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Preventing Unintended Pregnancy: The

Cost-Effectiveness of Three Methods of


Emergency Contraception

James Trussell, PhD, Jacqueline Koenig, Charlotte Ellertson, PhD,


and Felicia Stewart, MD

Introduction contraceptives available in the United


States (Table 1).6 Use of emergency
Emergency contraception prevents contraceptive pills reduces the risk of
pregnancy after unprotected sexual inter- pregnancy by at least 74%.7,8 About half
course. Emergency contraceptives avail- of women who take emergency contracep-
able in the United States include emer- tive pills experience nausea and 20%
gency contraceptive pills, minipills, and vomit; antinausea medicines may reduce
the copper-T intrauterine device (IUD). the risk of nausea.8 If vomiting occurs
All require a prescription.1 2 In this paper, within 2 hours after taking a dose, some
we examine the cost-effectiveness of clinicians recommend repeating it.2
- emergency contraceptive use by compar- Almost all women can safely use
ing the costs of treatment with the savings emergency contraceptive pills. Treatment
generated in the prevention of an unin- may not be appropriate for those who
tended pregnancy. have an active migraine with marked
Emergency contraceptive pills are neurological symptoms or crescendo mi-
ordinary birth control pills containing the graine.9 Combined oral contraceptives are
-hormones estrogen and progestin. Al- usually not prescribed as ongoing contra-
though this therapy is commonly known ception to women with a history of stroke
as the moming-after pill, the term is or blood clots in the legs or lungs.
misleading; emergency contraceptive pills However, there is no evidence that emer-
may be initiated earlier, immediately after gency contraceptive pills would be harm-
unprotected intercourse, or later, at least ful to such women given the very short
72 hours beyond. The current treatment duration of exposure and the low total
schedule is one dose within 72 hours after hormone content; indeed, no changes in
unprotected intercourse, and another dose clotting factors have been detected follow-
12 hours later. It is biologically implau- ing emergency contraceptive pill treat-
sible that efficacy would vanish after 72 ment.'0
hours.3 Emergency contraceptive pills are Minipills are birth control pills that
not more effective when started earlier or contain only progestin (and not estrogen).
less effective when started later in the Only levonorgestrel, the progestin in the
72-hour window.4 Therefore, clinical pro-
tocols that deny treatment beyond 72
hours seem excessively restrictive, particu- James Trussell is with the Woodrow Wilson
larly if emergency insertion of a copper-T School of Public and Intemational Affairs and
IUD is not possible or appropriate. with the Office of Population Research, Princeton
University, Princeton, NJ. Jacqueline Koenig is
Moreover, a recommendation to take the with the Office of Population Research, Princeton
first dose as soon as possible might be University, Princeton, NJ. Charlotte Ellertson is
counterproductive if taking the second with The Population Council, New York, NY.
Felicia Stewart is with the Henry J. Kaiser
dose 12 hours later (e.g., at 3 AM) would Family Foundation, Menlo Park, Calif.
be inconvenient. The goal should be to
.;.::.:

....... .. : . .. .. .. ... . Requests for reprints should be sent to


make the therapy as user friendly as James Trussell, PhD, Director, Office of Popula-
possible.5 tion Research, Princeton University, 21 Prospect
Ave, Princeton, NJ 08544-2091.
The hormones that have been studied This paper was accepted August 14, 1996.
in clinical trials of emergency contracep- Editor's Note. See related annotation by
tive pills are found in seven brands of oral Cates and Raymond (p 909) in this issue.
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.... June 1997, Vol. 87, No. 6
Emergency Contraception

