Market Hurdles Slow Emergency Contraception Sales

Emergency contraceptive pills ought to sell briskly nationwide, however, doctors don't promote them, women don't understand them and basic economic forces combine to make them widely unavailable. Second of two articles.

Box of Plan B, emergency contraceptive pills

(WOMENSENEWS)-Kathleen Boyle, a nurse working in a Planned Parenthood clinic in Glens Falls, N.Y., says it is not unusual to have as many as 15 requests a week for emergency contraceptive pills in a small city gateway to the state's mountainous, sparsely populated region.

However, most of these requests for what is essentially a high dose of birth control pills arise only after she and her co-workers inform patients that emergency contraception can prevent pregnancy.

Though emergency contraception has been around since the 1970s, few women know about them. Experts say, however, that their widespread use could dramatically reduce the number of abortions.

In fact, many hospitals routinely fail to provide emergency contraception to women who have been raped, even though the American Medical Association has determined that medical institutions should inform every rape victim about its availability. Surveys indicate half to two-thirds of hospitals fail to tell victims about this important option, according to NARAL, a pro-choice advocacy group. The organization also reports that 82 percent of Catholic hospitals do not provide emergency contraception to women who have been raped.

Medical Community Presses for Over-the-Counter Sales

A movement is spreading rapidly throughout the medical community to push for the pills to be sold at pharmacies without a prescription. Just last month, the American Medical Association's House of Delegates, without debate, called for broad availability in over-the-counter sales.

Leading the movement are its manufacturers and advocacy groups, but a wide range of health professionals have endorsed the idea as well.

Rod Mackenzie would like nothing better than to see emergency contraceptive pills, also known erroneously as "morning-after" pills, sold over the counter and become as well known as condoms. The pills work not only on the morning after but up to 72 hours after sexual contact. Their effectiveness improves if they're taken within 24 hours.

As president of Gynetics Inc., a pharmaceutical company that makes PREVEN, one of the two prescription drugs specifically designed for emergency contraception, Mackenzie and his young company would like to reap the profits of wide distribution.

Clearly, the need is there. Experts estimate that 1.7 million of the three million unintended pregnancies that occur each year in this country could be prevented with emergency contraceptive pills.

But Mackenzie also says that formidable obstacles must be surmounted before over-the-counter sales of emergency contraceptive pills dramatically reduce the number of unwanted pregnancies.

FDA Encourages Wide Access to Emergency Contraception

In this case, Mackenzie and other proponents are not concerned about obtaining approval from the U.S. Food and Drug Administration or fighting opposition from anti-choice groups. The FDA has already taken the unusual step of encouraging manufacturers to make it more widely available and the National Right to Life Committee, the largest pro-life group, seems ambivalent because the pills may prevent, rather than end, pregnancies.

The biggest obstacle is that most women and many physicians don't know about the pills or understand how they work, says Mackenzie.

Doctors infrequently prescribe them and rarely tell women during routine visits that these drugs are available, effective and safe, says James Trussell, an expert on emergency contraception and director of Princeton University's Population Research Center.

James TrussellWhat's more, women who are aware of the pill are frequently confused about emergency contraceptives. A recent survey showed many college students didn't understand the difference between emergency contraception pills, which prevent pregnancy, and the pills known as RU-486 that can induce an abortion after a pregnancy has been confirmed, Trussell says.

Given the reality of lack of information and education, the use of emergency contraceptive drugs is very low. And that's the issue for those who want to sell the pills.

Lack of Knowledge = Lack of Sales = Lack of Profit and Incentive

As long as use is low, retailers, such as Walgreens, Safeway and Osco Drugs, may be unwilling to stock the pills for over-the-counter sales, Mackenzie says. These companies calculate their return based on sales volume.

"If you can't promise a good return, they aren't likely to stock it," Mackenzie says.

Another problem: Once a product is sold over the counter, it can easily get lost in a sea of merchandise. If women don't know the drug is there, they won't buy it. The only remedy is a mass marketing campaign. Mackenzie says his firm, which started in 1995, cannot afford the tens of millions of dollars needed to adequately market this product to American women.

