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Friday, 9 December 2011

Emergency Contraception: When politics, values and science collide

Plan B ® is better known as the morning after pill.  Not the best or the most effective method of birth control, but an essential part of a program of reproductive wellbeing.  What caught DrPHealth’s attention is the US decision from the FDA on an application by the manufacturer for eliminating the US requirement for prescription for women 17 years or younger.  FDA decision on Plan B.  After careful scientific review the FDA was prepared to grant the request, only to have the Secretary of Health and Human Services directed the FDA to not approve the request.  
So the reaction might be, only south of the border – right?   Of course while the Canadian approval for drugs is undertaken by Health Canada, the decision of the conditions under which drugs are distributed is a provincial function.   So barriers for access can be erected and local conditions may not recognize that such disparity exists within the country.  
Here is where the Canadian fabric unravels.   Plan B is available over the counter in most provinces and territories without prescription – but there are exceptions.   Plan B is only available under prescription for all women in Quebec.   Access may be facilitated by CLSCs where physicians or nurses can dispense the medication.   In Saskatchewan, pharmacists can dispense without a prescription, but must be involved in the assessment (selling under the counter).  
Go further, and begin to ask the question if it is available without barriers to the roughly $40.00 cost that can be a challenge for young adults.   Depends on the community let alone the province.  In some instances a form of emergency contraception (ECP) may be available in some physician offices, emergency departments, or health units – but not in others.  
The science on unplanned pregnancies is very strong.   Expected pregnancies should be encouraged for the health of baby and mother.  Measuring unplanned, unwanted or unexpected is not something that has been consistently undertaken – the usual surrogate being the assumption that all pregnancies under 20 are unplanned (which is also not a correct assumption).   Teenage pregnancies have  been decreasing steadily in Canada.  There is lots of evidence that the strong family education programs in schools are being successful as sexual activity and age at first intercourse, and use of protection during last intercourse have ‘improved’.  Statistics Canada teen reproductive health behaviours  Therapeutic abortion rates increased steadily to the start of the century and more recent reports are suggested this trend is flattening which again is a positive trend. 
Forward thinking minds are envisioning a time when access to effective contraceptives are considered a preventive measure without any barriers (including cost).   Changes are occurring despite bureaucratic barriers that can impose the values of the minority on those that are directly affected by the circumstances.   Public Health has been on the forefront of supporting sexually active youth in their decisions, it is time to become proactive again. Can we not collectively demand that ECP access be equitable across provincial lines, and that ECP is readily available without a financial barrier from all emergency departments, public health units and preferably also pharmacies.
As for our colleagues south of the border, the approval of Plan B was significantly delayed many years in comparison to most other countries, patience and diligence in pushing is still required.  The US teenage birth rate is the highest of developing countries.   More staggering however is that the pregnancy rate is also the highest.   There are some fundamental public health interventions that are probably more important than whether Plan B is available to women under 17 without a prescription.  Some of this discussion means challenging some very difficult and engrained value systems by unmasking the extreme status of the US as an outlier internationally in this area.

1 comment:

  1. In 2003 I went to a Vancvouver pharmacy to get the morning after pill, and could not get it without consulting with the pharmacist first. I have no problem with a Pharmacist advising me of how to take it, how to allieve side effects, and what to watch out for. But I had to answer questions about why I wanted it -- it was a little embarrassing. Perhaps the consultation is useful for screening for cases of sexual abuse, or perhaps it was a short term program to evaluate the use of Plan B and it's now completely OTC. It might even have been a voluntary questionnaire - I can't remember. But I'm glad I was educated enough to ask for Plan B, and mature enough to deal with the awkwardness of answering certain questions in a relatively non-private setting. Mostly I'm glad I never had to ask for it again.