minipill Ovrette, has been studied as an


emergency contraceptive (Table 1). The TABLE 1-Oral Contraceptives Used for Emergency Contraception in the
treatment schedule is one dose within 48 United States
hours after unprotected intercourse and
another dose 12 hours later. The only Ethinyl-Estradiol Levonorgestrel
randomized trial comparing the two regi- Brand Pills per Dose per Dose, pg per Dose (mg)a
mens found that minipills are as effective
as emergency contraceptive pills but Ovral 2 white pillsb 100 0.50
Alesse 5 pink pillsb 100 0.50
result in less nausea and vomiting." For Nordette 4 light-orange pillsb 120 0.60
most women who cannot safely tolerate Levlen 4 light-orange pillsb 120 0.60
even very low doses of estrogen, minipills Lo/Ovral 4 white pillsb 120 0.60
are an excellent alternative to emergency Triphasil 4 yellow pillsb 120 0.50
Tri-Levlen 4 yellow pillsb 120 0.50
contraceptive pills. Ovrette 20 yellow pillsc 0 0.75
A copper-T IUD can be inserted up
to 7 days after unprotected intercourse to aThe progestin in Ovral, Lo/Ovral, and Ovrette is norgestrel, which contains two isomers, only
prevent pregnancy. Copper-T IUD inser- one of which (levonorgestrel) is bioactive; the amount of norgestrel in each dose is twice the
tion is extremely effective, reducing the amount of levonorgestrel.
bThe treatment schedule is one dose within 72 hours after unprotected intercourse and
risk of pregnancy following unprotected another dose 12 hours later.
intercourse by more than 99%.12 More- CThe treatment schedule is one dose within 48 hours after unprotected intercourse and
over, a copper-T IUD can be left in place
another dose 12 hours later.
to provide continuous, effective contracep-
tion for up to 10 years. Women at risk of
sexually transmitted infections may not be many women take birth control pills to The average cost of an unintended
good candidates for IUDs; insertion of the regulate their menstrual periods or de- pregnancy is $3795 in a managed care
IUD can lead to pelvic infection, which crease menstrual cramping rather than for setting and $1680 in a publicly funded
can cause infertility if untreated. Women contraception.' program.'6 These are the weighted aver-
not at risk of sexually transmitted infec- ages of the costs of ectopic pregnancy,
tions have little risk of pelvic infection Data and Methods induced abortion, spontaneous abortion,
following IUD insertion.13 and birth, with weights (0.0100, 0.4703,
Although some doctors have been We analyze the cost-effectiveness of 0.1228, and 0.3970, respectively) equal to
prescribing emergency contraceptives two different protocols for delivering the probabilities of each outcome follow-
since the 1970s, no company has applied emergency contraception: (1) women seek ing a contraceptive failure among women
to the Food and Drug Administration treatment from a clinician following using methods most compatible with
(FDA) to market oral contraceptives or unprotected intercourse, and (2) women emergency contraception: barrier contra-
IUDs for emergency contraception. While are provided emergency contraceptive
ceptives, spermicides, periodic absti-
considerable research attests to the safety pills during a routine visit to a clinician for nence, withdrawal, and no method. Esti-
and efficacy of emergency contraceptives, later use should unprotected intercourse
mates in our base model, hereafter denoted
manufacturers cannot market or advertise occur.6 We consider only costs associated
these products for postcoital use until they with medical care. We ignore psychologi- the averted-birth model, overstate the
seek and gain FDA approval for this cal and other nonmedical costs, such as medical costs of unintended pregnancies
specific purpose. Without commercial productivity loss associated with an unin- because we assume that the births, if
promotion, it is not surprising that clini- tended pregnancy and transportation ex- prevented, would never occur. In fact,
cians prescribe emergency contraceptives penses associated with emergency contra- only 31 % of unintended births are un-
infrequently and fail to provide informa- ceptive treatment. We consider two health wanted in the sense that they would not
tion about emergency contraception to care delivery systems: private managed occur at a later time, and the remainder
women during routine visits. As a conse- care and publicly funded programs. (69%) are timing failures (births that
quence, very few women know that Whether emergency contraceptives will occur sooner than intended).'7 Therefore,
emergency contraception is available. 14 be cost-effective depends on three factors: we also develop a delayed-birth model by
To inform women, a directory of clini- the cost of treatment, the probability of its assuming that women with timing failures
cians throughout the United States who preventing an unintended pregnancy, and would intentionally become pregnant 2
provide emergency contraceptives has the cost of an unintended pregnancy. Cost years later and by discounting costs
been published2; it is being continuously data for the managed care model were beyond the current year to present value at
expanded and is available on the World obtained principally from Medstat Sys- an annual rate of 5%. In the delayed-birth
Wide Web at http:Hopr.princeton.edu/ec/ tems, Inc (Ann Arbor, Mich). Its Market- model, the average cost of an unintended
and via a toll-free telephone hotline at Scan database reflects experience of large pregnancy falls to $1653 in a managed
1 -888-NOT-2-LATE. employers from 45 major metropolitan care setting and $779 in a publicly funded
Providing emergency contraception areas; cost estimates represent the 1991 program.
is legal, even though the FDA has not payments received by the providers from
specifically approved any product for this all sources.16 Cost estimates for the Provision following Unprotected
purpose. Once a medication or device has publicly funded model were obtained Intercourse
been approved for one use, it is a legal and from 1993 fee schedules and statistics for
medically accepted practice to prescribe it Medi-Cal, the California Medicaid pro- A review of 10 clinical trials assess-
for other appropriate uses.5 For example, gram. 16 ing the effectiveness of emergency contra-

