12/11/05

**Q. Does IHS have any policy on distribution of the morning after
pill?**

**A.** Yes, the IHS offers all FDA approved contraceptive agents

As an FDA approved contraceptive agent, post coital contraception, or
emergency contraception (EC), is available in the Indian Health system.

ACOG Practice Bulletin No. 69\* states the following is based on Level A
evidence

"Emergency contraception should be offered or made available to women
who have had unprotected or inadequately protected sexual intercourse
and who do not desire pregnancy."

EC are a series of FDA approved contraceptive regimens that work primary
by blocking conception, but other mechanisms have also been theorized.
As FDA approved regimens, they are covered in the general statements
about the availability of any FDA approved contraception regimens in the
IHS manual, Chapter 13\*\*, (3-13.12F2) below.

<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pt3chpt13.htm>

Research suggests that emergency contraception acts via of actions. The
two most commonly accepted actions are interruption of ovulation or
tubal function.

Depending on some providers' definition of when life begins, e.g., at
implantation versus the free zygote, some have construed emergency
contraception to be an abortifecient. Some have refused to prescribe or
to dispense the prescription after it has been prescribed by a provider.
While it the right of providers and health care workers to work within
their conscience, those health care personnel are also obliged to refer
the patient to a provider or facility that is able to meet their needs
at minimum of inconvenience.

The above approach should be applied to providers, along all aspects of
the spectrum. No matter what your feelings are about the nature of these
agents, e.g., one should not assume that the patient is thinking along
the same lines as you are until you ask.

Toward that end any provider licensed to write prescriptions, can
dispense medications. As a practical matter some women\'s clinics if
Plan B is not available then some keep a supply of bottles of 8 each
Lo-ovral attached to bottles of 2 each Compazine with instructions in
the women\'s clinic. These were kept in a locked cabinet. The physicians
and midwives would hand the meds to the patients with instructions prn.
Please note this should only be an interim solution while the health
care facility makes appropriate arrangements to fulfill its obligation
above. Please consult the ACOG/IHS Postgraduate OB/GYN PEDs Manual for
further prescriptive information.

<http://www.ihs.gov/MedicalPrograms/MCH/M/ACOG01.cfm>

**Online Resources**

Plan B

<http://www.go2planb.com/>

Not-2-Late

<http://ec.princeton.edu/>

**Here are other helpful Indian Health resources:**

Information about emergency contraception is also available alongside
information about all other techniques on our MCH Family Planning page.

Here is the url for our overall Family Planning page

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfamPlng.asp#MCHtop>

Here is the url for the EC section specifically

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfamPlng.asp#emergcon>

The Primary Care Forum is a listserv based forum which has quarterly
facilitated discussions moderated by national experts on a wide variety
of topics of interest to many types of staff. The discussion is
captured, all the content primer, and the moderator's summary on the
Primary Care Discussion Forum webpage, which is housed on the MCH
website.

In between our scheduled facilitated discussions, there was a
spontaneous discussion about EC last year. I personally learned a lot
about providers viewpoints on this topic during that discussion. I
captured that discussion and posted it.

Here is the Indian Health Primary Care Discussion page

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp>

Here is the EC discussion, specifically

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/ECDiscussion1604.doc>

If there are questions about this or other similar issues one may also
want to consult the Federal Register Vol. 47, No. 18 Wed. January 27,
1982. DHHS, PHS 42 CFR Part 36 Subpart F, Abortions and Related Medical
Services in Indian Health Service Facilities and Indian Health Service
Programs. Paragraph 36.55: Drugs and devices and termination of ectopic
pregnancies. \"Federal funds are available for drugs or devices to
prevent implantation of the fertilized ovum, and for medical procedures
necessary for the termination of an ectopic pregnancy.\"

\*\*Chapter 13, MCH, IHS Manual

<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pt3chpt13.htm>

(3-13.12F2)

[Contraceptive Services]{.underline} - All available Food and Drug
Administration (FDA) approved types of contraceptive (mechanical,
chemical and natural) methods should be available to those clients
requesting such services. The choice of method will be that of the
patient based on a careful explanation of each method in accordance with
the medical judgment of the provider. Adequate follow-up should be
available to respond promptly to complications or side effects of the
various methods as well as to assure proper and effective use of the
selected method.

**\*ACOG**

**Summary of Recommendations and Conclusions**

***The following recommendations are based on good and consistent
scientific evidence (Level A):***

-   Emergency contraception should be offered or made available to women
    who have had unprotected or inadequately protected sexual
    intercourse and who do not desire pregnancy.

-   The levonorgestrel-only regimen is more effective and is associated
    with less nausea and vomiting; therefore, if available, it should be
    used in preference to the combined estrogen--progestin regimen.

-   The 1.5-mg levonorgestrel-only regimen can be taken as a single
    dose.

-   The two 0.75-mg doses of the levonorgestrel-only regimen are equally
    effective if taken 12--24 hours apart.

-   To reduce the chance of nausea with the combined estrogen--progestin
    regimen, an antiemetic agent may be taken 1 hour before the first
    emergency contraception dose.

-   Prescription or provision of emergency contraception in advance of
    need can increase availability and use.

***The following recommendations are based on limited or inconsistent
scientific evidence (Level B):***

-   Treatment with emergency contraception should be initiated as soon
    as possible after unprotected or inadequately protected intercourse
    to maximize efficacy.

-   Emergency contraception should be made available to patients who
    request it up to 120 hours after unprotected intercourse.

-   No clinician examination or pregnancy testing is necessary before
    provision or prescription of emergency contraception.

***The following recommendations are based primarily on consensus and
expert opinion (Level C):***

-   No data specifically examine the risk of using hormonal methods of
    emergency contraception among women with contraindications to the
    use of conventional oral contraceptive preparations; nevertheless,
    emergency contraception may be made available to such women.

-   Clinical evaluation is indicated for women who have used emergency
    contraception if menses are delayed by a week or more after the
    expected time or if lower abdominal pain or persistent irregular
    bleeding develops.

-   Information regarding effective contraceptive methods should be made
    available either at the time emergency contraception is prescribed
    or at some convenient time thereafter.

-   Emergency contraception may be used even if the woman has used it
    before, even within the same menstrual cycle.

Emergency contraception. ACOG Practice Bulletin No. 69. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2005; 106:1443--52.

ACOG members

<http://www.acog.org/publications/educational_bulletins/pb069.cfm>

ACOG non-members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16319278&query_hl=27>

11/22/04njm

Revised 12/11/05