effective</a> after ovulation*, which usually occurs in the middle of each menstrual cycle. </p>
<p>The <a href="https://www.tga.gov.au/auspar/auspar-ulipristal-acetate">data from clinical trials</a> shows that within 72 hours of unprotected sex, there is a slightly lower risk of becoming pregnant with ulipristal than levonorgestrel. Ulipristal has some evidence to support use up to 120 hours after unprotected sex. So it is <a href="http://www.ncbi.nlm.nih.gov/pubmed/25740886">slightly more effective</a> than levonorgestrel up to 72 hours; and can work up to 120 hours. It is important to remember – the longer you wait after unprotected sex, the less effective either option is. </p>
<p>Women need to weigh up all these factors to make a decision for their circumstances. These can include the slightly higher efficacy of ulipristal, accessibility (without prescription from a pharmacy or needing to see their GP), the time elapsed since unprotected sex and cost.</p>
<p>It is also worth remembering there is no easy test from the GP surgery or pharmacy to determine if ovulation has already occurred. This means the morning after pill may not be effective.</p>
<p>The decision is not easy to make and the available information does not provide a clear solution. Each woman will have multiple factors that provide a unique mix, so it is not possible to provide blanket advice on a preferred option. Women requiring emergency contraception should discuss the matter with their GP or pharmacist. </p>
<hr>
<p><em>*Correction: originally this article stated only ulipristal is ineffective after ovulation. The article has been updated to more accurately reflect the available data.</em></p><img src="https://counter.theconversation.com/content/59152/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Esther Lau is affiliated with the Pharmaceutical Society of Australia.</span></em></p><p class="fine-print"><em><span>Lisa Nissen is affiliated with Pharmaceutical Society of Australia (QLD branch committee)
Member of the QUM advisory board for Abbvie - Hepatitis C </span></em></p><p class="fine-print"><em><span>Greg Kyle, Jose Manuel Serrano Santos, and Yasmin Antwertinger do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Until 2015 the “morning after pill” Postinor was the only oral emergency contraception available in Australia. A new option, EllaOne, is available. How are they different, and which should you choose?Esther Lau, Course coordinator and Lecturer - Pharmacy, Queensland University of TechnologyGreg Kyle, Professor of Pharmacy, Queensland University of TechnologyJose Manuel Serrano Santos, Pharmacy course Coordinator and Lecturer in Pharmacy Practice, Queensland University of TechnologyLisa Nissen, Professor; Head, School of Clinical Sciences, Queensland University of TechnologyYasmin Antwertinger, Associate Lecturer in Pharmaceutical Chemistry, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/418772015-06-01T05:59:54Z2015-06-01T05:59:54ZFor women, even a small co-pay for contraception can be a big deal<figure><img src="https://images.theconversation.com/files/83451/original/image-20150530-15228-1hsvted.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For contraception, choice and access are critical. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-155865605/stock-photo-chinese-doctor-talking-with-female-patient-in-doctors-office.html?src=7Ho0NXhkAXxi9G4eFtufuw-1-96">Doctor and patient via www.shutterstock.com.</a></span></figcaption></figure><p>On May 11, the Obama administration released <a href="http://www.dol.gov/ebsa/faqs/faq-aca26.html">updated guidance</a> on insurance coverage of contraception. The announcement provides much-needed clarification for insurance plans regulated by the Affordable Care Act (ACA). </p>
<p>Before this announcement, the guidance for what insurers were supposed to do was <a href="http://www.dol.gov/ebsa/faqs/faq-aca12.html">vague</a>. </p>
<p>The ACA requires insurers to provide women access to the full range of FDA-approved contraceptive methods at no cost. But insurers could use “reasonable medical management” to introduce cost containment measures like providing generics at no cost, while requiring co-pays for a branded equivalent.</p>
<p>Some insurers used reasonable medical management to restrict access to some forms of contraception – often the more expensive but longer-lasting forms. And that led to variation among insurance plans about which contraceptives required a co-pay and which did not. </p>
<p>The new guidance specifies that at least one birth control method from each of <a href="http://www.fda.gov/downloads/forconsumers/byaudience/forwomen/freepublications/ucm356451.pdf">18 different categories</a> must be covered without cost-sharing in all eligible plans. Reasonable medical management and cost containment strategies can still be used, as long as methods in each category are offered. </p>
<p>So why does it matter than some insurers were restricting access to some forms of contraception?</p>
<p>About half of pregnancies in the US <a href="http://www.guttmacher.org/pubs/journals/ajph.2013.301416.pdf">are unintended</a> – and that has much to do with access and use of contraception. Unintended pregnancies lead to an <a href="http://www.contraceptionjournal.org/article/s0010-7824(06)00447-1/abstract">estimated US$5 billion in costs</a> for the US healthcare system per year, while birth control use provides cost savings of $19 billion each year. Even small improvements in contraceptive use could result in a meaningful reduction in the number of unintended pregnancies.</p>