June 1997, Vol. 87, No. 6 American Journal of Public Health 933
Trussell et al.

broke or slipped. In contrast, women


TABLE 2-Savings Associated with a Single Use of Emergency relying on other methods would use
Contraception Prescribed after Unprotected Intercourse emergency contraceptive pills only when
they did not use their contraceptive or
Savings used it incorrectly; only at such times
Method Averted-Birth Modela Delayed-Birth Modelb would they know that intercourse was
unprotected. Therefore, we assume that
Managed care setting use of emergency contraceptive pills
ECPsc $142 $ 29 would prevent 74% of the pregnancies
Minipillsd $119 $ 6 during typical (both perfect and imper-
Copper-T IUDe -$123 -$275 fect) use of condoms and imperfect use of
the other methods.' 8
Public payer setting It may not be reasonable to assume
ECPsC $ 54 $ 6 that the typical woman would use emer-
Minipillsd $ 29 -$ 19 gency contraceptive pills after every
Copper-T IUDe -$ 53 -$117
detectable act of unprotected intercourse
Note. ECPs = emergency contraceptive pills; IUD = intrauterine device. since she does not use her regular
alncludes the full cost of all unintended births, both unwanted and mistimed. contraceptive perfectly. Therefore, we
bAssumes that 31 % of unintended births are unwanted in the sense that they would not occur model two scenarios, in which emergency
at a later time and that 69% are simply mistimed17 and would occur 2 years later.
COost is based on the assumption that women are prescribed an entire pack of Alesse, contraceptive pills are used after all and
Nordette, Levlen, Lo/Ovral, Triphasil, or Tri-Levlen (but not Ovral). An entire pack of Alesse after three quarters of all detectable
contains 21 active pills; only 10 are needed, unless a dose must be repeated after vomiting. unprotected acts of intercourse, respec-
An entire pack of Nordette, Levlen, or Lo/Ovral contains 21 active pills; only 8 are needed,
unless a dose must be repeated after vomiting. Triphasil and Tri-Levlen contain 10 yellow tively.
pills, of which only 8 are needed; there are not enough pills to repeat a dose. Ovral is more
expensive (about $33 per pack in a managed care setting and $32 per pack in a public
sector setting), but only 2 of 21 active pills are required per dose.
dCost is based on the assumption that women are prescribed two entire packs of Ovrette. Two Results
packs of Ovrette contain 56 active pills; only 40 are needed.
eWould result in significant savings if a women continued to use the IUD as a long-term method In the averted-birth model, a single
of birth control. Savings exceed costs in both the managed care and public sector settings in
the delayed-birth model when IUD use continues for as few as 4 months, even when the cost treatment with emergency contraceptive
of treating pelvic infection associated with IUD insertion is included.16 (There is a pills saves $142 in a managed care setting
typographical error in Table 3 of reference 16; the incidence of uterine perforation for the and $54 in a publicly funded setting
copper-T IUD is 0.06%, not 0.11%.)
(Table 2). A single treatment with mini-
pills is also cost-effective. In contrast, a
single treatment with the copper-T IUD
ceptive pills found that among every 1000 for the insertion, $109 for the device, and costs $123 and $53, respectively. In the
women treated with emergency contracep- $1 for treatment of uterine perforation).'6 delayed-birth model, a single treatment
tive pills, 19 become pregnant despite Advance Provision of Emergency with emergency contraceptive pills would
treatment whereas 72 would have become still save costs in both settings (Table 2). A
Contraceptive Pills
pregnant without treatment.8 Thus, 53 single treatment with minipills is cost-
pregnancies are avoided among every We assume that women using barrier effective in a managed care setting but not
1000 women treated, a 74% reduction. methods, spermicides, periodic absti- in a publicly funded program. Insertion of
Comparable effectiveness would be ex- nence, and withdrawal are routinely pro-
a copper-T IUD would not be cost-
pected among women treated with mini- vided one pack of Ovral annually- effective when used only as an emergency
pills. However, at most 1 woman would enough for five emergency contraceptive contraceptive and then removed.
become pregnant among 1000 women pill treatments.6 (We ignore here emer- In the averted-birth model, advance
treated with postcoital insertion of a gency contraceptive pill treatment among
women using oral contraceptives who
provision and consistent use of emer-
copper IUD, so 71 pregnancies would be
gency contraceptive pills in a managed
avoided. 12 miss pills.'8) The cost per woman would
care setting would annually produce
The average cost of treating women be $71 in a managed care setting ($38 for
the office visit and $33 for the drug) and savings ranging from a low of $263
in a managed care setting is $59 for
among those using the male condom to a
emergency contraceptive pills ($38 for the $49 in a publicly funded program ($17 for
office visit and $21 for the drug), $82 for the office visit and $32 for the drug). For high of $498 among those using the
minipills ($38 for the office visit and $44 diaphragm and cervical cap users, costs female condom (Table 3, column 1). If
would be lower ($33 in the managed care emergency contraceptive pills were used
for the drug since two packets of pills are
needed), and $392 for a copper-T IUD model and $32 in the publicly funded less consistently, then the savings would
($207 for the insertion, $184 for the model) since no extra office visit would be fall by about 30% (Table 3, column 2).
device, and $1 for treatment of uterine required beyond the one necessary to fit In the delayed-birth model, when
perforation). The average cost in a public the device. emergency contraceptive pills are used
sector setting is $35 for emergency Women relying on male or female consistently, annual savings would range
contraceptive pills ($17 for the office visit condoms could use emergency contracep- from a low of $72 among those using the
and $18 for the drug), $60 for minipills tive pills whenever condoms were used male condom to a high of $165 among
($17 for the office visit and $43 for the imperfectly (not used or used incorrectly) those using the female condom (Table 3,
drug), and $172 for a copper-T IUD ($62 or were used perfectly but nevertheless column 3). In the scenario where emer-

