Half of all pregnancies in the United States are unintended.
One might therefore assume that making the morning-after pill (MAP) more widely accessible would cut the unplanned pregnancy rate.
A new recent US study is the first to estimate the impact of making the morning-after pill available over the counter without prescription on abortions and risky sexual behaviour as measured by sexually transmitted infection (STI) rates.
Dr Karen Mulligan, associate professor of economics and finance at Middle Tennessee State University, found that providing individuals with over-the-counter access to emergency contraception (EC) leads to increased STI rates and has no effect on abortion rates.
Moreover, risky sexual behaviour such as engaging in unprotected sex and number of sexual encounters increases as a result of over-the-counter access to EC.
Mulligan’s analysis estimated that over the counter access increases STI rates by approximately 12% for women aged 15-44 and 9% for teenagers; these numbers are also consistent with the 12-17% increase in gonorrhea rates found in Washington as a result of expanded access.
She concluded that switching EC to over the counter status has three main effects on behaviour: individuals are more likely to have sex, they have a higher number of sexual encounters, and are less likely to use condoms.
The FDA approved access to emergency contraception, or Plan B (equivalent to Levonelle in the UK), through US pharmacies without a prescription in 2012 nationally. This followed pilot programmes in several states starting with Washington in 1998.
But the US’s persistence with this unproven strategy is apparently driven more by ideology than evidence.
In the light of Mulligan’s research, Dr David Paton, professor of industrial economics at Nottingham University Business School, today called on local and national governments in the UK to review their current policy of aggressive promotion of emergency contraception (EC) to young people in schools, pharmacies and sexual health centres.
‘It is very interesting to see further confirmation that access to emergency birth control (EBC) does not seem to reduce abortions but leads to higher rates of STIs. This paper is one of the first to explore the mechanisms whereby EBC affects STIs, finding that both rates of ‘unprotected’ sex and numbers of partners increase in response to over-the-counter EBC. Although this paper uses US data, it is consistent with evidence from the UK’, he said.
A previous 2012 American study showed that making emergency contraception available free over the counter without prescription leads to an increase in rates of sexually transmitted infections and does not decrease pregnancy or abortion rates.
Christine Durrance, Assistant Professor of Public Policy at the University of North Carolina, Chapel Hill, used county-level data as well as specific timing of changes in pharmacy access to consider the intended and unintended consequences of pharmacy access to emergency contraception in Washington.
The results were almost identical to those of a British study published in the Journal of Health Economics (full text) in December 2010 and reported in the Daily Telegraph in January 2011.
This research, by professors Sourafel Girma and David Paton of Nottingham University, compared areas of England where the scheme was introduced with others that declined to provide emergency contraception free from chemists (See my previous blogs on this here andhere).
The academics found that rates of pregnancy among girls under 16 remained the same, but that rates of sexually transmitted infections increased by 12%.
In fact, in a systematic review published in 2007, twenty-three studies published between 1998 and 2006, and analyzed by James Trussell’s team at Princeton University, measured the effect of increased EC access on EC use, unintended pregnancy, and abortion. Not a single study among the 23 found a reduction in unintended pregnancies or abortions following increased access to emergency contraception (see also fact sheet here).
The phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’.
The term has been applied to the fact that the wearing of seatbelts does not decrease the level of some forms of road traffic injuries since drivers are thereby encouraged to drive more recklessly.
In the same way it has been argued that making condoms readily available actually increases rather than decreases rates of pregnancy and sexually transmitted infections because condoms encourage teenagers to take more sexual risks in the false belief that they will not suffer harm.
Whilst condoms offer some protection against sexually transmitted infections the morning-after pill offers none.
Britain has the highest rate of teenage pregnancy in Western Europe. But international research has consistently failed to find any evidence that emergency birth control schemes achieve a reduction in teenage conception and abortion rates.
Now there is growing evidence showing that not only are such schemes failing to do any good, but they may in fact be doing harm.
Making the emergency contraceptive pill available over the counter free, without prescription, is sadly an ill-conceived knee-jerk response to Britain’s spiralling epidemic of unplanned pregnancy, abortion and sexually transmitted disease amongst teenagers. It is also not evidence-based.
The best way to counter the epidemic of unplanned pregnancy and sexually transmitted disease is to promote real behaviour change. The government would be well advised to enter into dialogue with leaders of communities in Britain where rates of sexually transmitted diseases and unplanned pregnancy are low, especially Christian faith communities, to learn about what actually works.