<h2>Why are co-pays such an important issue?</h2>
<p>Relative to other forms of healthcare, the low cost of so many contraceptive methods may make the individual out-of-pocket expense seem unimportant. But to many women, these costs are real. Cost is a big factor in choosing to use one form of contraception over another, using it consistently or even the likelihood of using contraception at all. </p>
<p>Notably, the most effective methods [such as long-acting reversible contraceptives, like intrauterine devices (IUDs) or hormone implants] have the highest up-front cost. And if women must share the cost, that discourages them from using these highly effective methods. </p>
<p>We <a href="http://journals.lww.com/lww-medicalcare/Abstract/2013/11000/The_Impact_of_Out_of_Pocket_Costs_on_the_Use_of.2.aspx">studied</a> the relationship between out-of-pocket costs and contraception use among almost 1.7 million women enrolled in the types of plans regulated by the ACA rules between January 1 and December 31 2011. Women in plans with the highest level of cost-sharing were 35% less likely to have an IUD placed than women with the lowest level of cost-sharing – suggesting that even higher-income women are sensitive to the price of contraceptives.</p>
<p>The <a href="http://www.ajog.org/article/s0002-9378(10)00430-8/abstract">Contraceptive Choice study</a>, which offered almost 10,000 women free birth control, demonstrated that low-income and uninsured women will select the most effective (and most expensive) birth control methods at high rates when cost is not a factor.</p>
<p>This is why the new White House guidelines are so important. The broader menu of options available will increase women’s access to their preferred method, which may in turn improve contraception use patterns and decrease unintended pregnancy. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83173/original/image-20150527-4820-1hl959p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83173/original/image-20150527-4820-1hl959p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83173/original/image-20150527-4820-1hl959p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83173/original/image-20150527-4820-1hl959p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83173/original/image-20150527-4820-1hl959p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83173/original/image-20150527-4820-1hl959p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83173/original/image-20150527-4820-1hl959p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There’s more to contraception than the birth control pill.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-161036582/stock-photo-colorful-oral-contraceptive-pill.html?src=eZQ2jA8NNZSN6pStrmVTKQ-1-3">Contraceptive pills via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>One contraceptive is not like another</h2>
<p>All contraceptives aim to prevent pregnancy, but there are a variety of ways they can do so. They aren’t interchangeable, and the method that may work best for one woman may not be suitable for another.</p>
<p>Under previous guidance, many insurers interpreted the law to mean they must cover at least one – but not all – option from each of five categories: hormonal contraception (like birth control pills, vaginal rings or patches), barrier methods (diaphragm), emergency contraception, implanted devices (like IUDs or hormone implants) and sterilization. </p>
<p>But this approach to grouping methods doesn’t reflect the clinical uses for each type of contraception. For instance, the contraceptive ring was considered a “hormonal” method, and since there is a generic pill containing the same hormones as the ring, insurers have often not covered it because they consider them equivalent. But the ring lasts for three weeks before needing to be replaced, while the pill needs to be taken every day. And this distinction is important for women who know that they will sometimes forget to take a pill every day. </p>
<p>Even methods that are similar – such as the copper IUD and the hormone-containing IUD – are not, in medical parlance, therapeutic equivalents. This means that they have different medical uses, health benefits or side effects. These products aren’t interchangeable – the best one for an individual woman will depend on her menstrual patterns, tolerance of side effects and prior birth control experience. Clinicians, therefore, use them in different situations.</p>
<p>When physicians helps a woman choose the “best” choice, we look at her medical history, lifestyle and a product’s unique characteristics. In contraception, it’s important to never underestimate the importance of side effects or ease of use, since they can drive how consistently a woman uses a particular method. If our goal is consistent, effective use, we must remove barriers to an individual’s choice of birth control method.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/83172/original/image-20150527-4840-1bscxn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/83172/original/image-20150527-4840-1bscxn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/83172/original/image-20150527-4840-1bscxn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/83172/original/image-20150527-4840-1bscxn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/83172/original/image-20150527-4840-1bscxn0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/83172/original/image-20150527-4840-1bscxn0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/83172/original/image-20150527-4840-1bscxn0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not the same.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-174200045/stock-photo-birth-control.html?src=i8dESY1ZvyrXIt2-mxT2ZA-1-51">Pills and IUD via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>How much of a difference will the new guidelines make?</h2>
