November 29, 2006 | Volume 3, Issue 2

Emergency Contraception

Getting Medicine's Best Kept Secret into the Hands of American Women

by Samantha Bushman

Abstract

Emergency Contraception has tremendous untapped potential to significantly reduce the incidence of unintended pregnancy and abortion in America. This article explores the current barriers inhibiting Plan B’s widespread use and presents policy recommendations aimed at overcoming them. It also discusses current abortion trends, addresses the magnitude of Plan B’s potential impact, and presents the cases of France and the United Kingdom as examples of emergency contraception’s success. Finally, emergency contraception is discussed in context as one method among many which could aid in reducing the number of unintended pregnancies and abortions in America.

Introduction

Dubbed “a best kept secret in medicine” by the American College of Obstetricians and Gynecologists (ACOG, 2006), emergency contraception remains one of the most underutilized methods of decreasing the incidence of unintended pregnancy in America today (ACOG, 2006; The Need to Increase Public Awareness, 2002). Despite its emergence on the market in 1999, Plan B, the dedicated product approved for emergency contraception, continues to be relatively unknown and inaccessible to many women across the country (ACOG, 2006; The Need, 2002). However, the Food and Drug Administration’s recent approval of Plan B’s over the counter status presents policy makers with an opportunity to capitalize on the drug’s potential.

To underscore the impact Plan B could have, consider that in the year 2000, the use of emergency contraception averted over 100,000 unintended pregnancies and an estimated 51,000 abortions in America¹ (Plan B Decision by FDA a Victory for Common Sense, 2006; Steps Being Taken to Improve Access, 2002). In light of the fact that emergency contraception had only been available for two years in the United States and was not well known, it seems evident that adopting policy to increase public awareness and ensure women’s access could significantly reduce the incidence of both unintended pregnancy and abortion in America. This article explores the current barriers inhibiting Plan B’s widespread use and presents policy recommendations aimed at overcoming them. It also discusses current abortion trends, addresses the magnitude of Plan B’s potential impact, and presents the cases of France and the United Kingdom as examples of emergency contraception’s success. Finally, emergency contraception is discussed in context as one method among many which could aid in reducing the number of unintended pregnancies and abortions in America.

Plan B: What it is and what it isn’t

There are a number of misperceptions surrounding the use of Plan B, which have served to limit its impact. First, many people confuse emergency contraception with Mifeprex (also known as RU-486), an abortifacient approved for use in the United States by the Food and Drug Administration in September of 2000 (FDA, 2006). Whereas Mifeprex induces the abortion of an established pregnancy, Plan B gives women a “second chance” at preventing pregnancy from occurring in the first place (NARAL, 2006).

If taken within 72 hours of contraceptive failure or unprotected sex, Plan B is up to 89% effective in preventing an unintended pregnancy (ACOG, 2006). While it has been shown to be effective up to 120 hours, the sooner it is taken, the higher the chances of preventing an unintended pregnancy (The Kaiser Foundation, 2003).

The Plan B regimen consists of a highly concentrated dose of the same hormones found in regular birth control pills, and the mechanisms by which it operates are also very much the same (Shorto, 2006; The Need, 2002). Depending on where a woman is in her menstrual cycle, Plan B can delay ovulation, inhibit fertilization, or prevent the implantation of a fertilized egg (Shorto, 2006; The Need, 2002). Scientific evidence has repeatedly shown that Plan B has no effect on an established pregnancy (2002). Furthermore, if it were taken after implantation, the drug would not have any negative impact on the fertilized egg or subsequent fetal development (2002).

As evidenced by previous research and its recent approval for over the counter status, while Plan B is highly effective, it is also very safe. Since the levels of hormone are low and the duration of exposure is short, Plan B is “considered to be safe for nearly every woman” (The Need, 2002). There are also no known risk factors associated with its use (2002). In terms of side effects, one in four women reports nausea, and one in 18 reports vomiting (2002). Headache and dizziness may also occur (ACOG, 2006).

Allies & Opponents

Research has shown that many Americans are in favor of Plan B’s widespread use. In a study conducted in 2002 by the Peter D. Hart Research Associates on behalf of the Reproductive Health Technologies Project, seventy-five percent of voters who were educated about emergency contraception “favored legislation aimed at expanding public health information about emergency contraception” (The Need, 2002). In addition, “over 70% of voters reported that they consider the 72 hour window of effectiveness a compelling reason for women to know about this back up option in advance of an emergency situation” (2002).

