EMERGENCY CONTRACEPTION IN THE COVID-19 ERA: Advance access is more important than ever

Publication date: 2020

May 2020 EMERGENCY CONTRACEPTION IN THE COVID-19 ERA: Advance access is more important than ever The rapid spread of COVID-19 has highlighted fundamental gaps in the American healthcare system, weaknesses in our social fabric, and striking racial and economic disparities. Access to reproductive healthcare is as essential as ever, yet the pandemic layers new barriers upon existing challenges. Now more than ever, emergency contraception (EC) is an important option for individuals who want to prevent pregnancy on their own terms. Having EC on hand before it is needed can make that a possibility any time, but particularly during this crisis. EC Basics There are two types of dedicated EC pills: progestin-only and ulipristal acetate (UPA). Progestin-only EC, sold as Plan B One-Step and generics such as Take Action, Aftera, and AfterPill, is approved for over-the-counter (OTC) sale in every state, with no restrictions on the age or gender of the person purchasing it. Progestin-only EC is generally the easiest to get and people can purchase multiple doses for future use, but is not the most effective option. Ulipristal acetate, sold as ella, is typically more effective (particularly for those who weigh more than 165 pounds) but requires a prescription. A copper IUD provided five days (or more) after sex is by far the most effective option for EC and can provide up to 12 years of highly effective contraception if desired, but it requires insertion by a trained healthcare provider. Emergency contraception is not the same thing as the abortion pill; EC prevents pregnancy before it occurs and will not end an existing pregnancy. The COVID-19 Context Physical distancing and stay-at-home orders are necessary public health measures to limit the spread of COVID-19. These measures may naturally lead to an increase in consensual sexual activity between partners who find themselves in close quarters. At the same time, sexual assault, coerced sex, and contraceptive sabotage are also likely to increase, as reports of intimate partner violence around the world increase with the continuing pandemic. EC E FF IC A C Y A N D W EI G H T ST A TE M EN T Em e rg e n c y C o nt ra c e p tio n in t he C O V ID -1 9 Er a https://www.ncbi.nlm.nih.gov/pubmed/20116841 http://americansocietyforec.org/wordpress/wp-content/uploads/2019/11/asec_ec_efficacy_and_weight_statement.pdf https://www.ncbi.nlm.nih.gov/pubmed/31176689 https://www.ncbi.nlm.nih.gov/pubmed/22570193 https://www.cecinfo.org/wp-content/uploads/2014/01/ASEC_MedAbort_FactSheet_2013.pdf https://ec.princeton.edu/questions/ecwork.html https://ec.princeton.edu/questions/ecwork.html https://ec.princeton.edu/questions/ecabt.html https://www.bedsider.org/features/252-abuse-by-birth-control-sabotage https://www.nytimes.com/2020/04/06/world/coronavirus-domestic-violence.html Access to reproductive healthcare may be inhibited by several factors during the pandemic. Healthcare providers may be limiting visits and declining to take new patients. When appointments are available, it may be difficult to get to an appointment or refill contraceptive prescriptions due to loss of income and health insurance coverage tied to employment, lack of childcare, and fears about exposure to the virus. Long-acting and reversible forms of contraception, such as IUDs and implants, are effective at preventing pregnancy for many years without any daily, weekly, or monthly tasks to remember, but require a hands-on insertion process that people may be uncomfortable with at this time. In the midst of a potential decline in ongoing contraception or uptake of new methods, several states rapidly acted to limit access to abortion. In this environment of public health crisis and economic uncertainty, avoiding pregnancy may be even more important than ever, and timely access to EC is crucial. Barriers to EC Access EC pills are more likely to work the sooner they are taken, and delays can mean the difference between preventing pregnancy and becoming pregnant. But barriers to EC existed prior to the COVID-19 pandemic. Since its introduction there have been several documented cases of pharmacists refusing to provide EC to people who needed it due to the pharmacist’s personal beliefs against contraception or unscientific beliefs about how pregnancy works. Individuals seeking progestin-only EC often found that, despite its OTC status, pharmacies refused to stock it on store shelves and staff unnecessarily asked for identification as proof of age. UPA is restricted by its prescription-only status, and this limitation is compounded by the fact that many pharmacies do not routinely stock it. The price of progestin-only EC in retail outlets - $40-$50 on average - puts it beyond the reach of many who need it. Most insurance plans should fully cover prescribed EC; but not everyone is insured, and most plans do not cover OTC products without a prescription. The Coronavirus Aid, Relief, and Economic Security (CARES) Act now allows OTC products, including EC, to be reimbursed by Flexible Spending and Healthcare Savings accounts, but setting aside savings through these programs is not available to or feasible for everyone. These existing barriers are exacerbated by restrictions on movement and concerns about exposure to COVID-19 that may leave individuals reluctant to make additional trips to stores or clinics. These are unprecedented times that call for new recommendations for people at risk of pregnancy. http://reproductiverights.org/document/how-state-covid-19-orders-can-impact-abortion-access http://americansocietyforec.org/uploads/3/4/5/6/34568220/asec_2017_ec_access_report.pdf https://nwlc.org/resources/pharmacy-refusals-101/ https://nwlc.org/resources/pharmacy-refusals-101/ https://www.ncbi.nlm.nih.gov/pubmed/29097224 https://www.benefitresource.com/blog/cares-act/ Recommendations for people at risk of pregnancy  Keep EC on hand in advance of need  EC experts have long recommended that individuals at risk of pregnancy who do not want to be pregnant keep a supply of EC at home before they need it. This recommendation is more relevant than ever, as it may be difficult to get to clinics and retail stores. Innovations in technology and transit make it easier than ever to buy EC online with fast delivery.  