The first time that I asked my general practitioner in Hong Kong for a prescription for birth control pills, she stopped scribbling down her notes in my file and looked up at me. “You don’t need a prescription for that,” she said, bemused. In Hong Kong, as in some other parts of the world, birth control pills are available over the counter; you can pick up your favorite brand in the drug store aisle next to condoms and pregnancy tests. Sitting there in the doctor’s chair, I felt 1) a little guilty of the beloved American habit of assuming U.S. policy is the global norm and 2) a little surprised at being the person in the room with the most conservative notions about contraception.
Then again, who could blame me? This week’s news from Washington once again sets the U.S. apart from a lot of the world on the family-planning front. On Thursday, President Barack Obama endorsed the decision of Secretary of Health and Human Services Kathleen Sebelius to overrule the Food and Drug Administration’s recommendation that Plan B One-Step, a brand of emergency contraception, be sold without a prescription to people under 17. Currently, the “morning after” pill is only sold over the counter to women and men 17 and older; teenagers 16 and younger have to go to the doctor to get access to the contraceptive. The drug, designed to be used in the first days after sex, is often mistakenly conflated with RU 486, the so-called abortion pill, and has been caught up in a political tussle between its advocates in the scientific and reproductive-rights community and opponents in the pro-life community since it was first approved by the FDA in 1999. Sebelius’ decision on Dec. 8 was the first time a Health and Human Services Secretary has ever publicly overruled the FDA.
This despite the fact that — though nowhere near as popular as the Pill — emergency contraception is being embraced as never before. Emergency contraception, most commonly a dose of the synthetic hormone levonorgestrel that can stop ovulation within three to five days, is legal in over 140 nations, and available over the counter in more than 60 nations. In 2009, the Indian market for emergency-contraceptive pills grew 47%, according to Euromonitor International. In a recent government poll in China, nearly half the 40,000 respondents said they prefer emergency contraception to condoms. Since the World Health Organization deemed the emergency oral contraception safe and effective in the mid-1990s, the pill has been gaining popularity in Thailand, Finland, Kenya, Ghana and Mexico. Even in the U.S., despite its political hurdles, the percentage of American women who had used emergency contraception more than doubled from 2006 to ’08 to 9.7%, according to a recent study.
Emergency contraception has always had a complicated history in the U.S. After oral contraceptive pills became commercially available, doctors and researchers recognized that if those hormones could be used to prevent pregnancy by inhibiting ovulation, they could also be used in higher doses after sex to stop ovulation before fertilization had the chance to occur. By the 1970s, doctors at some clinics, Planned Parenthood centers and college campuses in the U.S. were prescribing women a combination of regular birth control pills they could take immediately after unprotected sex to avoid getting pregnant. The cut-up packets of birth control pills came to be known as the morning-after pill. The name stuck, but the market potential in the U.S. didn’t. The American pharmaceutical industry “wouldn’t touch it,” says Elizabeth Raymond, a senior medical associate at Gynuity Health Projects, a research group. Without a domestic company peddling this new option, most American women didn’t know it existed, while in other parts of the world, it was slowly becoming available. In the 1980s, says Raymond, a Hungarian drug company was marketing a hormonal contraception product to be taken after sex in over two dozen countries, but it wasn’t until the mid-1990s, when the conflict in the Balkans brought rape as a tool of war into the international spotlight, that the drug’s public-health potential came into focus. After a call to action on the part of several advocacy groups, the World Health Organization launched an international trial that eventually determined a 1.5 mg dose of levonorgestrel was both safe and effective as a contraceptive up to five days after unprotected sex. The FDA and E.U. quickly followed suit. Today, four brands of FDA-approved emergency contraception are available in the U.S. for women 17 and older.
So why is this contraceptive finally beginning to catch on? In many places where emergency-contraception use is growing, cities are crowded, money is tight, and smaller families directly translate into a better quality of life. It gives couples a choice when a condom breaks, or when planning goes out the window in the heat of the moment. It offers a measure of control to victims of sexual violence and women whose partners refuse to use birth control. “Nearly half the pregnancies in many countries are unwanted — including the U.S.,” says Dr. John Townshend, vice president of reproductive health for the Population Council. “In many countries, abortion isn’t safe. This is a low-cost, safe option, and it’s available over the counter.”
But, as with any drug, the role that the government plays paves the way for success or failure. In China, where a state-enforced one-child policy has been in place for three decades, emergency contraception was embraced early by Beijing as another tool in the nation’s birth control kit. The drug has been available in China since the early 1990s, and in ’96 — before the method was approved by the FDA — the state-backed China Family Planning Association was training pharmacists across 12 provinces on teaching customers how to use it. Today, Yuting, the most popular emergency-contraception brand in China, costs a little over $2 for a two-pill dose. “I first learned about [the morning-after pill] from a roommate when I was in college,” says Ling Chen, a 24-year-old from Beijing who asked that her real name not be used. Chen says she has now taken emergency contraception on three occasions — mostly because as a grad student in an increasingly expensive city, she simply can’t afford to be a mom. “Even if I was married, the cost of raising a child is too high in Beijing these days.”
Still, even in these growing markets, the drug has a long way to go. Its availability in places that perhaps need it the most — in overcrowded nations or refugee camps where rape is rampant — has been historically unreliable. In China and India, some doctors worry that education has not kept pace with the contraceptive’s word-of-mouth popularity or aggressive advertising, leaving them anxious as they see more women use it as their go-to method of contraception every time they have unprotected sex. “Everybody — every single citizen, including the children — knows about the i-pill,” says Dr. Rishma Dhillon Pai, a gynecologist in Mumbai, referring to the popular emergency-contraception brand in India. “Even my son, who’s 11, says, ‘Chill, take an i-pill.’”
With reporting by Mridu Khullar Relph and Jessie Jiang.