Emergency contraception: have we come full circle?

Two decades ago, Dr. Felicia Stewart, then serving as Medical Director of the Planned Parenthood affiliate in Sacramento, CA, began her campaign to let out of the closet “America's best-kept secret” — emergency contraception (EC) [1]. The method had been suppressed because many providers thought the method was “not effective enough” or would lead women to use it “too much” (in place of using other more effective methods). Advocates disagreed, believing that EC could help some women prevent pregnancy, that women could learn to use the method appropriately, and that women had the right to this important option. When Dr. Stewart and other women's health advocates pushed to move EC “from secret to shelf,” they had women's needs in mind — in particular the need for a method that, unlike others, could be used after sex and one that was safe enough to provide without the barrier of a medical interface [2]. The success of this 20-year effort is evident in the many dedicated EC products now available worldwide, the increase in women's awareness and use of EC, and, in the United States, the full-on direct to consumer marketing of EC by a pharmaceutical company, not to mention the popularity of the method among women [3]. Today, in the midst of this forward trajectory of increased access and awareness, we have encountered a curve ball that has us circling back to where we started. Recent analyses suggesting that EC is not as effective in reducing unwanted pregnancy rates at a population level as we once hoped [4,5] seem to have put the brakes on funding and have revived the original arguments that EC is “not effective enough” to be promoted as an option and that women are “abusing” it, using it repeatedly instead of using other more effective methods. Some in the field have also again voiced concerns that by providing it directly to women we are missing opportunities to provide women with a full range of reproductive health services. Our response to this recent round of questioning is that EC still fills a unique and important role in the mix of available contraceptive methods, that it is effective enough to be promoted as a contraceptive option and that women's use of the method does not constitute a problem (in terms of lower effectiveness) but rather contributes in a positive way to every woman's significant challenge of how to avoid unplanned pregnancies over her lengthy fertile years.