Get EC online  Progestin-only EC is OTC and can be purchased from websites such as Amazon, which offers several brands at lower prices (starting at $9.99) than in stores. Some brand names of products approved for sale in the United States are Plan B One-Step, Aftera, AfterPill, EContra EZ, My Choice, My Way, New Day, Option 2, React, and Take Action. If purchasing from a site such as Amazon, carefully consider the seller to ensure that the product will be sent by a reputable company, such as AfterPill or Option2. The tag “sold and shipped by Amazon” may provide some additional assurance, but is not a guarantee of quality.  UPA EC cannot be purchased through regular retail outlets because it is a prescription-only product. However, there are online services (such as Nurx, Simple Health, Twentyeight Health, Virtuwell, and Planned Parenthood Direct) that can ship UPA EC after a brief virtual consultation with a physician (read this FDA guidance on how to identify legitimate online pharmacies). Insurance may cover the cost of the medication purchased on these sites, but there may be a consultation fee that is not covered (for example, Nurx charges a $15 fee that is not reimbursable). Ulipristal acetate is typically more effective than progestin- only EC for all users, but especially those who weigh more than 165 pounds.  Get EC by prescription at the pharmacy  In some states, a pharmacist can directly prescribe contraceptives; this may include EC. If you live in one of these states, call your pharmacy to ask if a pharmacist can prescribe ella, and if they have it in stock.  Ask your healthcare provider to call in or electronically transfer a prescription for ulipristal acetate (ella) or progestin-only EC to your local pharmacy, so you can have it on hand for when you need it. If you have insurance, your plan should cover prescribed EC with no out-of-pocket costs (you shouldn’t have to pay a deductible or co-payment).  Get EC over-the-counter at the pharmacy or other store  Look for EC on your next visit to a store that sells OTC medications. Progestin- only EC should be available in the OTC aisle - but as noted earlier, it may not be stocked on the shelf and is likely to be more expensive than online sources.  Remember, there are no restrictions on the age or gender of the person purchasing progestin-only EC. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/07/access-to-emergency-contraception https://www.amazon.com/s?k=emergency+contraception&ref=nb_sb_noss_1 https://www.amazon.com/AfterPill-Emergency-Contraceptive-Pill-Unit/dp/B00LWF9AZI/ref=sr_1_1?crid=1OH695C6SLSLP&dchild=1&keywords=afterpill&qid=1588621627&sprefix=emergency+contraception%2Caps%2C239&sr=8-1 https://www.amazon.com/Option-2-Levonorgestrel-1-5mg-Tablet/dp/B07FS852FQ/ref=sr_1_1?dchild=1&keywords=option+2&qid=1588621653&sr=8-1 https://www.nurx.com/birth-control/emergency-contraception/ella/ https://www.simplehealth.com/birth-control https://twentyeighthealth.com/ https://www.virtuwell.com/condition/birth-control https://www.plannedparenthood.org/get-care/ppdirect https://www.fda.gov/consumers/consumer-updates/how-buy-medicines-safely-online-pharmacy https://naspa.us/resource/contraceptives/  Access no-cost EC from community partners (where available)  In some communities, organizations can provide EC at no cost. One example is the Reproductive Justice Action Collective in New Orleans.  SisterReach, a reproductive justice organization in Tennessee, is mailing out free safer sex kits to anyone in need. These kits include EC, internal and external condoms, dental dams, and lube.  Local abortion funds (such as the Yellowhammer Fund serving Alabama, Mississippi, and the Florida panhandle) may also provide free EC. Find your local abortion fund here. Accessing other forms of contraception If an IUD or implant is your preferred method, or if you need your IUD or implant removed, contact your health care provider so they can provide information about available appointments and special instructions during the COVID-19 pandemic. You can get other ongoing methods of contraception online, and you may be able to use your insurance.  See who prescribes the pill online and get your contraceptive prescription, and sometimes EC, mailed to you  Planned Parenthood Direct app provides safe, remote access to essential health care during this public health crisis and beyond, including contraception and UTI treatment EC is an important back-up contraceptive option at any time. This is true more than ever during the COVID-19 pandemic, when access to ongoing contraception may be limited and efforts are underway to limit access to abortion in some states. Purchasing EC in advance of need can help people maintain autonomy and reduce the risk of pregnancy during this crisis. For more information, contact Kelly Cleland kelly@americansocietyforec.org www.americansocietyforec.org https://www.rejacnola.org/ https://www.sisterreach.org/safesexkit.html https://www.sisterreach.org/safesexkit.html https://www.amazon.com/Option-2-Levonorgestrel-1-5mg-Tablet/dp/B07FS852FQ/ref=sr_1_1?dchild=1&keywords=option+2&qid=1588621653&sr=8-1 https://abortionfunds.org/need-abortion/#funds-list https://freethepill.org/online-pill-prescribing-resources/ https://click.everyaction.com/k/17193833/185987810/1479730684?nvep=ew0KICAiVGVuYW50VXJpIjogIm5ncHZhbjovL3Zhbi9BVi9QUEZBLzEvMTk4NDQiLA0KICAiRGlzdHJpYnV0aW9uVW5pcXVlSWQiOiAiNWQwMzdlOTYtNjc4Mi1lYTExLWE5NGMtMDAxNTVkMDNiMWU4IiwNCiAgIkVtYWlsQWRkcmVzcyI6ICJhY2hhdWRocmlAZXZlcnRocml2ZWlsLm9yZyINCn0%3D&hmac=4DBcDsicXOOx4JftTGYEMiTWPuXpNBURrN_mjoJ6cUU=&emci=f17fc0eb-e280-ea11-a94c-00155d03b1e8&emdi=5d037e96-6782-ea11-a94c-00155d03b1e8&ceid=10306710

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