<p>In the months before the White House released the new guidelines, three different reports captured the coverage variations between insurance plans.</p>
<p>A report from the <a href="http://www.contraceptionjournal.org/article/s0010-7824(14)00687-8/pdf">Guttmacher Institute</a>, a nonprofit organization focused on reproductive health, in September 2014 found that women continued to report out-of-pocket costs, especially for the most effective methods, like the IUD. </p>
<p>In April, a report from the <a href="http://kff.org/private-insurance/report/coverage-of-contraceptive-services-a-review-of-health-insurance-plans-in-five-states/">Kaiser Family Foundation</a> looked at coverage for 12 contraceptive methods among 20 different insurance carriers in five states. The organization found significant variation in interpretation and coverage among the plans. They also found that methods such as the vaginal ring and patch (which don’t need to be taken daily), and the most effective methods like the implant and IUD, were less likely to be covered without cost-sharing. </p>
<p>Further gaps were identified by the <a href="http://www.nwlc.org/resource/state-birth-control-coverage-health-plan-violations-affordable-care-act">National Women’s Law Center</a> in an analysis of more than 100 insurance plans in 15 states. They concluded that 33 plans in 13 states did not comply with the ACA. These plans were not covering all FDA-approved methods. They imposed cost-sharing, only covered generic methods or were not covering associated services, such as counseling or administration visits. </p>
<p>If our nation wishes to reduce the high number of unintended pregnancies – and the costs and abortions that result from them – improving women’s access to the contraceptive methods they prefer, and that they will use consistently, is key. The updated guidelines from the White House mean that American women face fewer barriers to use the contraceptive method of their choice.</p><img src="https://counter.theconversation.com/content/41877/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vanessa K Dalton is a paid expert witness for Bayer. She is also a contributing editor for the Medical Letter. She has also previously served on an expert panel for Johnson and Johnson.</span></em></p><p class="fine-print"><em><span>Lauren MacAfee does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In May, the White House clarified the guidelines for contraceptive coverage, ending cost containment practices that made it hard for some women to access the method of their choice.Vanessa K Dalton, Associate Professor, University of MichiganLauren MacAfee, Fellow, Family Planning, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/242592014-04-15T20:37:47Z2014-04-15T20:37:47ZExplainer: what is the morning-after pill and how does it work?<figure><img src="https://images.theconversation.com/files/46039/original/c9cbwbpk-1397091399.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The morning-after pill is available in Australian pharmacies without prescription.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-174171731/stock-photo-morning-after-pill.html?src=WrlnZy3AoV4VamGqmyR6Pw-1-12">Shutterstock</a></span></figcaption></figure><p>Condoms break, contraceptive pills are missed and in the throes of passion, contraception might be overlooked. So from time to time, a woman may need emergency contraception, known as the morning-after pill.</p>
<p>The morning-after pill is available in Australian pharmacies without prescription. The pharmacist may ask you about what contraception you are using and what other medication you’re taking. But you will not be required to show identification. </p>
<p>The most commonly used morning-after pill available in Australia is <a href="http://www.nps.org.au/medicines/contraceptive-methods/progestogen-only-contraceptives/levonorgestrel-progestogen-only-contraceptives/postinor-1-tablets">Postinor</a>. This pill contains the hormone progestogen and can be taken as a single dose (1.5 mg) or as two doses (0.75 mg, 12 hours apart). Both are equally as effective.</p>
<h2>How does it work?</h2>
<p>The chance of pregnancy is greatest in the two days leading up to and including ovulation. An egg lives for 24 hours and sperm can live for up to three to five days, therefore conception can occur several days after sex. </p>
<p>The morning-after pill works by delaying the increase in the hormone that starts ovulation, the release of an egg. By delaying or stopping the egg from being released, the sperm can’t reach the egg and pregnancy can’t occur. </p>
<p>The morning-after pill therefore needs to be taken before the hormone surge occurs; its <a href="http://www.bmj.com/content/344/bmj.e1492:%20http://www.la-press.com/emerging-options-for-emergency-contraception-article-a3547">effectiveness decreases</a> the closer it’s given to ovulation and it is not effective if given after fertilisation has occurred. </p>
<p><a href="http://www.fpnsw.org.au/682847_8.html">Copper intrauterine devices</a> (IUDs) are an alternative method of contraception and can be inserted up to five days after unprotected sex. Depending on the type, IUDs protect against pregnancy for five or ten years.</p>
