Imagine this scenario that untold numbers of women find themselves in each year. Maybe you had unprotected intercourse, or the condom broke, or maybe you accidentally missed taking a birth control pill or two. You don't want to get pregnant, so you rush to the pharmacy for emergency contraception. All the while, the clock is ticking.
"These medications are incredibly time sensitive," says Dr. Sonya Borrero, a professor of medicine at the University of Pittsburgh who focuses on reproductive health equity. She says emergency contraception pills need to be taken within five days after unprotected sex — "but the sooner, the better."
Surveys show that roughly a quarter of American women have, at some point in their lives, used emergency contraception pills to prevent an unintended pregnancy. This type of contraception is effective, safe and legal throughout the United States. And yet researchers are finding it's not always available when people need it.
Take, for example, levonorgestrel, a form of emergency contraception better known under the brand name Plan B, although it's also available in generic versions with names including My Way, Take Action and My Choice, to name a few. Borrero says Plan B is supposed to be available over the counter, on the shelf, stocked for all ages.
But when Borrero sent a team of medical students to pharmacies across western Pennsylvania to see what these stores actually had on hand, they found a third of pharmacies didn't stock Plan B at all. And when they did have it, "most of the time it wasn't really on the shelf. It was either behind the counter or in one of those locked boxes," which means a customer would have to ask someone to hand them the emergency contraception. She says that could be a real deterrent for some people.
"You can imagine, especially for a teen, going and asking for one of these products and being concerned about potential judgment can be a significant barrier to purchasing," Borrero says.
Pharmacists say there are good reasons for putting Plan B under lock and key. Don Downing, a clinical professor at the University of Washington School of Pharmacy, spent many years as a retail pharmacist, and he also helped develop Plan B. He says many pharmacists have told him over the years that Plan B is frequently a target of theft, and a lot of pharmacies are struggling financially and can't afford to cover the losses. He says he'd rather see it locked up in the store than not available at all.
"If they could make it available by keeping it behind the counter, that may be ultimately more helpful to a woman than not stocking it at all," Downing says.
Noah Rosenthal is a merchandising analyst with Hamacher Resource Group, which provides analysis and consulting for retail pharmacies. He notes that Plan B and its generics retail for about $40 to $50, and this cost is a key reason why some retailers may stock emergency contraception in a locked box or behind the counter. In an email to NPR, he noted that before 2006, Plan B could only be dispensed by a pharmacist, so some pharmacies may not have moved it even after the FDA cleared it for over-the-counter sale. He added, "Some pharmacists may elect to place these items behind the counter for religious or other personal views."
Borrero's findings were even bleaker for the other form of emergency contraception pill sold in pharmacies — Ella, which requires a prescription. The study found only 5% of pharmacies had it available for immediate purchase.
"So 5% was abysmal. I really was very surprised," Borrero says. "I was really thinking it would be something like 50% — 5% was crazy."
It's a nationwide problem
And the problem isn't just confined to Pennsylvania. Studies conducted in pharmacies across the U.S. have found similar problems with emergency contraception access and availability. When it comes to Ella, the prescription form of emergency contraception pill, lack of knowledge is a big obstacle, says Rebecca Stone, a clinical associate professor at the University of Georgia College of Pharmacy who has conducted similar studies.
Ella is "not very well known by prescribers — meaning physicians, nurse practitioners, any type of traditional prescriber, nor by pharmacists," Stone says.
And if providers aren't prescribing it, pharmacies are less likely to keep it in stock. "That's kind of chicken and the egg," Stone says.
That's really concerning, because Ella is more effective, says Kelly Cleland, executive director of the American Society for Emergency Contraception. Evidence shows Plan B works best in the first 72 hours after unprotected intercourse, then its efficacy wanes over five days. In contrast, Ella is effective throughout the five-day window. It's also more effective for women who are overweight or obese.
"There is an issue with Plan B and its generics potentially not working for people who weigh more than 165 pounds," Cleland notes. "And for those folks, it seems like Ella is more effective" — up to 195 pounds. "So it's important that Ella is available in stock and that people know about it." (For women heavier than the recommended weight for Ella, a copper IUD is the recommended choice for emergency contraception, but it needs to be inserted by a trained clinician.)
Cleland says pharmacies will often offer to order Ella overnight. "But that's not good enough for such a time-sensitive product. It might be OK for your antibiotic, but it's not OK for something that you need to take as soon as possible."
People who work in reproductive health want to see more education on emergency contraception — for pharmacists, for women and for health care professionals, whom surveys show aren't always well versed in all the emergency contraception options available. Advocates say expanding access and education will become more critical in a post Roe v. Wade America.
Training for providers
Laura Bellis is already on the case. She's the executive director of Take Control Initiative, a contraception access program in Tulsa County, Okla. This month, the program rolled out training for doctors and other providers it works with after many of them said they had lots of questions about emergency contraception.
"Sometimes clinicians are like, 'Can I just hand this to anyone?' And the answer is yes," says Bellis, noting that confusion persists about whether emergency contraception pills are age restricted. They're not. "If someone is, you know, of reproductive age, there's nothing precluding giving this to them. It's safe to have on hand. They could put it in their medicine cabinet at home."
Bellis says having emergency contraception on hand is especially critical in places like her home state. In May, Oklahoma adopted the nation's most restrictive abortion law. It's now illegal in all but a few cases. "And so with that, we know how critical it is that folks have access to last lines of defense, like emergency contraception," she says.
She says the Take Control Initiative offers free kits with levonorgestrel pills that people can pick up at various community sites around Tulsa County — they usually cost around $40 to $50 at a pharmacy, or can be found cheaper online. The group has also been using social media to raise awareness about the weight considerations involved in choosing emergency contraception. She says its help line has received more calls than ever before in recent months from people interested in getting IUDs placed as a form of emergency contraception.
Dr. Leah Upton, a family physician and medical director of a federally qualified health clinic in Tulsa, Okla., says she's seen what can happen when patients don't get emergency contraception in time. She recalls one 15-year-old patient who told Upton she had trouble accessing both contraception and emergency contraception.
"As we know, there's a window of time that you have to get that in. In addition, there's the cost." The patient, Upton says, was in a turbulent time in her life — she had been kicked out of her home and was living with a relative. "Somewhere between transportation and costs and all of the other things she was dealing with in her life at the time, she couldn't get that emergency contraception, or contraception care in general. And so I didn't see her as a family planning patient. I saw her as a prenatal patient."
Cynthia Harper is a professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco and a longtime contraception researcher. She helped develop the training that the Take Control Initiative is offering, which recommends that providers routinely offer patients advanced prescriptions for emergency contraception. She's planning to make it available to providers across the country.
"This is just going to become so much more important in those states where [abortion] restrictions are imminent or have happened," she says.