But Sharon Camp, president and chief executive officer of Women's Capital Corp., which makes Plan B, PREVEN's rival, discounts the idea that the pills would get lost on the pharmacy's over-the-counter product shelves. "If we can get Plan B out on the counter, it's going to help women recognize they have a chance to prevent an unwanted pregnancy," she says.

Camp also estimated that non-profit health and population organizations spend about $15 million a year marketing emergency contraceptives. She says these groups are raising consumer awareness and training providers at local and national levels.

"We have tried to partner with every one of those activities. Where these efforts are underway, we've got Plan B into distribution locally," she says. As a result, sales have increased tenfold during the last year, Camp noted. "If we had a huge marketing budget, then we'd grow this market a lot faster, but we are growing it."

But, for Mackenzie, there's one more worry. The cost averages about $23 a dose, and because it's a prescription drug, Medicaid and other third-party insurers or health maintenance organizations now pay for PREVEN and Plan-B. If these drugs were sold over the counter, women would have to pay for the pills themselves.

For Many Women, $23 to Prevent Unintended Pregnancy Is a Bargain

Camp, however, dismisses the insurance questions.

"We don't find women seeking reimbursement for this product," she says. "It may well be that women are embarrassed about having unprotected sex or having a contraception accident. So their need for privacy outweighs their need for reimbursement."

As for low-income women and adolescents who might not be able to afford the pills, Camp says she believes they will continue to go to Planned Parenthood clinics or other places where they now obtain contraceptives at free or reduced prices.

One state's experiment may provide a third way to increase availability of emergency contraception pills.

A Washington state program allows pharmacists to dispense emergency contraceptive pills without a prescription. Begun in 1998, the Emergency Contraception Collaborative Agreement Pilot Project was the first of its kind in the United States, says Jane Hutchings, senior program officer for Program for Appropriate Technology in Health, a nonprofit organization that oversees the project.

During the project's first 16 months, 11,969 prescriptions were dispensed and an estimated 677 unwanted pregnancies were prevented, Hutchings says. Washington state data indicate that half of those unintended pregnancies would have ended in abortion. The state health department has said that the program may have contributed to the steepest yearly decline in abortion rates that the state has seen in more than a decade, Hutchings says.

Some States Permit Pharmacists to Prescribe Emergency Contraceptives

The key feature of the project is pharmacist prescriptive authority, an ongoing collaborative agreement between a pharmacist and a prescribing clinician that enables the pharmacist to prescribe emergency contraception directly to women. Since the pills must be taken within 72 hours of intercourse, easy access is critical to effective use.

But Mackenzie, from the pharmaceutical company, points out that this approach creates hurdles that might be insurmountable in some cases: The pharmacists must receive special training. A physician must authorize the pharmacist to prescribe the drugs. The pharmacist must have a 10-minute to 15-minute conversation with a woman who wants the pills to obtain certain information. The woman must sign a release. She must pay for the drug.

Twenty-one other states have laws that, to one degree or another, permit pharmacists to dispense emergency contraception without a prescription. But many of those laws are more restrictive than Washington's law, so the chances of widespread use are still low, Hutchings says.

For Mackenzie, who has had 35 years of experience dealing with women's health issues, a bigger change must be made before large numbers of women have access to the pills. Women do not routinely learn enough in school about their bodies, about human reproduction and how contraception works, he says.

FLASH: Intercourse Itself Does Not Cause Pregnancy

"American women have a belief that pregnancy starts at the moment of intercourse. Nothing could be further from the truth," he said.

In other countries, France and Sweden for example, girls are taught about these things early on, he notes. As a result, these countries have significantly higher rates of contraceptive use than does the United States.

Without similar education, American women must rely on the "sweat and panic" approach if they think they are pregnant and don't want to be.

"All girls talk about this," says Mackenzie. "They wait and pray and then if they have a period, they're blessedly relieved. If they don't, they have another challenge."

Melinda Voss has a master's degree in public health. A former reporter for the Des Moines Register, she now freelances and teaches journalism at the University of Minnesota.