However, this sentiment is not universally shared. The point of contention, which has ignited a firestorm of controversy around Plan B, is the drug’s potential to prevent the implantation of a fertilized egg into the uterine wall. Opponents of emergency contraception contend that life begins at conception, and any method which may prevent the implantation of a fertilized egg is in essence inducing an abortion. Although this notion is at odds with the medical establishment’s definition, which states that pregnancy begins with the implantation of a fertilized egg (ACOG, 2006; Shorto, 2006; The Need, 2002), opponents of emergency contraception have successfully garnered significant support against the method. This has also compounded the general public’s misperception that Plan B induces abortion (2002).

This stance has also contributed to a number of obstacles which have impeded women’s access to Plan B since it was approved for use in 1999. The most troubling instances in recent years have been pharmacists refusing to fill prescriptions for emergency contraception and emergency room staff in Catholic hospitals withholding emergency contraception from rape survivors. In addition, the Food and Drug Administration’s delay in granting Plan B over the counter status has also served as a significant barrier to access.

In cases of pharmacist refusals, which have been well documented in many states, women with valid prescriptions have been denied emergency contraception on the grounds that providing the drug was against the pharmacist’s moral beliefs. Given the drug’s time sensitive nature and the fact that women in the overwhelming majority of cases had to contact a provider to prescribe the drug before the prescription could be filled, pharmacist refusals could serve to increase the incidence of unintended pregnancy—particularly in rural areas where the next nearest pharmacy may be located many miles away. In effect, pharmacists’ “moral beliefs” can translate to unintended pregnancies and subsequently, possible abortions. There have also been many reported cases where women were able to have their prescriptions filled but were humiliated by pharmacists who chastised them for needing it in the first place. Although Plan B is now available “over the counter” for women over the age of 18, the drug cannot be purchased directly off the shelf. Instead, women must approach the pharmacist and show identification that proves they are over the age of 18 before the drug can be dispensed. Women under the age of 18 must still contact a provider for a prescription in order to access the drug. Since pharmacists continue to play a central role in dispensing the drug in both instances, it is very likely that these problems will continue.

In the absence of a federal policy, the situation in the emergency rooms of Catholic hospitals will also persist. It is estimated that 32,000 women each year become pregnant as a result of rape or incest (Steps, 2002). In addition, the American Medical Association considers pregnancy prevention an integral part of treating women who have been sexually assaulted (2002). Nevertheless, since Catholic Doctrine holds that life begins at conception and providing emergency contraception may prevent a fertilized egg from implanting into the lining of the uterus, many Catholic hospitals’ emergency room protocols do not include provisions for discussing or providing Plan B as an option to survivors of rape and incest. Here, offering emergency contraception is conceptualized as being akin to offering the patient an abortion. While some states have enacted policies mandating that emergency contraception be offered in emergency rooms regardless of the hospital’s religious affiliation, the majority of states have not.

Finally, the Food and Drug Administration’s indecision about Plan B’s over the counter status has significantly impeded women’s access, and at the same time, has raised questions about the institution’s susceptibility to outside political influence (Grimes, 2004). Despite overwhelming scientific and medical evidence regarding the safety of Plan B, a decision about the drug’s over the counter status was suspended for nearly three years (Davidoff, 2006). Although Plan B met each of the FDA‘s criteria for over the counter status, including the safety and efficacy standards, a decision was nonetheless withheld without any further explanation (2006).

In addition, while all of the scientific and medical evidence indicates that the drug is safe for all women of childbearing age, when Plan B was approved for “over the counter” sale, dual status with age restrictions was imposed. As discussed previously, women over the age of 18 can purchase Plan B without a prescription, while women under the age of 18 still need to visit a provider for a prescription before they can access the drug (Kauffman & Stein, 2006). This places additional burdens on young women, who, by the very nature of their age will have a more difficult time accessing Plan B in a timely manner than older women who have access to additional resources. It is also particularly worrisome in light of the fact that the rate of teen pregnancy in the United States ranks highest among industrialized Western nations (NARAL, 2006).

In deciding the case of Plan B’s over the counter status, the Food and Drug Administration deviated from a number of its standard operating procedures and protocols without due cause (Davidoff, 2006). To protect the scientific integrity of the agency from political influence, a thorough review of the events leading up to the three year indecision and the subsequent dual status recommendation of Plan B’s over the counter status is in order.

