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DARSHAK SANGHAVI

Plan B is almost here. Time for our next move.

A FEW WEEKS ago, the Food and Drug Administration finally approved over-the-counter sales of Plan B, the so-called morning after pill, in one of its most contentious decisions in decades. Every major medical authority, including the American College of Obstetricians and Gynecologists and the New England Journal of Medicine, had criticized the FDA's prior stonewalling.

That ire was well deserved. But now that Plan B will hit shelves this winter, it's worth assessing the likely impact on unplanned pregnancies. In fact, unless additional steps are taken, approval of over-the-counter Plan B sales may not reduce them at all.

One-third of American women have abortions by age 45. Though unprotected sex causes pregnancy less than 1 in 10 times, the cumulative risk is high. To avoid pregnancy, the average woman must prevent conception thousands of times during her life -- and mistakes often happen.

That's where Plan B comes in. It reduces the chance of pregnancy from 8 percent to 2 percent, if taken within days of unprotected sex. Planned Parenthood recently reported that over-the-counter access to Plan B could prevent 800,000 abortions per year.

But that figure unrealistically assumes that the drug will be used with perfect timing after every episode of unprotected sex.

Easier access may increase use. In a 1998 study, 1,000 Scottish women were divided into two groups; one was given Plan B-like pills to keep at home just in case, while the other needed to get a prescription to use the drug. Half the women with pills at home used them, while only one-quarter of the other group did.

But the higher usage didn't clearly reduce unwanted pregnancies; 3 percent of women in the home-access group still had them within a year, a rate lower by a small but not "statistically significant" amount than the other group.

The Scottish study showed that easier access made women more likely to take Plan B following failed contraception. But the lack of a major decrease in unwanted pregnancies suggests that they either had unprotected sex repeatedly (without also repeatedly taking the pills), lied to researchers about taking them, or used them incorrectly.

So now that the FDA has acted on Plan B, what can be done to reduce unwanted pregnancies on a larger scale?

First, the availability and proper use of Plan B must be publicized more. Unfortunately, the drug's maker, Barr Laboratories, has no plans for an ad campaign to promote use. A survey in last month's Southern Medical Journal found that a third of women hadn't previously heard of post-coital contraception, 80 percent thought it was the same thing as taking the abortion drug RU-486, and only 16 percent had discussed it with a physician. To address this problem, the American College of Obstetricians and Gynecologists in May kicked off the ``Ask Me" campaign, encouraging women to learn about emergency contraception, but more efforts are needed.

That's especially important for adolescents, who are largely ignorant of emergency contraception -- and still will need prescriptions. (The Society for Adolescent Medicine and the American Academy of Pediatrics object to this restriction.)

Second, other barriers must be removed. Making Plan B available over-the-counter will ease access, but at a projected cost of $25 to $40 per dose, it's unlikely many will stock it for "just-in-case" use. Insurers should cover Plan B fully. Availability is critical, since even having one dose at home doesn't prevent most unwanted pregnancies. Physicians thus should recommend that many women keep it available in their purse, like condoms.

Third, women who've used Plan B but relapse and need emergency contraception yet again should use more reliable regular birth control. One option: In many women, urgent placement of an intra uterine device, or IUD, after unprotected sex is safe and over 99 percent effective in preventing pregnancy, which is better than Plan B's 80 percent efficacy. Also, IUDs stay in the uterus and provide reversible, long-term contraception.

Fourth, Plan B's approval should herald more realistic strategies to combat unwanted pregnancy at many levels, especially in schools. In a 1999 study, children getting contraceptive education weren't more likely to have sex -- and were two-thirds less likely to have unprotected sex than those taking abstinence-only classes.

The FDA was right to do what it did. But simply making the drug available over-the-counter and stopping there isn't enough.

Dr. Darshak Sanghavi is an assistant professor of pediatrics at UMass Medical School and the author of "A Map of the Child: A Pediatrician's Tour of the Body."  

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