934 American Journal of Public Health June 1997, Vol. 87, No. 6
Emergency Contraception

gency contraceptive pills are used less


consistently, there would still be cost TABLE 3-Cost Savings Associated with the Advance Provision of
savings among users of all methods Emergency Contraceptive Pills
(Table 3, column 4).
In the averted-birth model, when Savings
publicly funded programs provide emer-
gency contraceptive pills in advance, their Averted-Birth Modela Delayed-Birth Modelb
consistent use would produce annual cost Method Scenario 1c Scenario 2d Scenario 1 c Scenario 2d
savings ranging from a low of $99 among
users of the male condom to a high of Managed care setting
$205 among users of the female condom Male condom $263 $179 $ 72 $ 37
(Table 3, column 1). If women use Female condom $498 $356 $165 $106
emergency contraceptive pills less consis- Spermicides $362 $254 $114 $ 68
Diaphragm $314 $228 $114 $ 77
tently, the cost savings would be reduced Sponge $361 $253 $113 $ 67
by about a third on average (Table 3, Cervical cap $298 $215 $107 $ 72
column 2). In the delayed-birth model, if Withdrawal $362 $253 $117 $ 70
emergency contraceptive pills were used Periodic abstinence $396 $279 $133 $ 82
consistently, cost savings would range
from a low of $19 among users of the Public payer setting
male condom to a high of $65 among Malecondom $ 99 $ 62 $ 19 $ 2
users of the female condom (Table 3, Female condom $205 $141 $ 65 $ 36
Spermicides $141 $ 94 $ 37 $ 16
column 3). In the scenario where women Diaphragm $120 $ 82 $ 36 $ 19
use emergency contraceptive pills less Sponge $142 $ 94 $ 38 $ 16
consistently, benefits would still exceed Cervical cap $112 $ 76 $ 33 $ 16
costs for users of all methods (Table 3, Withdrawal $143 $ 95 $ 40 $ 18
column 4). Periodic abstinence $158 $106 $ 47 $ 23

Note. We assume that for methods other than condoms, pregnancy rates during imperfect use
Discussion would be reduced by 74% so that the pregnancy rate during typical use of a method
combined with consistent use of emergency contraceptive pills would be Ppfp + 0.26(ft - Pp
Emergency contraception reduces fp), where ft and fp are failure rates during typical and perfect use, respectively, and Pp is the
proportion of use that is perfect, here conservatively assumed to be 90%.1 When emergency
expenditures on medical care by prevent- contraceptive pills are used after only three quarters of all unprotected acts of intercourse,
ing unintended pregnancies, which are the pregnancy rate during typical use of a method would be Ppfp + (1.0 - 0.75 x 0.74)(ft -
expensive. Emergency contraceptive pills Ppfp). We ignore the distinction between annual probabilities of failure (f, and fp) and annual
failure rates because the two are nearly identical. Consider the following simple birth-interval
are cost-effective regardless of whether model for women using spermicides. An annual probability of failure during typical use of .21
they are provided when the emergency implies an average monthly probability of failure of .0195 (=1.0 - 11.0 - .2111/12). If we
assume this probability is constant over time, the average waiting time to conception while
arises or provided in advance to be used using spermicides is 51 months (=1/.0195). If we then ignore ectopic pregnancies,
when needed. Minipills are also a cost- spontaneous abortions, and stillbirths and assume that every other pregnancy ends in
