Emergency contraception: The next frontier for our two-tier reproductive health system?


The new post-coital contraceptive, ulipristal (also known as ella), has been FDA approved.  As a doctor who wants women to have as many choices as possible, I’m thrilled to have another option to offer to women.  But this particular new choice actually leaves me feeling queasy.

Ella is being reported in the media as the new emergency contraceptive that works for 5 days, as compared with Plan B’s 3 days.  While it’s true that ella is FDA approved for 5 days, and Plan B for 3 days, it is well known that Plan B continues to be effective for up to 5 days after unprotected sex, though efficacy decreases with time.  Several months ago I wrote a post with my colleague Nick Fogelson at the Academic Ob/Gyn dissecting the evidence for ella’s claims of superiority as a post-coital contraceptive and found it lacking.  Yes, ella works as well as Plan B.  It may even be more effective than Plan B, but the studies that have been published to date do not provide conclusive evidence to support that.

Despite the inability to draw a definitive conclusion from the published study, the fact is that there is a trend towards superiority in preventing unwanted pregnancy after unprotected sex.  For the sake of argument, let’s assume that ella is, in fact, more effective.  Where does this leave us?

Frankly, in a very problematic position.  For starters, Plan B is currently available over-the-counter, without prescription, for anyone over 16.  Ella will be available only by prescription and, although prices have not yet been released, it’s a safe bet to say that it will be more expensive than Plan B.  Add to this time off from work, paying for a doctor’s visit, and either a higher co-pay or no coverage of Ella due to the existence of a cheaper alternative, and you can start to see that ella will be an option only for the haves.  The have-nots will be tracked into the same two-tier reproductive health system that leads to poor women running out of their contraceptive pills, getting abortion procedures up to 3 weeks later than their more well-off peers, continuing unwanted pregnancies somewhere between 18 to 35 percent of the time, and resorting to do-it-yourself abortions.

As I’ve said, it remains to be seen if ella is indeed more effective than Plan B.  But even if it isn’t, it’s being marketed that way and reporting on it in the mainstream media has faithfully followed the formula set out by the pharmaceutical company.  Most women in need of emergency contraception don’t have time to read the journal article and take a statistics class to understand it.  Imagine you’re a woman (or part of a couple) in need of emergency contraception.  You google “emergency contraception” and come across an article reporting that of those who took ella within 72 hours of unprotected intercourse, 0.9 percent got pregnant, and of those who took Plan B within 72 hours 1.7 percent got pregnant.  As most rational people would, you decide that you would prefer the option more likely to work, because after all you really don’t want to be pregnant.  So, do you spend $10 to $70 for Plan B over-the-counter and hope that you’re in that 98.3 percent of people who don’t get pregnant, or do you spend $100 -$150 for that 99.1 percent chance?  Do you call your doctor for a prescription, setting ahead the clock another 12 to 24 hours and thereby leading to lower effectiveness?  Do you take a day off from work to go see a doctor if you’re unable to get a prescription over the phone?

While these seem like theoretical calculations, this could very well become a reality for some women and their partners.  We’re not talking about whether you should spring for the premium tires for your car; we’re talking about a very real biological event that can profoundly change your life.  Regardless of whether ella truly is more effective than Plan B, a very worrisome situation has been set up here, and I’m not sure how consumers will be able to navigate it.

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