<p>In the past, the morning-after pill has been thought to prevent implantation and has therefore been termed an abortifacient. This is categorically <a href="http://www.ncbi.nlm.nih.gov/pubmed/22018122">incorrect</a>. </p>
<p>Implantation can only occur if an embryo is created when a sperm enters an egg. If fertilisation has not occurred then an embryo has not been created and therefore the morning-after pill is not preventing implantation. </p>
<p>Pharmacists should therefore have no hesitation in dispensing the morning-after pill, no matter what their personal beliefs on abortion.</p>
<h2>How effective is it?</h2>
<p>The earlier the morning-after pill is taken after unprotected sex, the greater the success in preventing pregnancy. Ideally the pill should be taken within 72 hours, in which case the rate of efficacy is <a href="http://www.la-press.com/emerging-options-for-emergency-contraception-article-a3547">around 85%</a>. </p>
<p>If taken after 72 hours, the effectiveness reduces. At 120 hours, the risk of pregnancy is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22018122">five times greater</a> than if taken within 24 hours of unprotected sex.</p>
<p>After taking the morning-after pill, women should use a barrier method of contraception, such as condoms, for the remainder of their cycle. The morning-after pill might delay the next period. But if it’s more than 21 days late, it’s best to take a pregnancy test. </p>
<p><a>Recent research</a> has shown that as a woman’s weight increases, the effectiveness of the morning-after pill decreases. Obese women (with a <a href="https://theconversation.com/explainer-overweight-obese-bmi-what-does-it-all-mean-7011">body mass index</a> of 30 or above) who take the morning-after pill are four times as likely as their healthy weight counterparts to become pregnant. </p>
<p>Being obese doesn’t preclude women from taking the morning-after pill but it’s important to note it reduces its efficacy. In such cases, women may choose to have a copper IUD inserted instead.</p>
<p>There are medicines that interact with the morning-after pill and potentially make it less effective: some anti-epilepsy medicines, St John’s Wort and drugs for tuberculosis and HIV. These medicines speed up the breakdown of the morning-after pill in the body. </p>
<p>It’s important to tell your pharmacists about other medicines you’re taking in case there is a drug interaction. In such cases, your pharmacist may recommended you take a higher dose of Postinor.</p>
<h2>Is it safe?</h2>
<p>There have been no deaths or reports of serious problems after taking the morning-after pill and it’s also safe to use while breastfeeding. If pregnancy does occur, there is <a href="http://www.bmj.com/content/344/bmj.e1492">no evidence</a> the drug will cause any harm to the fetus.</p>
<p>It has <a href="http://www.bmj.com/content/331/7511/271">never been shown</a> that accessibility to the morning-after pill leads to an increase in use, an increase in unprotected sex or to a decrease in the use of ongoing contraception.</p>
<p>It’s important that all women – especially teenagers – are well informed on the availability of the morning-after pill. This information should be given in an impartial manner without judgement. </p><img src="https://counter.theconversation.com/content/24259/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Beverley Vollenhoven receives funding from the NHMRC. </span></em></p>Condoms break, contraceptive pills are missed and in the throes of passion, contraception might be overlooked. So from time to time, a woman may need emergency contraception, known as the morning-after…Beverley Vollenhoven, Clinician, Monash IVF; Head of Gynaecology, Monash Health; Associate Professor of Gynaecology and Deputy Director of Obstetrics and Gynaecology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/209962013-12-02T14:55:33Z2013-12-02T14:55:33ZOverweight women shouldn’t panic about contraception<figure><img src="https://images.theconversation.com/files/36678/original/tdcvqwpx-1385981917.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1024%2C682&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Weighing up the options.</span> <span class="attribution"><span class="source">Puuikibeach</span></span></figcaption></figure><p>The warning made by HRA Pharma, the French manufacturer behind Norvelo emergency contraceptive pills, that the product <a href="http://www.theguardian.com/society/2013/nov/26/morning-after-contraceptive-doesnt-work-overweight-women">is ineffective</a> in women who weigh more than 80kg (12st 7lb) and has reduced effectiveness in women over 75kg is a major one, especially given the relatively small amount of data on which it appears to be based.</p>
<p>The decision was based on <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60101-8/abstract">a 2011 meta-analysis</a> that combined data from two studies comparing levonorgestrel, the active ingredient in the Norvelo contraceptive, to another emergency contraceptive called ulipristal acetate (UPA). A total of 1731 women took levonorgestrel pills, 38 of whom became pregnant, while 1714 women took UPA, 22 of whom became pregnant. Obese women accounted for 13.6% of the total study population, and overweight women accounted for 21.6%. </p>