induced abortion, the waiting time to a conception leading to a live birth would be 106
effective emergency contraceptive. Inser- months: 51 months to get pregnant the first time, 3 months' gestation until the abortion, 1
tion of a copper-T IUD is not cost saving month of postpartum nonsusceptibility following the abortion, and 51 months to get pregnant
when used solely as an emergency contra- again. The entire interval from one birth to the next would be 117 months: 2 months of
postpartum nonsusceptibility following the birth (assuming minimal breastfeeding), 106
ceptive. Unlike the other two altematives, months of waiting time to the next live-birth conception, and 9 months for gestation. Hence a
however, insertion of a copper-T IUD can birth occurs every 117 months or 9.75 years, so the birth rate per year is 0.103 (=1/9.75).
provide continuous contraceptive protec- Because there are two pregnancies for each birth, the pregnancy rate per year is 0.206
(=2 x .103), a rate that is very close to the annual probability of failure of .21. Differences
tion for up to 10 years thereafter and are even smaller for more effective methods.
would produce considerable savings if alncludes the full cost of all unintended births, both unwanted and mistimed.
bAssumes that 31% of unintended births are unwanted in the sense that they would not occur
used as an ongoing method of contracep- at a later time and that 69% are simply mistimed l7and would occur 2 years later.
tion.'6 Savings exceed costs in both the CAssumes that emergency contraceptive pills are used each time they would be appropriate.
managed care and public sector settings dAssumes that emergency contraceptive pills are used in three quarters of situations where
they would be appropriate.
when IUD use continues for as few as 4
months, even under the least favorable
assumptions. 16
Cost savings in our models are likely minipills cost-effective even under the fewer pills are needed. Some clinicians
to be understated, for six reasons. First, in least favorable assumptions. When emer- cut the 21-pill pack into 1-dose units; 4
the scenario in which emergency contra- gency contraceptive pills are prescribed in packs of Ovral provide 42 single doses,
ception is provided only after unprotected advance, women would not need to visit a enough for 21 courses of therapy, exclud-
intercourse, we have assumed that an clinician each year for a prescription as ing repeated doses. If this strategy is used,
office visit is always required for emer- we assumed, but instead could renew their and a single extra dose is provided to each
gency contraceptive pills and minipills. In prescriptions for emergency contraceptive woman in case of vomiting, then the cost
fact, many clinicians are willing to pills by telephone as needed. of the drug would fall in a managed care
prescribe via telephone-especially for Second, we have assumed that an setting to $9 for Ovral ($33 x 6/21),
established patients-since a physical entire pack of emergency contraceptive compared with $21 for other brands of
examination is not medically necessary. pills or 2 entire packs of minipills are emergency contraceptive pills, and in a
Elimination of the office visit would make prescribed in an emergency, even though public sector setting to $9 ($32 X 6/21),

