Confusion, clinic closures may have caused big declines in contraception use, study shows

This article was reprinted with permission from Virginia Mercury

Clinic closures in the wake of the Dobbs decision and questions about the legality of emergency contraceptives, including disinformation that some are abortion drugs, may have contributed to a sharp drop in the rate of prescriptions for contraceptives in states with the most restrictive abortion bans, according to a University of California Los Angeles study.

The decline was significant in most states with restrictive bans following Dobbs in June 2022 that returned regulation of abortion procedures to the states, the study found. The group of researchers, led by pharmacy professor Dima Qato, used data from national prescription audit databases to estimate the monthly volume of prescriptions dispensed at pharmacies nationwide and state-by-state. It represents estimates from more than 93% of retail pharmacies.

“Given that abortion would be restricted in many states even more after Dobbs, I wondered whether now more people would get covered through contraception to prevent pregnancy and the need for an abortion,” Qato said.

Over the past six months, especially in states with near-total abortion bans, lawmakers have discussed proposals that would protect access to contraception, but those efforts have largely failed because of concern over whether that would include emergency contraception. Some anti-abortion organizations call Plan B, which is an emergency contraceptive designed to prevent pregnancy after unprotected sex, an abortion drug because it can prevent the implantation of a fertilized egg.

The researchers think those conversations have led to confusion among residents who aren’t sure if emergency contraceptives are still legal in their state. That confusion could also extend to pharmacists. While Plan B is available over the counter at many retail stores and pharmacies, including Amazon, it can also be obtained by prescription, which is the only data point the study captured. According to the research, the rate of obtaining it through prescription between 2021 and 2023 dropped more than 70% in four states with near-total bans — Arkansas, Kentucky, Louisiana and Tennessee. It declined by about 60% in Missouri.

The increases peaked in July 2022 and then dropped to levels lower than the pre-Dobbs period, Qato said.

“For patients that are seeking emergency contraception but can’t get it prescribed or filled, that’s where it matters,” Qato said. “They want to take it, they know it’s an option, and now they’re faced with hesitant prescribers and pharmacies.”

Half of women surveyed in ban states are unsure if Plan B is legal 

Kaiser Family Foundation poll released in early 2023 found that more than 30% of adults surveyed were unsure if Plan B was legal in all 50 states and over the counter — and half of women living in states with abortion bans were under the impression that emergency contraceptives were illegal or were unsure if they were legal.

Conversely, in two states with near-total bans, Idaho and South Dakota, the rate of prescriptions for emergency contraceptives increased by 148% and 182%, respectively. Those numbers were attributed to increases in ulipristal, which is also known as Ella, rather than levonorgestrel, known as Plan B. Ella can be effective at preventing pregnancy up to five days after unprotected sex, while Plan B is most effective within three days and is also less effective in people who weigh more than 165 pounds, while Ella does not have that limitation.

Between the 12 states with the most restrictive bans, the combined decline of emergency contraceptive prescriptions was 60%, and the decline for oral contraceptives was 24%.

Qato said she expected to see lower rates of emergency contraceptive use in the most restrictive states, particularly with the conversations likening them to abortion drugs, but she wasn’t expecting to also see a drop in monthly oral contraceptive prescriptions. Among states with the most restrictive bans, the largest decrease of 28% was in Texas, while most other states had decreases of about 20%, including Kentucky, Louisiana, Alabama and Tennessee.

Qato also theorized that the closure of abortion clinics in those states with bans contributed to the decreases, since most clinics that provided abortions prior to Dobbs also offered prescriptions for oral and emergency contraceptives, IUDs and other family planning services such as screenings for sexually transmitted diseases. The study found no change in the use of IUDs and other forms of contraception such as the patch or vaginal ring.

Over-the-counter options only help certain people 

In her research, Qato noted that two years after Iowa imposed Medicaid coverage restrictions on family planning clinics that provided abortions, the use of contraceptives declined by two-thirds.

A report from the Guttmacher Institute released this week showed 42 clinics that provided abortions nationwide closed their doors between 2020 and 2024. The number of abortions have also increased during that time, and more than 80% still take place at brick-and-mortar clinics rather than via telehealth or by mail.

While Plan B and Opill — an oral contraceptive — are available over the counter, Qato said those options are still untenable for some people who need contraceptives the most, including low-income women and women of color.

“Opill is convenient for those who don’t want to go to the doctor and have that discretionary income to purchase it, but low-income women relied on clinics that are now closed, they relied on prescriptions that they now don’t have,” Qato said. “Those options are accessible, but not affordable to women who could really benefit from it.”

While Qato said there should be a focus on restoring and protecting access to abortion, there should also be efforts to protect contraception in the most restrictive states. She is alarmed to see initial increases after Dobbs and then such steep declines.

“It suggests that we may observe increases in live births from unintended pregnancies in women who were forced to have a child that wasn’t planned because the state didn’t protect or introduced fear of criminalization or liability for patients, doctors, or pharmacists,” she said. “A woman may not feel safe choosing emergency contraception in those states anymore.”

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