<p>The move has also raised alarm in the US over Plan B emergency pills, which have an identical formula to Norvelo. The FDA in the US said <a href="http://www.businessweek.com/articles/2013-11-27/plan-bs-problem-with-heavier-women-isnt-news-in-europe">it was reviewing</a> the research.</p>
<p>While the study that sparked these concerns raises important concerns about the efficacy of levonorgestrel emergency contraception in overweight and obese women, the relatively small number of these women in the study and low number of pregnancies means we should be cautious in applying the results too broadly. Two important questions remain to be answered: how might obesity affect levonorgestrel emergency contraception, and what are the risks of changing the labelling on these pills based on the current evidence?</p>
<p>You are generally considered to be overweight if you <a href="http://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx?Tag=">have a BMI</a> (your weight in kilogrammes divided by your height in metres) of around 25 to 29 and obese between 30 to 40. It is estimated that around 15-20% of pregnant women in the UK are overweight or obese, rising to <a href="http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Obesity_in_Pregnancy#1">more than a half</a> in the US.</p>
<p>And there are numerous ways that obesity can affect how a drug interacts with the body. Obese individuals may absorb a drug faster through the gut, have a different metabolism and serum concentrations of a drug, and can eliminate a drug either faster or slower from the body. This all depends on the various characteristics of a drug. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736633/">One study</a> that investigated the pharmacokinetics of an oral contraceptive pill containing levonorgestrel found that the maximum serum concentration in the body and time taken to achieve it were not different in normal weight and obese women. It was noted that obese women had a larger area under the concentration-time curve and that levonorgestrel had a longer half-life – this means that it took a greater overall exposure and a longer time to reach a steady state of concentration. The findings were in women who had taken a daily pill for 21 days, and it is unclear how these findings relate to a one-time dose of levonorgestrel as in an emergency contraception pill. </p>
<p>Without a clearer understanding of the pharmacokinetics of levonorgestrel as an emergency contraception in normal weight and obese women, it remains difficult to interpret the available data. For instance, it is unclear whether giving a larger dose of levonorgestrel to obese women would counteract the apparent decreased efficacy of a current recommended dose.</p>
<p>Ultimately, the decision of whether to allow overweight and obese women to continue using levonorgestrel as an emergency contraception must balance benefit and risk. While the meta-analysis that underpinned the decision does indicate reduced efficacy in women with a BMI greater than 25 kg/m2, what are the risks to obese women taking this regimen? </p>
<p>There are no medical dangers associated with levonorgestrel as an emergency pill and the risks of obesity <a href="http://www.theguardian.com/lifeandstyle/2013/sep/18/weight-jeopardises-health-pregnant-women-babies">during pregnancy</a> are well known – these <a href="http://www.nhs.uk/conditions/pregnancy-and-baby/pages/overweight-pregnant.aspx#close">can include</a> developing gestational diabetes or more complications during childbirth. </p>
<p>Until there are additional data to support the conclusion that these pills are ineffective in overweight and obese women, it seems most prudent to encourage the use of more effective emergency contraceptives, such as the copper IUD or UPA, but this doesn’t mean taking away levonorgestrel as an option.</p><img src="https://counter.theconversation.com/content/20996/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jenny Robinson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The warning made by HRA Pharma, the French manufacturer behind Norvelo emergency contraceptive pills, that the product is ineffective in women who weigh more than 80kg (12st 7lb) and has reduced effectiveness…Jenny Robinson, Fellow in Clinical Pharmacology, Johns Hopkins UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/184772013-09-24T04:47:16Z2013-09-24T04:47:16ZPolitics of the pill: why we don’t have better contraceptives<figure><img src="https://images.theconversation.com/files/31822/original/kcht2kk8-1379987185.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women are generally comfortable with post-sex contraceptives but anti-abortion campaigners aren't.</span> <span class="attribution"><span class="source">WarmSleepy</span></span></figcaption></figure><p>More than 50 years after Australian women <a href="https://theconversation.com/the-pills-50th-anniversary-do-we-have-freer-sex-and-better-managed-fertility-4379">first had access to the oral contraceptive pill</a>, research into new contraceptives has stalled and women are stuck with new versions of old products to manage their fertility. Why? Sadly, the answer comes down to politics. </p>
<p>US obstetrician-gynaecologist and researcher Elizabeth Raymond and her colleagues write in today’s <a href="http://press.psprings.co.uk/jfprhc/september/jfprhc100702.pdf">Journal of Family Planning and Reproductive Health Care</a> about a contraceptive pill that could be taken once a month, when a woman’s period was delayed, to prevent pregnancy. They say that such a pill is scientifically feasible and should be researched. </p>