June 1997, Vol. 87, No. 6 American Journal of Public Health 935
Trussell et al.

compared with $18. The cost of minipills therefore, continued use would not be a many countries, a tablet containing the
is based on the assumption that women rational choice.6 Moreover, one in two 0.75 mg levonorgestrel found in 20
are prescribed 2 packs of Ovrette. Since a women experiences nausea and one in Ovrette minipills is available. In Malay-
pack of Ovrette contains 28 active pills, five women vomits after taking emer- sia, for instance, a brand called Postinor
only 1.5 packs are needed for each gency contraceptive pills. Use of antinau- costs about $3 to $6 for a 10-pill strip.20
treatment; thus, the cost of the drug would sea medicines might halve, but not Although such products would undoubt-
fall by 25%, and the cost of minipills eliminate, the incidence of nausea and edly cost more in the United States,
would exceed the benefits by only $8 vomiting.8 This experience is likely to having specifically labeled products would
under the least favorable assumptions. In dissuade such users from having unpro- be likely to reduce the cost of each dose of
the scenario in which emergency contra- tected intercourse often. emergency contraception.
ceptive pills are provided in advance, Sixth, we have underestimated the More than half of all pregnancies in
every woman is assumed to receive 1 cost of a birth resulting from an unin- the United States are unintended: 3.5
pack of Ovral annually. Costs will be tended pregnancy. We assumed that unin- million each year.21 Unintended preg-
overestimated since most women would tended births that were not unwanted (in nancy is a major public health problem
not use their full supply and would not the sense that they would never occur) are that affects not only the individuals
need additional emergency contraceptive simply postponed for 2 years and would directly involved but also the wider
pills every year. be intended at that time. In fact, the society.'9 Insurers in both the public and
Third, we assume that managed care average period that such births would be private sectors generally cover the medi-
providers would pay average wholesale postponed may be much longer; the cal costs of unintended pregnancy, with
prices for oral contraceptives and IUDs. longer such births are postponed, the more coverage for abortion showing the most
In fact, many providers receive discounts. likely it is that they would never occur. variation. Some private insurers provide
In the public sector model, we used Moreover, we have incorrectly assumed broad coverage for all contraceptive meth-
maximum Medi-Cal payments for these that the medical care cost of an unin- ods, but most do not.22 Public payers
contraceptives even though they are very tended birth is no greater than the average generally provide broader contraceptive
high; many publicly funded programs, for cost of all births. Finally, by confining our coverage than private payers, although
example, pay less than $1 per cycle of oral attention to medical care costs, we have payment levels often are low, perhaps low
contraceptives whereas we have assumed ignored the additional social cost savings enough to limit access.23 Our findings
that they pay $32 for Ovral, $21 for that would result from use of emergency strongly suggest that extending explicit
Ovrette, and $18 for other brands of contraception. These include not only the coverage to emergency contraception
emergency contraceptive pills. Thus, we monetary costs of unwanted pregnancies would result in cost savings by reducing
have overstated the cost of emergency and births but also the considerable the incidence of unintended pregnancy.
contraceptives. psychological costs of unintended preg- Several innovations in service deliv-
