Prescribe morning after pills in advance, say pediatricians

NEW YORK - Wading into the incendiary subject of birth control for young teenagers, the American Academy of Pediatrics (AAP) on Monday called on the nation's pediatricians to counsel all of their adolescent patients about emergency contraception and make advance prescriptions for it available to girls under 17.

Because current federal policy bans over-the-counter sales of the pills to girls under 17, having a prescription on hand could help younger teens obtain emergency contraception more quickly than if they have to contact a physician only after they need it.

Calling the AAP decision "significant," Susan Wood, former assistant commissioner for women's health at the Food and Drug Administration (FDA), said, "it's not often you see physician organisations saying that their patients are better off without the physician involvement."

The announcement was controversial with some religious groups.

"Since when should the physicians take over the responsibility of what parents should be doing?," said Michael O'Dea, founder and executive director of Christus Medicus Foundation.

The non-profit foundation provides consulting services to health plans which wish to avoid payments to physicians and hospitals for providing abortions, sterilization, contraception and other services it considers inconsistent with biblical teachings.

"Parents are the primary educators of children, not physicians or the government," O'Dea said. "This is a violation of parents rights to be the primary educator of their children."

The United States Conference of Catholic Bishops, which represents the country's Catholic church leadership, called the recommendation "tragic."

"It is a very sad day when physicians think that "good medicine" is to attack an adolescent girl's healthy fertility with potent drugs just to prevent a possible pregnancy," said Theresa Notare, assistant director for the Conference's Natural Family Planning Program.

"This recommendation becomes tragic when we consider that the recommendation is built upon overriding a parent's rights over their own children," she said.

Whether pediatricians heed the recommendation remains to be seen.

"Some pediatricians are already doing this," said Dr. Melissa Kottke, director of The Jane Fonda Center for Adolescent Reproductive Health at Emory University and medical director for the teen services programme at Grady Memorial Hospital in Atlanta where it is common practice to provide Plan B, "a morning after pill", in an advanced fashion.

"Pediatricians who primarily take care of adolescents may already be comfortable with it but what this recommendation does is provide encouragement and support for pediatricians who take care of the full spectrum of pediatrics."

Dr. Cora Breuner, a pediatrician at Seattle Children's Hospital who led the AAP panel that produced the recommendations said pediatricians in general have preferred not to talk about emergency contraception, let alone offer advance prescriptions.

"We tend not to like bringing up stuff that's controversial," she said.

Emergency contraception for adolescents has been one of the most politically fraught areas in healthcare for almost a decade.

In 2005 the US Food and Drug Administration declined to approve any over-the-counter sales of Plan B, overruling its panel of outside experts as well as its own scientists. Last December the FDA reversed that stance and moved to approve over-the-counter sales with no age limits. But Health and Human Services (HHS) Secretary Kathleen Sebelius overruled it, ordering that for girls under 17 the pills remain available only by prescription.

The FDA subsequently denied a Citizen's Petition that would have allowed over-the-counter access to emergency contraception for women of all ages.

As a result, teenagers "face a significant barrier if they suddenly need emergency contraception at midnight on a Saturday," said Susan Wood, former assistant commissioner for women's health at the FDA. She resigned from the agency in 2005 over its Plan B decision and is now director of the Jacobs Institute of Women's Health at George Washington University in Washington, D.C.

The Center for Reproductive Rights, a global legal advocacy organisation devoted to reproductive rights, has filed a lawsuit seeking to overturn Sebelius' decision and welcomed the AAP recommendation.

"We are very pleased to see this recommendation because it represents progress towards our ultimate goal which is that women of all ages should have unrestricted access to emergency contraception, said Janet Crepps, senior counsel in the US legal programme at the Center.

Women's advocates also hailed the recommendation, saying it offers a workaround current health policy which places unnecessary hurdles in the way of young teenagers obtaining emergency contraception.

"This shames the department of Health and Human Services and its nakedly political attempt to override science and medicine,"said Terry O'Neill, president of the National Organisation for Women, a non-profit advocacy organisation. "HHS's policy means doctors have to use this workaround, and good for them, but they shouldn't have to do it," she said.

A spokeswoman for HHS, Erin Shields Britt, declined on behalf of the department to comment.

The most common form of emergency contraception is a high dose of a regular birth-control pill such as Plan B and Plan B One-Step from Teva Pharmaceutical Industries Ltd or Next Choice from Watson Pharmaceuticals Inc . They generally sell for $10 to $80 and, although they can work as long as 120 hours after unprotected sex, are most effective in the first 24 hours.

All work by preventing ovulation, not by stopping the implantation of a fertilized egg. "These are not abortifacients," said Seattle Children's Breuner. Abortifacients are drugs or devices used to cause abortion.

Greater use of emergency contraception

A 2006-08 survey found that 14 per cent of sexually experienced girls had used emergency contraception, up from 8 per cent in a 2002 survey. The most common reason was condom failure, but 13 per cent of the girls said it was because of rape.

A 2010 analysis of seven randomized studies of emergency contraception found that having a morning-after prescription in hand did not increase teens' sexual activity or decrease use of standard contraceptives but did increase use of the pill and shorten the time before a teenager used it after sex.

"It's just common sense that requiring a prescription is a barrier," said Bill Alpert, chief programme officer of the National Campaign to Prevent Teen and Unplanned Pregnancy. "If an august and respected medical group like AAP is suggesting providing emergency contraception to minors is OK, that is a big deal."

That is especially so when teens face other obstacles to getting emergency contraception. For instance, in a 2012 study that had 17-year-olds telephone pharmacies asking about morning-after pills, only 57 per cent of them correctly told the caller that she could get the drugs without a prescription.

Another barrier is that some physicians refuse to provide the prescriptions to teenagers, while others do so only in cases of rape, AAP's research shows, suggesting that the refusal "may be related to the physician's beliefs about whether it is OK for teenagers to have sex."

But pediatricians,said AAP in its policy statement, "have a duty to inform their patients about relevant, legally available treatment options," even those "to which they object."

One factor in the AAP's recommendation, which is being published in the journal "Pediatrics," is that although teen pregnancies in the United States have declined since 1991, the rate is higher than in most other developed countries.

The per cent of 15- to 18-year-olds who report ever having intercourse - just over 40 per cent, according to the US

Centers for Disease Control and Prevention - is, however, lower than in many developed countries. In other words, fewer of America's teens are having sex but more are getting pregnant.

"We think this is a big deal," Breuner said of the new recommendation. "The mothership of pediatricians has come out in favour of encouraging routine counseling and advance emergency-contraception prescriptions as one part of a public health strategy to reduce teen pregnancy."