Additional Barriers & Efforts to Educate and Inform

In addition to these obstacles, other less pernicious factors have also prevented the widespread use of emergency contraception. As previously stated, the news of emergency contraception has not yet trickled down to all American women, and many are still unaware that this back up method is available. Others are misinformed about how the drug works or are unsure of how to access it. In the marketplace, these factors have often translated into a perceived lack of demand. As such, many pharmacies do not regularly keep Plan B in stock, acknowledging that women are not regularly asking for it. This is a substantial obstacle to overcome in ensuring women’s timely access to emergency contraception.

In the effort to inform women about Plan B, one significant resource that has not been fully leveraged is the nation’s health care providers—a primary source of women’s contraceptive information (ACOG, 2006; The Need, 2002). A study by the Kaiser Foundation in 2000 revealed that “only one in 5 obstetrician-gynecologists discuss emergency contraception as a part of their routine counseling” (2002). While this study is now somewhat dated, five years later in May of 2006, the American College of Obstetricians and Gynecologists (ACOG) felt it necessary to launch a campaign “to step up efforts to get emergency contraception to women” (ACOG, 2006), echoing an earlier effort in April of 2001 to encourage physicians to “proactively discuss emergency contraception with women and to offer advance prescriptions for the method” (2002).

ACOG‘s new campaign is entitled “Ask Me,” and the theme is “Accidents happen. Morning afters can be tough” (ACOG, 2006). Posters for physician examination and waiting rooms and “Ask Me” buttons worn by physicians are designed “to promote dialogue between the patient and her ob-gyn about emergency contraception” (2006). According to Dr. Iffath Hoskins, a member of ACOG‘s Committee on Health for Underserved Women, “This is ACOG‘s way of standing up for our patients. One of our goals is to make awareness of emergency contraception so widespread that it’s no longer a best-kept secret in medicine. We’re hopeful that the ‘Ask Me’ campaign will accomplish that. This would have a profound impact on women’s health” (ACOG, 2006).

Additional components of the campaign include educating women about what emergency contraception is and how it works, as well as dispelling the confusion between emergency contraception and Mifeprex (ACOG, 2006). The campaign also encourages advance prescriptions and purchase of Plan B. Research has shown that “women are more likely to use emergency contraception if they have it readily available” (2006).

ACOG is not alone in its consciousness raising efforts. In March of 2002, the Reproductive Health Technologies Project (RHTP) collaborated with more than 100 medical and women’s groups in launching the “Back Up Your Birth Control Campaign” (The Need, 2002). According to RHTP President, Kirsten Moore, women were encouraged to initiate conversations with their physicians, physicians were encouraged to talk with their patients, pharmacists were encouraged to stock the product, and organizations were encouraged to make awareness of emergency contraception a primary objective of their outreach efforts (2002). Planned Parenthood affiliates nationwide recently designated December 6, 2006 as “Free EC Day,” and many Planned Parenthood health centers will be offering emergency contraception free of charge in an effort to increase access (Free EC Day, 2006).

In addition to organizational efforts, legislators have also introduced policy which would widely disseminate information about emergency contraception. Originally introduced in March of 2002 by Representative Louise Slaughter (D-NY) and Senator Patty Murray (D-WA), the Emergency Contraception Education Act (HR 3326), as it would later be called, would allocate 10 million dollars over the course of 5 years to educate the general public about the “safety, efficacy, and availability” of emergency contraception (Steps, 2002). According to the Library of Congress search engine, four years later, the Emergency Contraception Education Act remains stalled in the first step of the legislative process in the House of Representatives despite 95 cosponsors. No action has been taken on the bill since July 29, 2005 when it was referred to the Subcommittee on Health.

While a number of medical and progressive organizations continue to advocate for increased access and awareness of Plan B, there are just as many opponents that continue to advocate against it. However, there are two very powerful and practical arguments in favor of emergency contraception: the staggering unintended pregnancy and abortion statistics in the U.S. and the success of emergency contraception’s implementation in France and the United Kingdom.

Abortion Trends & the Power of Plan B

New research suggests that the previously steady decline in the unintended pregnancy rates has begun to stall, as has the decline in abortion rates (Gold, 2006). Between 1992 and 1996, the U.S. abortion rate declined by 3.4% each year, and between 1996 and 2000, it declined by 1.2% each year (2006). Since 2000, the decline has slowed sharply (2006).

