There are far fewer people visiting the emergency department (ED) for emergency contraception (EC) now when compared to 2006, before the Food and Drug Administration’s (FDA’s) approval of an over-the-counter (OTC) EC pill, research shows.1
The FDA approved OTC use of EC for adults in 2006 and minors in 2013. EC-related ED visits fell by 96% from 2006 to 2020. There were 47,858 EC-related encounters in EDs from 2006 to 2020. Some of these were for people seeking care for sexual assault.1
Most of the EC-related ED visits involved people who did not have insurance to cover a primary care visit for the medication or who had other obstacles to obtaining the medication through any other clinic or office.
After the OTC status was approved, fewer people had to visit EDs to obtain EC. “With increasing coverage and ability to get policy changes that allow people to get EC over the counter or without parental consent, a lot of people didn’t have to go to the ER anymore,” says Erica E. Marsh, MD, MSCI, FACOG, study co-author and a professor of obstetrics and gynecology at the University of Michigan Medical School. “Now, there is a lot more access.”
OTC Status Is a Huge Factor
People who need EC as a backup contraceptive method during consensual sexual intercourse can buy Plan B or other EC at their local drug store. Of the people who still use the ED for obtaining EC, there now is a higher proportion who are victims of sexual assault and rape.1
“It’s likely that a higher percentage of ED visits now than historically are associated with emergency contraception in the setting of sexual assault,” Marsh says. “When we looked at the proportion of visits who were also coded for sexual assault, it was less than one-half a percent in 2006 and went up to 7.7% in 2020.”
The FDA’s approval of the nation’s first OTC EC was the chief factor in the huge drop in ED visits for EC, Marsh notes.
“The huge drop we saw from 2006 to 2007 was almost certainly in response to that policy change,” she says. “Then, in 2013, the Affordable Care Act mandated that insurers fully cover contraceptive services without copay, which removed the barrier to EC for individuals who had that coverage.”
Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta, points out that the coverage of contraceptive services without a copay should lead to more clinicians offering women insertion of a copper intrauterine device (IUD) as their EC. Not only is the copper IUD more effective for EC, but it offers long-term contraceptive care for women who tolerate their IUD well.
A trend analysis shows that EC-related ED visits decreased by 96% from 2006 to 2020. There were 17,019 visits in 2006, and it was down to 659 visits in 2020.
“The largest decrease was from 2006 to 2007, when it decreased by 67%,” Marsh says. “From 2007 to 2020, there was more gradual decrease of 7% per year.” From 2007 to 2020, it decreased from 5,616 to 659 visits.
Marsh worked on this study out of her interest in reproductive justice and assessing women’s access to care. “I wanted to see what care women are accessing via the emergency room vs. having a trusted relationship in an outpatient setting,” she explains. “This study is one where we saw the power of policy. It has shone an incredible light on [what happens] when we increase access and remove barriers. We see less of a strain on our healthcare services.”
The big concern for advocates of reproductive justice are the new barriers installed in abortion-ban states. There is a philosophical movement, and some policies and practices supporting this could block access to EC as well. “We’re going to see the return of barriers that were once removed being put back in place,” Marsh says.
Lawmakers likely will enact barriers related to OTC access and the cost of EC. “When those barriers return, the concern is that instead of going from preventing an unwanted pregnancy before it happens — which is what emergency contraception does — we’ll decrease access to that and push women back into positions where they get pregnant and are in an environment where they have even more limited options,” she explains.
Advance Provision
Advance provision of EC could be a solution that works for some people. “I think we have to empower women to control their reproduction,” Marsh adds. “Having emergency contraception on hand or easily accessible is very effective.”
Some groups will not be able to or know how to stock EC ahead of time, so some sort of national policy is needed to ensure EC can stay on pharmacy shelves in every state.
“We don’t want to take steps backward in preventing unwanted pregnancy, given our current climate,” Marsh says. “We not only need the policies to be protective, but we need future policies to expand access to timely, cost-effective, and equitable care for preventing unintended pregnancy.”
- Vogt EL, Chibber S, Jiang C, et al. Trends in encounters for emergency contraception in US emergency departments, 2006-2020. JAMA Netw Open 2024;7:e2353672.