<p>But they fear politics is standing in the way of research into these novel methods because so-called “post-fertilisation fertility control agents” are seen as unacceptable to anti-abortion activists.</p>
<p>There is some subtlety to their argument. Fertilisation occurs when the sperm and egg join, and implantation of the fertilised egg in the uterus wall is considered the commencement of pregnancy. In order to be called a contraceptive, a technology needs to work before implantation. A drug capable of disrupting implantation is considered an abortifacient – a drug that induces abortion. </p>
<p>The authors argue that some women would be comfortable with a technology that acts in this brief window after fertilisation and before implantation.</p>
<h2>Mimicking nature</h2>
<p>When we look back over the history of research and development into contraceptives, it’s clear that women’s needs and concerns are rarely at the forefront. In the 1930s, for instance, researchers knew that female sex hormones could be used as a contraceptive, but this finding was not followed up due to fear of upsetting the Catholic Church.</p>
<p>The introduction of the pill would have occurred much later than 1960 if it were not for feminist philanthropist Katherine McCormick. She became increasingly frustrated while funding birth control clinics in the 1950s because of the lack of safe, reliable birth control options for women. </p>
<p>She and birth control activist Margaret Sanger offered money to an unconventional researcher, Gregory Pincus, who was working outside of academia, to pursue this unpopular line of research. Pincus recruited John Rock, and the pill was developed in secrecy and trialled in Puerto Rica and Haiti. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/31823/original/7h4fvbmq-1379987412.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/31823/original/7h4fvbmq-1379987412.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/31823/original/7h4fvbmq-1379987412.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/31823/original/7h4fvbmq-1379987412.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/31823/original/7h4fvbmq-1379987412.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=564&fit=crop&dpr=1 754w, https://images.theconversation.com/files/31823/original/7h4fvbmq-1379987412.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=564&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/31823/original/7h4fvbmq-1379987412.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=564&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The pill was introduced in Australia in 1961 but was initially available only to married women to control their family size.</span>
<span class="attribution"><span class="source">State Library of South Australia</span></span>
</figcaption>
</figure>
<p>Early trials did not mention the word “contraceptive”. While the researchers knew it was possible to stop a woman menstruating with the pill, they instead manipulated the regimen of the pill so that users would menstruate and have a 28-day cycle. In this way, the pill’s promoters were able to argue that the hormones in the pill were “mimicking nature” and were therefore “natural”. This was necessary to convince conservative forces to support its introduction. </p>
<p>The pill’s cause was also helped greatly by the population control movement, which was concerned about rapidly increasing populations, and the eugenics movement, which was concerned about high fertility rates among the poor.</p>
<h2>Modern battles</h2>
<p>There is <a href="http://www.theaustralian.com.au/higher-education/coalition-angers-research-community/story-e6frgcjx-1226712215714">plenty of evidence</a> that political forces still influence research agendas today. The introduction of <a href="https://theconversation.com/finally-greater-access-to-ru486-now-lets-collect-abortion-data-15722">medication abortion</a> in Australia was delayed due to <a href="https://theconversation.com/politics-v-womens-health-ru486-and-the-tga-saga-9472">political opposition</a>, and has only this year become more widely available in Australia, despite being used successfully in Europe for many years. </p>
<p>There is also no evidence of innovation in contraceptive methods. New methods introduced since 1960 are just different delivery methods for the same types of hormones used in the pill (implants and injectables) or newer versions of the IUD (Mirena). Nothing genuinely new has been developed. </p>
<p>And where is that male pill? It has been touted as <a href="https://theconversation.com/male-contraceptive-pill-a-step-closer-8905">being on the verge of release</a> for years.</p>
<p>We now accept that contraception is a fact of life. Women expect to be having sex for a number of years before commencing child-bearing, if at all, and they manage this using contraception. </p>
<p>But we still have trouble with abortion. Despite one in three Australian women <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Abortion_in_Australia">having an abortion in their lifetime</a>, we still blame the woman, and lament the poor decisions that led to her need for abortion. </p>
<p>We wrongly define women as either “good” managers of fertility, or “bad” ones. “Bad” managers of fertility either have a failure of contraception and need an abortion, or contracept after sex (using the emergency contraception), while “good” managers of fertility contracept before sex (using a hormonal or barrier method, or both).</p>