Keeping with the spirit of disheartening news, according to the latest report by the Guttmacher Institute, nearly half of all pregnancies in the United States are unintended, and four out of ten will end in an abortion (Facts on Induced Abortion, 2006). Additionally, estimates indicate that half of all women in the United States have experienced an unintended pregnancy (2006). If the current rates persist, more than one third of American women will have had an abortion by the age of 45 (2006).

While there is virtually no consensus when it comes to the abortion debate, advocates on both sides agree that reducing the number of abortions in America is both a practical and desirable goal.

According to ACOG, if emergency contraception were widely available, it would have the potential to prevent at least half of the unintended pregnancies in the United States (ACOG, 2006)—approximately 1.7 million pregnancies each year (Planned Parenthood, 2006; Steps, 2002). In addition, widespread use of emergency contraception has the potential to reduce the number of abortions by 50% (ACOG, 2006)—which translates to approximately 800,000 abortions per year (Planned Parenthood, 2006; Steps, 2002). When one examines the hard facts, it is difficult to imagine why we as a nation are not doing everything possible to facilitate women’s access to emergency contraception.

A Scientifically Unsubstantiated Argument

Let us revisit the fundamental argument used by opponents of emergency contraception. These opponents believe that life begins when a sperm meets an egg. They also believe that any method which prevents the implantation of a fertilized egg is in essence taking a life. Thus, because Plan B may prevent implantation, it is equated by opponents to inducing an abortion. As stated by Russell Shorto, a contributing writer for the New York Times Magazine, while individuals are well within their rights to believe that pregnancy begins when a sperm meets an egg, there are two “twists,” which undermine several elements of their argument (Shorto, 2006).

First, according to Dr. Susan Wood, scientist and former Director of the FDA‘s Office of Women’s Health, “There is no direct evidence that it [Plan B] blocks implantation. We can’t tell for sure because very little research has been done on direct implantation of human eggs. You run into moral problems doing research on a woman’s body and a human embryo. And since half of all fertilized eggs do not implant anyway, it would be difficult to know if this was the mechanism responsible” (Shorto, 2006).

Second, Shorto reiterates the point made earlier that emergency contraception is comprised of the same hormones and works in a similar manner to that of regular birth control pills. Since both methods serve to stop ovulation, prevent fertilization, or impeded implantation, if emergency contraception is an abortifacient, by logical extension, birth control is as well (Shorto, 2006). Given that 76 million women worldwide use oral contraceptives (2006) and 98% of women aged 15–44 who have ever had intercourse have used at least one contraceptive method, several of which may also prevent the implantation of a fertilized egg (Contraceptive Use, 2005), this notion may be a hard sell.

Despite the scientific evidence, including the medical definition of pregnancy, some opponents will never be convinced that emergency contraception does not induce abortion. However, American women need and deserve all of the available information to decide whether or not emergency contraception is right for them.

Emergency Contraception’s Success in France & the United Kingdom

According to a report by Heather Boonestra, a contributing writer at The Guttmacher Report on Public Policy, the abortion rate in France is half that of the United States: 12 per 1,000 women aged 14–44. She notes that when the decline in abortion rate had begun to stagnate in late 1990s, the French government quickly responded to address the trend. One of the major interventions it successfully imposed was increasing women’s access to emergency contraception (Steps, 2002).

“Emergency contraception has been available in France since the early 1970s, and a product specifically packaged for post coital use became available in May 1999” (Steps, 2002). One month later in April of 1999, the government switched the drug to non-prescription status, allowing it to be made available upon request from pharmacists (2002).

This policy has several features which have removed the barriers impeding French women’s access to emergency contraception. First, timely access is ensured, because the drug can be dispensed directly by pharmacists to all women. Second, 65% of the cost of emergency contraception purchased at pharmacies is reimbursed to women under the national health insurance, and emergency contraception is available for free at all French family planning clinics (Steps, 2002). This effectively decreases the potential financial burdens of accessing the drug. Third, to increase access to young women, in December of 2000, a law was enacted which allows nurses in public and parochial high schools to dispense emergency contraception to students (2002). To further increase access, in January of 2002, a decree allowing minors to obtain free emergency contraception from pharmacies without parental authorization was also issued (2002). Under the decree, pharmacists are required to counsel young women and provide them with information about other more reliable forms of birth control (2002). The French government recognizes the importance of young women having access to emergency contraception and fosters an environment where adolescents are encouraged to speak with and seek help from adults.

According to Elizabeth Aubeny, President of the French Association for Contraception, widespread access has served the dual purpose of “renewing interest in all methods of contraception” and facilitating an open dialogue “about what to do to prevent pregnancy and sexually transmitted diseases” (Steps, 2002). ”…the more you talk about contraception, the more women use it and the fewer abortions there are” (2002).

