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Issue: Availability of Emergency Contraception in the Military
4/6/2009 -

The U.S. District Court for the Eastern District of New York ruled in late March the Food and Drug Administration (FDA) did not properly evaluate whether or not the emergency contraceptive (EC) Plan B should be made available over-the-counter. The court ordered the FDA to extend over-the-counter access to Plan B to 17 year olds and to reconsider making it available without a prescription for those younger.
 
This ruling does not apply to DoD but it got our attention at MHS, considering there are over 200,000 women serving. We thought we would pose the question in this month’s healthy debate:
 
Should DoD take steps to make emergency contraception more readily available to service members around the world? 
  • Currently, it is up to individual military health facilities to decide whether or not to make EC available. Does this policy go far enough to meet our female service members’ health needs?
  • Does our current policy impact the health and readiness of our force?
  • What about in the unfortunate case of a female service member who is sexually assaulted? 
 
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Comments (21)
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Ana at 2009-04-07 08:38:55 wrote:

Definitely - the DoD should strive to provide all of its female members with access to products and services that are publicly available in the U.S. If I can go to Planned Parenthood to get emergency contraception, a DoD service member should have the same right, especially since they are working towards keeping the rest of us safe in the U.S.
Barbara at 2009-04-07 11:23:59 wrote:

I definately believe this should be available to service women - we are American Citizens and our government has decided that this drug should be available. To leave this option up to the administrators of individual medical health facilities after our government has decided otherwise is to disregard the decision made by our government. If they have additional health concerns due to the use of the drug, perhaps they need to add a follow up appointment to check for whatever side effects they are worried about.
Gail West MSN, RN at 2009-04-07 11:41:56 wrote:

OTC emergency contraception allows the woman (or girl) to react to a situation and not to the whole problem. If a girl, under 17 is sexually active and concerned about emergency contraception, who talks to her about the risks of STD's or ongoing contraception? If a woman is sexually assaulted, the emergency contraception takes care of one issue, but what about the risk of STD's or psychological issues stemming from the asault. Without the intervention of a health care professional, many women will have partial care rather than the holistic care we have been advocating.
Charles at 2009-04-07 11:54:17 wrote:

It is absolutely essential for the DoD to provide this emergency contraceptive service to service members and their families. The Army Medical Command has had a policy in place since 2006 requiring military treatment facility (MTF) Commanders to ensure that each MTF pharmacy develop and implement procedures for ordering, storing. dispensing, distributing, and accounting for Plan B. Further, to ensure patient accessibility to Plan B each MTF Commander was directed to develop policies to make certain that patients are able to receive Plan B if their healthcare providers or pharmacists have moral or ethical beliefs that conflict with the prescribing, dispensing, or distributing of Plan B.
bob at 2009-04-07 14:17:54 wrote:

Quote
Originally Posted By Gail West MSN, RN on 2009-04-07 11:41:56 :
OTC emergency contraception allows the woman (or girl) to react to a situation and not to the whole problem. If a girl, under 17 is sexually active and concerned about emergency contraception, who talks to her about the risks of STD's or ongoing contraception? If a woman is sexually assaulted, the emergency contraception takes care of one issue, but what about the risk of STD's or psychological issues stemming from the asault. Without the intervention of a health care professional, many women will have partial care rather than the holistic care we have been advocating.
Access to ecp should not be delayed until counseling is available since ecp effectiveness is rapidly deminishes with time
Dee at 2009-04-07 17:53:10 wrote:

The policy should be the same throughout all MTFs. It should not be up to the facility. This should definitely be available to female service members, spouses, and children.
Sean at 2009-04-07 18:56:26 wrote:

Absolutely not should EC be available to active duty females or dependents. It is still a chemical abortion. I would not be against "EC" if it only prevented egg release or fertilization. But as long as it can prevent a fertilized egg from implanting--it will always be abortion. BUT I think we are still missing the big picture--a woman, knowing she had or may have had an abortion has a much higher psychological (depression/anxiety later) and physical morbidity (higher rates of breast/ovarian cancer) than carrying an unplanned pregnancy (even in cases of rape or incest) to term. Many times I have had teenage females in my office who were not counseled prior to taking EC, on the possible mechanism of action (may prevent implantation of a fertilized egg)---and this violates informed consent---that a patient fully understands/comprehends the treatment options. Shame on us. And to treat a child without parental consent---shame on us again. And if the CDC cannot give albuterol without 4 forms signed by the physician and a review by the SNRT committee, why would it be ok to give OCPs without a prescription? Lastly, we must be careful to justify ethical issues by arguing from a legal perspective. Just because something is legal does not make it ethically right. Wait until the government legalizes/mandates euthanasia and we have outlived our 'usefulness'. Please read stories surrounding unfortunate cases in oregon--especially one where a terminally ill patient was denied life prolonging medications but offered medications "to give her a peaceful and quiet death." When we make a decision of convenience, one day someone will make a decision of convenience for us. The original Hippocratic oath contains this line: I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.


Have we forgotten that as medical professionals we are entrusted with life, and now we have devolved into arguing about how easy we are supposed to provide access to taking it. We are the US Military and should be the last bastion of honor, compassion and courage. How sad to make a life and death decision based on convenience and/or economics. Shame, shame, shame on us all.
COL (ret) Allan R. Glass at 2009-04-08 07:43:43 wrote:

Given that MTF pharmacies may stock Plan B (as per Charles), the key issue is the procedure that must be followed for a woman to obtain the medication.

Under current FDA rules, Plan B is considered an over-the-counter drug (no prescription needed)in civilian pharmacies for women 18 and over. This is critical because speed is of the essence when using Plan B - any delay in administering the medication, such as trying to find a health care provider to write a prescription, can greatly decrease the drug's effectiveness.

The military's policy is different. The TRICARE Retail Pharmacy program generally does not pay for over-the-counter medications, even though it will pay for Plan B for women under 18 - for these women, Plan B requires a prescription and is not an over-the-counter drug. Thus, a military woman over 18 can get Plan B from a civilian pharmacy right away, as an over-the-counter drug, but the military and TRICARE will not pay for it - roughly $50 or so. If the woman goes to Planned Parenthood, the cost will be much less, but they are not open all the time and their office may not be convenient.

The policy for MTF pharmacies is unclear - they vary from place to place as to whether they dispense particular over-the-counter prescriptions. However, as best as I can determine, MTF pharmacies can still require a prescription even though a medication is classified by the FDA as over-the-counter. This seems to be a general policy, not directed specifically at Plan B. In other words, even if an MTF carries Plan B in its formulary, I doubt whether the pharmacy would dispense the medication without a prescription, as a civilian pharmacy would. And finding a health care provider in the military system to write a prescription may take considerable time, pushing the situation beyond the window of time for which Plan B is effective.
Patrick at 2009-04-08 17:39:24 wrote:

Strongly recommend against: Given the commonly held understanding in the medical profession as well as within the FDA of the abortifacient effect of EC (now if they would only inform the patient being administered the pills in clear language) and current law which states that “funds available to the Department of Defense may not be used to perform abortions except where the life of the mother would be endangered if the fetus were carried to term” one could logically conclude then that current and the possible future expansion of MHS policy relating to the distribution of EC can be considered unlawful. From a purely legalistic perspective, setting aside my other ethical/conscientious objections, if my interpretation of the above law is correct, this makes me an unwilling accomplice in an illicit drug transaction in my opinion. I echo Sean’s earlier comments, shame on us all.

I recommend visiting a support message board where women discuss their experiences using EC.

As we enter into the Month of the Military Child, it’s my hope that the MHS would promote policies that celebrate the vibrancy of these children rather than on their destruction.
Dr. Olson at 2009-04-08 20:53:52 wrote:

Plan B is FDA-approved, and its efficacy is dependent on timely administration. It is my belief that this should be a CORE FORMULARY item for DoD MTFs, not discretionary. Discretion allows too much room for personal/moral/religious beliefs to affect an entire facility and, perhaps, region (as opposed to a clinician's personal decision not to prescribe, so long as they provide an alternative means to the medication). Our female servicemembers and dependents deserve uniform, reliable access to this medication.
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