<p>We leave women carrying a lot of baggage around managing fertility – and blame them when something goes wrong – without many tools to do so.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/31825/original/t4vq6rwd-1379988237.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/31825/original/t4vq6rwd-1379988237.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/31825/original/t4vq6rwd-1379988237.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/31825/original/t4vq6rwd-1379988237.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/31825/original/t4vq6rwd-1379988237.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/31825/original/t4vq6rwd-1379988237.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/31825/original/t4vq6rwd-1379988237.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women expect to be having sex for a number of years before commencing child-bearing, if at all.</span>
<span class="attribution"><span class="source">Flickr/gareth Computer Malfunction Solved</span></span>
</figcaption>
</figure>
<h2>Towards real innovation</h2>
<p>An idea developed in social science studies of technology is that our science and technology reflect back to us our values as a society. If this is so, then the research into contraceptive technology indicates we believe contraception is a “woman’s” problem, not a man’s, and that it is okay to contracept before sex, but not after. </p>
<p>However, if we are serious about reducing the number of abortions in Australia, we need to find better contraceptives, offer men and women more options, and support them to use them as effectively as possible. </p>
<p>We need another Katherine McCormick: someone who is inspired to put resources into addressing the issues that women face today, because if history is anything to go by, governments and business are unlikely to take the risk.</p>
<p>We also need the imagination to devise genuinely new options and we need to break out of the old stereotypes about good and bad women, and instead look at how the technology we have limits and constrains our choices.</p><img src="https://counter.theconversation.com/content/18477/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Louise Keogh receives funding from the National Health and Medical Research Council.</span></em></p>More than 50 years after Australian women first had access to the oral contraceptive pill, research into new contraceptives has stalled and women are stuck with new versions of old products to manage their…Louise Keogh, Health Sociologist & Senior Lecturer, Centre for Women's Health, Gender & Society, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/102502013-03-20T00:15:24Z2013-03-20T00:15:24ZNote to pharmacists on how not to sell the morning-after pill<figure><img src="https://images.theconversation.com/files/21390/original/npd7shyk-1363649535.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pharmacists could have an empathetic conversation with women rather than having them fill in an intrusive questionnaire.</span> <span class="attribution"><span class="source">Tim Parkinson</span></span></figcaption></figure><p>The emergency contraceptive pill (morning-after pill) contains a hormone called levonorgestrel and can be bought without a prescription. It’s used to prevent pregnancy after unprotected sex, but many women are uncomfortable with their interaction with pharmacists when buying this drug.</p>
<p>The morning-after pill is licensed by the <a href="http://www.tga.gov.au/">Therapeutic Goods Administration</a> (TGA) to be used within three days of unprotected sex, but there’s <a href="http://www.ncbi.nlm.nih.gov/pubmed/21664508">evidence</a> that it’s effective for up to four days. Still, the sooner it is taken, the more effective it is.</p>
<p>It’s available as a tablet and is classified as “Pharmacist Only” medicine. The law requires pharmacists to supply such medicines only for a therapeutic need, and to personally deliver or supervise their delivery, and personally give directions for their use. To establish a therapeutic need, a pharmacist must ask the customer questions about her medical problem, medical history and the medications she’s taking. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/21237342">Our recent study</a> of emergency contraceptive pill recommendations by pharmacists across Australia found that most of them used the Pharmaceutical Society of Australia’s (<a href="http://www.psa.org.au/">PSA</a>) written protocol to guide their supply. Pharmacists tended to follow the protocol rigidly, rather than using their discretion. </p>
<p>As recommended, many provided information to women about the emergency contraception in a part of the pharmacy where confidentiality could be assured. But 62% of the women we spoke to expressed concern about the lack of privacy. What’s more, many women were confused about this type of pill – some thought it caused an abortion (32%) and others that it would cause defects if they were to fall pregnant later (61%).</p>
<p>Only 20% of pharmacists always informed women about how the emergency contraceptive pill worked, while the majority spoke about how long it would remain effective after unprotected sex. Many pharmacists agreed that the pill shouldn’t be supplied if unprotected sex had occurred longer than three days ago. </p>