While the French experience illustrates strategies to removing barriers to access, the success of public education campaigns orchestrated by the United Kingdom illustrates potential vehicles to informing the public about emergency contraception. According to Boonestra, in 1984, only 12% of women seeking abortions had a good working knowledge of emergency contraception. “Since the late 1980s, there have been several campaigns—largely government funded—aimed at improving awareness as a way of addressing the problem of unintended pregnancy” (Steps, 2002). The largest campaign was launched in 1995 and invested close to $2.5 million dollars over the course of three years. The campaign was comprised of advertisements in women’s magazines, health professional’s journals, and on the radio. It also made use of a 24 hour hotline where women could access information about emergency contraception. By 1996, the data revealed that awareness had climbed to 76% among a similar sample of women (Steps, 2002). This 64% increase illustrates that marketing can have a substantial impact on awareness and that engaging providers and the general public is a worthwhile use of time and resources.

Policy Recommendations

Although there are many contraceptive options available to most American women, contraception fails, and none of these options are one hundred percent effective one hundred percent of the time. Emergency contraception has tremendous untapped potential to reduce the incidence of unintended pregnancy and abortion in America. To maximize the benefits, it is essential to implement policy aimed at increasing awareness and ensuring women’s timely access to emergency contraception.

Given the success of education campaigns in the United Kingdom, a logical first step is to enact a national, government funded education campaign similar to The Emergency Contraception Education Act proposed by Representative Denise Slaughter and Senator Patty Murray. In addition to providing information about the safety, efficacy, and availability of Plan B, the campaign should also work to dispel the misperceptions regarding Plan B’s use. The campaign’s primary targets should be all women of child bearing age, health care providers, and pharmacists, each of whom has a unique role in accessing emergency contraception.

While it is possible that some of the barriers to access will dissipate once a critical mass of people learn what Plan B is and how it works, three major barriers will remain. Action needs to be taken immediately to ensure pharmacies have Plan B in stock, to guarantee rape survivors have access to the drug in emergency rooms, and to promote women’s efforts to prevent unintended pregnancy in the event of pharmacist refusals.

First, stocking issues in pharmacies pose an extremely serious threat to access. It is absolutely critical that the drug be readily available for women to purchase. Here, providers need to advocate on behalf of their patients, and women need to be vocal in making their need for the drug known. The continuation of grassroots efforts by reproductive rights organizations is also in order.

Second, as a matter of public health, policy makers must ensure that rape survivors have access to emergency contraception in the emergency room of every single American hospital regardless of its religious affiliation. There is no reason to deny women access to an FDA approved drug that is likely to spare them the pain and suffering of contending with an unintended pregnancy and a possible abortion as the result of a sexual assault.

Third, it is crucial that women are guaranteed timely access to emergency contraception. Policy makers must actively address the conflict between patients’ rights to access medication and pharmacists’ rights to their moral beliefs, and come to a resolution which ensures that women have timely access to a legal, safe, and effective FDA approved drug. It is imperative that this also extend to young women under the age of 18 who are forced to contend with the additional step of getting a prescription from a provider.

While some individuals fear that adolescent access to emergency contraception will lead to reckless sexual abandon, several studies, including one conducted by ACOG in September of 2005 indicate that access to emergency contraception does “not increase their sexual risk behavior” (Nevius, 2006). In addition, the headaches, dizziness, and nausea that are associated with Plan B are likely to deter frequent and repeated use (Davidoff, 2006).

Until Plan B is available over the counter to women under the age of 18, it would also be favorable to adopt a federal policy to facilitate collaborative drug therapy agreements between pharmacists and health care providers, which have already been enacted in 9 states (NPR, 2006). Collaborative agreements allow physicians and nurse practitioners to delegate authority to prescribe Plan B to pharmacists, which would eliminate the additional time constraints of contacting and visiting a provider to get a prescription (Steps, 2002). While this is an imperfect solution and has implications for conflict between providers and pharmacists over the scope of medical practice (2002), it is a feasible interim solution to increase timely access to young women. It also bears mention that while there are some pharmacists who object to the method and refuse to fill prescriptions, there are many pharmacists who could serve as an excellent resource for young women in this capacity.