Fourth, we assumed that use of nancy. A recent report from the Institute of ery would also enhance the potential for
emergency contraceptive pills following Medicine concludes: emergency contraception to reduce the
unprotected intercourse prevents 74% of With an unwanted pregnancy especially,
number of unintended pregnancies signifi-
pregnancies that otherwise would have the mother is more likely to seek cantly. Perhaps the greatest impact would
occurred. The true effectiveness rate of prenatal care after the first trimester or result from changing provider practices so
emergency contraceptive pills is probably not to obtain care. She is more likely to that women seen by primary and reproduc-
higher-perhaps 80%-because the ob- expose the fetus to harmful substances tive health care clinicians would be
served number of pregnancies is likely to by smoking tobacco and drinking alco- routinely informed about emergency con-
hol. The child of an unwanted concep-
be too high and the expected number of tion is at greater risk of weighing less traception before the need arises; the
pregnancies is probably too low in the than 2,500 grams at birth, of dying in its recent clinical practice pattem issued by
studies evaluating the efficacy of emer- first year of life, of being abused, and of the American College of Obstetricians
gency contraceptive pills.7-8 not receiving sufficient resources for and Gynecologists should further this
Fifth, when examining advance pro- healthy development. The mother may goal.24 Information could be provided
be at greater risk of physical abuse
vision of emergency contraceptive pills, herself, and her relationship with her during counseling or by brochures, audio-
we have assumed in the worst-case partner is at greater risk of dissolution. cassettes or videocassettes, or wallet
scenario that they will be used on only Both mother and father may suffer cards. A more proactive step would be to
three quarters of occasions when they are economic hardship and fail to achieve prescribe or dispense emergency contra-
their educational and career goals. The ceptive pills in advance so that the therapy
needed. Women and couples who do not health and social risks associated with a
consistently use methods of ongoing mistimed conception are similar to those would be immediately accessible if the
contraception may nevertheless use emer- associated with an unwanted concep- need arises. Availability would also be
gency contraceptive pills far more consis- tion, although they are not as great.'9(P81) enhanced if manufacturers sought FDA
tently. One might argue instead that a Emergency contraceptives would be approval for, and then actively promoted,
woman who knows she can use emer- even more cost-effective in the United emergency contraceptives; the recent FDA
gency contraceptive pills will become less States if they were not inconvenient and notice in the Federal Register declaring
diligent with her ongoing contraceptive inefficiently packaged. In other countries, emergency contraceptive pills to be safe
method. Common sense, however, sug- specifically packaged and labeled prod- and effective will make gaining approval
gests two reasons to refute that argument. ucts are available. In the United Kingdom, far easier in addition to giving explicit
The most compelling is that if used as an for instance, a packet of 4 PC4 tablets is official sanction for the use of emergency
ongoing method, emergency contracep- sold by Schering to the National Health contraceptive pills.25 Until clinicians,
tive pill therapy would be far less effective Service for $2.20. PC4 tablets are manufacturers, or insurers make these
than any other contraceptive method; identical to Ovral tablets. Similarly, in changes, the only way to improve access

