Time for a Plan C

Originally published in The Washington Monthly on November 26, 2013.
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After years of fighting to make Plan B available without a prescription to girls of any age, the discouraging announcement that Norlevo, a European drug identical to Plan B, loses effectiveness in women who weigh more than 165 pounds and is completely ineffective for women who weigh more than 176 pounds, casts a dark shadow on what was previously celebrated as a victory for women’s health and empowerment. The racial and economic disparities of those who can benefit from Plan B turn out to be much starker than previously understood.

Manufacturers of the European drug announced that they will be updating their packaging information to reflect the weight limits, but it’s unclear yet whether the U.S. will make similar changes to the American version.

When the Obama Administration decided this past June to allow a federal district judge’s ruling to stand—which said that girls younger than 17 should be allowed to purchase plan B over the counter—it seemed like hard-won triumph for the scientific community and women’s rights organizations.

Planned Parenthood Federation of America president Cecile Richards, called the government’s decision to drop the appeal “a huge breakthrough for access to birth control and a historic moment for women’s health and equity.”

Yet this turns out to be a far greater “breakthrough” for some women than for others.

People knew Plan B was hard for poor people to access before this announcement. It’s expensive! One package typically costs between $30 to $65, which can be hard to raise on very short notice. In an economy where nearly 2/3 of the 3.6 million minimum wage workers are women, the affordability of Plan B is already a difficult if not impossible expense.

And, as one might expect, American women often come in over this new weight range. According to the Centers for Disease Control and Prevention, the average weight of American women during the years of 2007-2010 was 166.2 pounds. The average weight of non-Hispanic black women aged 20-39 was 186 pounds, and among Mexican-American women, 78 percent were overweight or obese.

To sum up: Plan B is an ineffective and often unaffordable emergency contraceptive for many American women, particularly minorities.

According to the Guttmacher Institute, in 2006, black women had the highest unintended pregnancy rate of any racial or ethnic groups. At 91 per 1,000 women aged 15-44, it was more than double that of non-Hispanic white women.

Plan B is not an abortion pill, like RU-486, which must be administered in a doctor’s office. Instead, it prevents the fertilization of an egg—which is why it must be used within about 120 hours of intercourse. The drug has been available by prescription since 1999, and contains levonorgestrel, a synthetic version of the hormone progestin. Levonorgestrel has been used in birth control pills for more than 35 years; Plan B contains a higher dose and is taken as two separate doses 12 hours apart.

But drug makers say they’re unsure if increasing levonorgestrel levels further would boost its effectiveness for women over 165 pounds. A spokeswoman for the European drug said, “A dose increase of levonorgestrel is not proven to be a solution for this problem.”

The spokeswoman recommended women with higher weight consider intrauterine devices (IUDs) as an alternative. Yet IUDs are even more expensive, costing anywhere from $500-$1000.

As the abortion fight wages on around the country, with more and more states and cities looking for ways to limit access to abortions or ban them entirely, the fact that a safe and legal abortion alternative is ineffective for many women is rotten news.

At least under the Affordable Care Act, women do have more options than they did several years ago. Birth control and preventive services like mammograms are now covered (barring more legal challenges); insurance premiums are now equal across genders.

But unplanned pregnancy is still a problem—even birth control isn’t 100% effective.

The U.S. Department of Health and Human Services’ Healthy People 2020 campaign aims to reduce unintended pregnancy by 10%, from 49% of pregnancies to 44% of pregnancies, over the next 10 years. According to the Guttmacher Institute, about half of the 6.7 million pregnancies in the United States each year (3.2 million) are unintended.

An emergency contraceptive that disproportionately benefits wealthier and skinnier Americans cannot be the only (relatively) affordable option. If we truly want to help reduce unplanned pregnancy and improve all women’s health and equality, then we need a plan C.

Common sense on Plan B.

Originally published in the Baltimore Sun on April 9, 2013.

Last week, a federal district judge in New York ruled that girls younger than 17 should be allowed to purchase the Plan B contraceptive pill over the counter. Unlike the Obama administration, Judge Edward Korman got this one right. The 2011 decision by Health and Human Services Secretary Kathleen Sebelius to restrict access for younger girls not only denied them a safe and legal means to prevent unwanted pregnancy but ignored all scientific evidence that supported its access.

Emergency contraceptive pills, commonly known as “Plan B,” are drugs that work to prevent pregnancy if taken shortly after sexual intercourse. Plan B, which has been available by prescription since 1999, contains levonorgestrel, a synthetic version of the hormone progestin. Levonorgestrel has been used in birth control pills for more than 35 years; Plan B contains a higher dose and is taken as two separate doses 12 hours apart.

Given that teen pregnancy rates in the United States, while declining, are still high for an industrialized nation, the need for easier access to all forms of safe and effective contraception is great. And there is no question that Plan B is safe; aspirin is more dangerous and susceptible to misuse. For that reason, the Food and Drug Administration recommended in 2011 that Plan B be made available over the counter without a prescription.

Nonetheless, President Barack Obama defended Ms. Sebelius’ decision to reject the FDA recommendation, saying at the time that he believed the nation should exercise “common sense” when deciding what medicines to allow over the counter. White House spokesman Jay Carney reiterated that line on Friday, again calling it a “common-sense approach.”

Common sense would be to make decisions based on reputable scientific research, as Mr. Obama had pledged to do during his first inaugural address, when he said he would “restore science to its rightful place” in policymaking. Instead, “common-sense” effectively means “compromise” with those whose real agenda is to erode access to contraception and those who mistakenly think Plan B has something to do with abortion.

Plan B is not an abortion pill, like RU-486, which must be administered in a doctor’s office. Instead, it prevents the fertilization of an egg, which is why it must be used within about 120 hours of intercourse. Nonetheless, Plan B has become a target of abortion-rights foes and those who think that increasing access to contraception somehow leads to promiscuity.

The Obama administration’s decision to reject the Food and Drug Administration’s advice on Plan B was a surprising one for a president who has otherwise done much good for the cause of women’s health care. Under the Affordable Care Act, women can now receive free birth control; they can get preventive services like mammograms, new baby care and well-child visits without co-pays; and there are greater crackdowns on discriminatory insurance premiums based on gender.

The only conceivable explanation for the president’s decision was that it was an attempt, amid a re-election campaign, to avoid fueling the trumped-up narrative that his efforts to extend contraception access amounted to a “war on religion.” Judge Korman called the ban “politically motivated, scientifically unjustified and contrary to agency precedent.” His decision was supported by scientists, experts, women’s reproductive health groups and the American Academy of Pediatrics, which had advised its members to issue blanket Plan B prescriptions to teen girls as a means to get around the Obama administration policy.

This ruling comes at a time when women’s reproductive rights are being put at risk in state houses across the country. North Dakota recently passed legislation to ban any abortion after six weeks, the strictest such measure in the nation. It trumped legislation passed in Arkansas earlier this year to ban abortions in the 12th week of pregnancy, and it is about to be leapfrogged by a Kansas bill that defines life as beginning at fertilization.

It is unclear yet whether the Obama administration will try to fight the Plan B ruling. Mr. Carney said in a news conference that the president’s opinion “has not changed.” But now, the president doesn’t even have the excuse of political expediency to justify his position. The science is clear, and so are the public health benefits of making Plan B widely available. The president should let this decision stand.