Conclusion: The Importance of a Comprehensive Approach

While it is evident that increased access to emergency contraception could significantly decrease the incidence of unintended pregnancy and abortion in America, it is important to keep in mind that it is only one strategy. To address the issues of unintended pregnancy and abortion most effectively, a comprehensive approach, which includes the implementation of comprehensive sex education programs and increased access to family planning services is essential.

Despite the dramatic teen pregnancy rate and the overwhelming evidence that abstinence-only education is ineffective, millions of dollars continue to be sunk into these programs annually. In addition to omitting information about contraception, which leaves teens vulnerable to both unintended pregnancy and sexually transmitted infections (FPA, 2006), “A 2004 Congressional report on the content of federally funded abstinence-only curricula found that 80% of the curricula, used by over two-thirds of federal grantees in 2003, contained false, misleading or distorted information about reproductive health” (2006). Specifically, “they conveyed false information about the effectiveness of contraceptives, false information about the risks of abortion, religious beliefs as scientific fact, stereotypes about boys and girls as scientific fact, and medical and scientific errors of fact” (McKeon, 2006).

At the same time, “research has identified highly effective sex education programs that affect multiple health behaviors and/or achieve positive health impacts” (McKeon, 2006). The behavioral outcomes of comprehensive sex education programs include “delaying the initiation of sex as well as reducing the frequency of sex, the number of new partners, and the incidence of unprotected sex, and/or increasing the use of condoms and contraception among sexually active participants” (2006). Given this information, it seems evident that switching to comprehensive sex education could be extremely beneficial in preventing unintended pregnancy among American youth.

Increasing access to family planning services is critical and also has a number of benefits. First, “family planning centers serve the needs of an ever increasing poor and diverse population” (FPA, 2006). Many American women do not have health insurance and face a considerable financial burdens meeting their reproductive health care needs. Family planning programs play a critical role in preventing the incidence of unintended pregnancy by providing young and low income women in particular with contraceptive methods that would be otherwise inaccessible. For each dollar spent on family planning, three dollars are saved in Medicaid costs for prenatal and newborn care (FPA, 2006).

Widespread access to emergency contraception has the power to significantly decrease the incidence of unintended pregnancy and abortion, as does comprehensive sex education and increased access to family planning services. When these methods begin to operate in tandem, we will see a significant reduction in the incidence of unintended pregnancy and abortion in America.

Footnote

¹ In addition to Plan B, Preven, another emergency contraception regimen was also available on the market in 2000. Preven was approved for use in the United States in 1998 (Friedman, 2006). It was later taken off the market in August of 2004 (2006), because Plan B was found to be more effective and had fewer side effects (Association for Reproductive Health Professionals).

References

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Food and Drug Administration, (2006, April 10). Mifeprex Information. Retrieved September 14, 2006, from http://www.fda.gov/cder/drug/infopage/mifepristone/

Friedman, A. (2006, August 1). Over-the-Counter Insurgency. Mother Jones. Retrieved September 14, 2006, from http://www.motherjones.com/news

Gold, R. (2006). Rekindling Efforts to Prevent Unplanned Pregnancy: A Matter of “Equity and Common Sense.” Guttmacher Policy Review. 9(3).

Grimes, D. A. (2004). Emergency Contraception: Politics Trumps Science at the U.S. Food and Drug Administration. The American College of Obstetricians and Gynecologists. 104(2), 220–221.

Kaiser Foundation. (2003, June 3). Effective Up to 120 hours After Unprotected Sex, Study Says. Retrieved September 12, 2006, from http://www.kaisernetwork.org/daily_reports

Kauffman, M. & Stein, R. (2006, August 24). Plan B Approval Said to Be Near; Adults Could Buy Morning After Pill Over the Counter. The Washington Post. pp. A1.

McKeon, B. (2006). Effective Sex Education. Advocates for Reproductive Youth. Retrieved September 12, 2006, from http://www.advocatesforyouth.org

NARAL, Pro-Choice America. (2006). Unintended Pregnancy Prevention Act. Retrieved September 12, 2006, from http://www.prochoiceny.org/s06factsheets/

Nevius, C.W. (2006, August 25). Wider access to pill changes everything. The Washington Post, pp. A12.

Planned Parenthood Federation of America. (2006). Emergency Contraception. Retrieved November 24, 2006, from http://www.plannedparenthood.org/birthcontrolpregnancy/emergency-contraception.htm

Planned Parenthood Federation of America. (2006, November 15). “Free EC Day” Highlights Backup Birth Control. Retrieved November 27, 2006, from http://www.ppaction.org/pprm/pprm_free_ec_day.html

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