936 American Journal of Public Health June 1997, Vol. 87, No. 6
Emergency Contraception

is to inform women directly about the Emergency contraceptive pills: a simple comparison of 15 methods. Am J Public
availability of emergency contraception proposal to reduce unintended pregnancies. Health. 1995;85:494-503.
so that they themselves can demand better Fam Planti Perspect. 1992;24:269-273. 17. Forrest JD, Singh S. The sexual and
7. Trussell J, Stewart F. The effectiveness of reproductive behavior ofAmerican women,
clinical care. D postcoital hormonal contraception. Fam 1982-1988. Fam Planti Perspect. 1990;22:
Planti Perspect. 1992;24:262-264. 206-214.
8. Trussell J, Ellertson C, Stewart F. The 18. Guillebaud J. When do you need to give
Acknowledgments effectiveness of the Yuzpe regimen of emergency contraception for missed pills?
This work was supported in part by grants from emergency contraception. Farn Plann Per- Fertil Control Rev. 1995;4:18-20.
The Andrew W. Mellon Foundation and the spect. 1996;28:58-64,87. 19. Brown SS, Eisenberg L, eds. The Best
Summit Charitable Foundation. 9. Webb A. How safe is the Yuzpe method of Intentions: Unintended Pregnancy and the
The authors have no personal financial emergency contraception? Fertil Control Well-Being of Children and Families.
interest whatsoever in the commercial success Rev: 1995;4:16-18. Washington, DC: National Academy Press;
or failure of emergency contraception. Char- 10. Webb A, Tabemer D. Clotting factors after 1995.
lotte Ellertson is employed by The Population emergency contraception. Advt Contracept. 20. Glasier A, Ketting E, Palan VT, et al. Case
Council, a not-for-profit research organization 1993;9:75-82. studies in emergency contraception from
that receives royalties on sales of the copper-T 11. Ho PC, Kwan MSW. Aprospective random- six countries. Int Fam Plann Perspect.
IUD. ized comparison of levonorgestrel with the 1996;22:57-61.
21. Harlap S, Kost K, Forrest JD. Preventing
Yuzpe regimen in postcoital contraception. Pregnancx, Protecting Health: A New Look
References 12.
Hum Reprod. 1993;8:389-392.
Trussell J, Ellertson C. Efficacy of emer-
at Birth Control Choices in the United
1. Hatcher RA, Trussell J, Stewart F, et al. States. New York, NY: The Alan Guttma-
Contraceptive Technology: 16th rev. ed. gency contraception. Fertil Control Rev. cher Institute; 1991.
New York, NY: Irvington Publishers; 1994. 1995;4:8-1 1. 22. Unieven and Unequal: Insurance Coverage
2. Hatcher RA, Trussell J, Stewart F, Howells 13. Farley TMM, Rosenberg MJ, Rowe PJ, and Reproductive Health Services. New
S, Russell CR, Kowal D. Emergency Chen J-H, Meirik 0. Intrauterine devices York, NY: The Alan Guttmacher Institute;
Coontraception: The Nation s Best Kept and pelvic inflammatory disease: an inter- 1994.
Secret. Decatur, Ga: Bridging the Gap national perspective. Lancet. 1992;339: 23. Sollom T, Gold RB, Saul R. Public funding
Communications; 1995. 785-788. for contraceptive, sterilization and abortion
3. Grou F, Rodrigues I. The morning-after 14. Delbanco SF, Mauldon J, Smith MD. Little services, 1994. Fam Plann Perspect. 1996;
pill-how long after? Am J Obstet Gyne- knowledge and limited practice: emer- 28:166-173.
col. 1994;171:1529-1534. gency contraceptive pills, the public and 24. Emergency Oral Contraception. ACOG
4. Trussell J, Ellertson C, Rodrfguez G. The the obstetrician-gynecologist. Obstet Gyne- Practice Patterns. No. 3. Washington, DC:
Yuzpe regimen of emergency contracep- col. 1997;89:1006- 011. The American College of Obstetricians and
tion: how long after the morning after? 15. Food and Drug Administration. Use of Gynecologists; 1996.
Obstet Gvnecol. 1996;88:150-154. approved drugs for unlabeled indications. 25. Prescription drug products: certain com-
5. Webb A. Emergency contraception. Fertil FDA Drug Bull. 1982;12:4-5. bined oral contraceptives for use as postco-
Control Rev. 1995;4:3-7. 16. Trussell J, Leveque JA, Koenig JD, et al. ital emergency contraception. 62(37) Fed-
6. Trussell J, Stewart F, Guest F, Hatcher RA. The economic value of contraception: a eral Register 8610-8612. 1997.

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