<p>If a woman had unprotected sex outside of this timeframe, a pharmacist can still supply the emergency contraceptive pill. This supply is called “off label” as it is outside of the TGA-licensed use. In such cases, pharmacists should inform women about the effectiveness of this emergency contraception beyond three days and document that they supplied it. (Or they could recommend the woman have an intrauterine device (IUD) placed instead. This IUD is the most effective form of emergency contraception and can be inserted up to five days after unprotected sex.) </p>
<p>But in situations where the emergency contraceptive pill is supplied within licensed use, documentation is not mandatory. The PSA checklist that women may be asked to complete in the pharmacy when they request the emergency contraceptive pill is also not required. It contains some irrelevant and ambiguous questions. </p>
<p>Completed checklists were initiated to protect both parties in the event that the woman becomes pregnant. They include a statement for the woman to read and sign and are stored in the dispensary and, later, shredded. </p>
<p>The emergency contraception pill is <a href="http://www.who.int/mediacentre/factsheets/fs244/en/">not dangerous</a> under any known circumstances or in women with any particular conditions, so using checklists is an outdated practice. It would better if the pharmacist had an empathetic conversation with the woman about her situation, to minimise any shame or embarrassment she may be feeling.</p>
<p>Many pharmacists in our study thought that supplying the emergency contraceptive pill for future use (“advance supply”) was unacceptable. There’s no evidence that advance supply has a negative impact on sexual health; in fact, advance supply would be good practice. Women need to be able to access this pill as soon as possible after they having unprotected sex. </p>
<p>In 2000, the head of the <a href="http://www.acog.org/">American College of Obstetricians and Gynecologists</a> recommended that “every woman store [a packet of the ECP] in her medicine cabinet”. </p>
<p>We also found 22% of pharmacists felt it was reasonable for their religious faith to influence supply. Pharmacists can refuse supply on such grounds, but must refer the woman to another supplier. Pharmacists who decline supply on religious grounds do so in the belief this contraception is an abortion pill, but the latest <a href="http://www.cecinfo.org/custom-content/uploads/2012/12/ICEC_FIGO_MoA_Statement_March_2012.pdf">evidence</a> shows that this is untrue. </p>
<p>The emergency contraceptive pill doesn’t prevent implantation of a fertilised egg and, if taken after implantation, has no effect on an existing pregnancy. It’s not the same as a medicine called mifepristone or RU-486, which was recently approved for medical abortion in Australia.</p>
<p>Australian common law states that a person has to be 16 years or older to consent to medical treatment. The revised PSA protocol now includes provision for those under the age of 16 to be able to access the emergency contraceptive pill. The new guideline has been extensively revised to help pharmacists assure that the women they serve can access and use this pill effectively, safely and unobtrusively. </p>
<p>The emergency contraceptive pill is a medicine that all women should be aware of. It’s available from pharmacies and the sooner it’s taken, the more effective it is. Pharmacists should help women access this pill because it can prevent unwanted and ill-timed pregnancies. Such pregnancies may carry a high risk of death or unhealthy state of mind for the rest of a woman’s life, especially where safe abortion isn’t accessible. </p>
<p>This is the third article in our short series about pharmacies. Click on the link below to read the previous instalments:</p>
<p><strong>Part One:</strong> <a href="https://theconversation.com/pharmacy-gravy-train-drives-up-the-cost-of-prescription-drugs-10016">Pharmacy gravy train drives up the cost of prescription drugs</a></p>
<p><strong>Part Two:</strong> <a href="https://theconversation.com/online-pharmaceuticals-bricks-not-clicks-keep-us-safe-12654">Online pharmaceuticals: bricks, not clicks, keep us safe</a></p>
<p><strong>Part Four:</strong> <a href="https://theconversation.com/pharmacists-should-drop-products-that-arent-backed-by-evidence-12646">Pharmacists should drop products that aren’t backed by evidence</a></p>
<p><strong>Part Five:</strong> <a href="https://theconversation.com/why-you-have-to-show-id-to-buy-cold-and-flu-tablets-2173">Why you have to show ID to buy cold and flu tablets</a></p><img src="https://counter.theconversation.com/content/10250/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>We received funding to do our study with pharmacists and women from the Australian Research Council in partnership with Sexual Health and Family Planning Australia.</span></em></p><p class="fine-print"><em><span>Angela Taft has received funding from the ARC to conduct a study on emergency contraceptive pills and a small amount as part of an ARC Linkage grant for this study from Schering. She has for many years been the National Coordinator or Co-Coordinator of the Public Health Associations Women’s Health Special Interest Group, which lobbied for ECP to be made available over the counter in its efforts to reduce or prevent unwanted pregnancies and bring down abortion rate.</span></em></p>The emergency contraceptive pill (morning-after pill) contains a hormone called levonorgestrel and can be bought without a prescription. It’s used to prevent pregnancy after unprotected sex, but many women…Safeera Hussainy, Lecturer in Pharmacy Practice, Monash UniversityAngela Taft, Associate Professor in Public Health, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.