Emergency Birth Control Pill Does NOT Cause Abortion
No, Emergency Contraception does NOT cause the termination of a pregnancy.
Emergency Contraception (Emergency Birth Control) does not affect a pregnancy which has already been established. Nonetheless, despite medical and scientific data proving those statements, misinformation and misunderstandings regarding two common Emergency Birth Control pills predominate current social media channels. So, as a Board Certified OBGYN Physician with over 20 years of clinical experience in direct patient care, as well as experience in academic medicine and scientific research, I am here to set the record straight. Now more than ever, proper understanding and increased access to emergency contraception is VITAL as a way to reduce the likelihood of an ill-timed pregnancy. Emergency Birth Control is also an important aspect of post sexual assault care after penile-vaginal intercourse when the female victim is at risk of pregnancy.
TWO ORAL MEDICATIONS: Oral emergency contraception (EC) is highly effective at reducing pregnancy after unprotected or ill-protected vaginal-penile penetration if taken within 72 (Levonorgestrel)-120 hours (Ulipristal acetate) of the event. Levonorgestrel (LNG) and ulipristal acetate (UPA) are the two currently available, oral methods of EC in the United States. LNG, of which Plan B is a common brand name, is available over-the-counter without age restriction as Plan B ONE STEP (Plan B One-Step FDA Approval History. Drugs.com. https://www.drugs.com/history/plan-b-one-step.html. Published June 17, 2022. Accessed July 04, 2022). Almost a quarter of women in the U.S. have used EC (Guttmacher Institute, 2021).
HOW IT WORKS: Ulipristal acetate and the levonorgestrel-only regimen have been shown to inhibit or delay ovulation as their primary mechanism of action (Emergency contraception. Practice Bulletin №152. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e1–11). Levonorgestrel delays follicular development when administered before the level of luteinizing hormone increases. Ulipristal acetate inhibits follicular rupture even after the level of luteinizing hormone has started to increase. Review of the evidence suggests that emergency contraception is unlikely to prevent implantation of a fertilized egg (Emergency contraception. Practice Bulletin №152. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e1–11).
Healthcare providers need to understand EC’s mechanisms of action and provide patients with accurate information. This is particularly critical as more states are banning abortion or have trigger laws that will make abortions illegal. One state recently introduced legislation to ban EC (Guttmacher Institute, 2022a). Personhood is defined in some states at the point of fertilization, a true biological principle which cannot be measured or assessed clinically as a clinical pregnancy diagnosis requires the detection of human chorionic gonadotropin in the urine or serum of the patient. This only occurs 7–10 days after fertilization with the physical act of implantation into the uterine decidua. Successful implantation is the result of a complex molecular interaction between the hormone-primed uterus and a mature blastocyst. The estimated rate of implantation following fertilization in natural cycles is 15% to 30% (Miller JF, Williamson E, Glue J, Gordon YB, Grudzinskas JG, Sykes A. Fetal loss after implantation. A prospective study. Lancet 1980;13(2):554–6). Patients, as well as healthcare providers, may have religious, cultural, or moral beliefs that life begins at fertilization. Therefore, to protect access to EC, it is important to understand EC’s mechanisms.
UNDERSTANDING THE SCIENCE: Complicating this issue is that the U.S. Food and Drug Administration (FDA) has not updated the package inserts for LNG and UPA to reflect what is supported by current medical science. While both package inserts state LNG and UPA work primarily by preventing ovulation or fertilization, both also state the medications may alter the endometrium and may affect or inhibit implantation. This contrasts with published clinical data which has evaluated endometrial receptivity, endometrial preimplantation biomarkers, and endometrial gene expression before and after LNG administration. That data confirmed, “Neither the magnitude nor nature nor direction of the changes endorses the hypothesis that LNG interferes with endometrial receptivity” (Gemzell-Danielsson K, Berger C, P G L L. Emergency contraception — mechanisms of action. Contraception. 2013;87(3):300–8). Similarly, the effect of UPA on embryo implantation processes has been studied in in-vitro endometrial constructs. With use of these implantation models, Berger et al, confirmed, “There was no significant difference in the embryo attachment rate between the UPA treated group and the control group” (Berger C, Boggavarapu NR, Menezes J, Lalitkumar PG, Gemzell-Danielsson K. Effects of ulipristal acetate on human embryo attachment and endometrial cell gene expression in an in vitro co-culture system. Hum Reprod. 2015;30(4):800–11). This study demonstrated “for the first time that UPA in the dose used for EC does not affect human embryo or implantation process as the rate of blastocyst attachment to the UPA exposed endometrial construct did not significantly differ from that of controls” (Berger C, Boggavarapu NR, Menezes J, Lalitkumar PG, Gemzell-Danielsson K. Effects of ulipristal acetate on human embryo attachment and endometrial cell gene expression in an in vitro co-culture system. Hum Reprod. 2015;30(4):800–11). Similarly, Li et al published a literature search utilizing MEDLINE, EMBASE, PubMed, Web of Science and the Cochrane register for all publications containing the words ulipristal acetate with key words and MeSH headings endometrium, implantation, ad mechanism of action. These authors concluded, “An anti-implantation effect of UPA is highly unlikely at the dose used for EC. Maintaining the warning on the FDA-approved label that ‘it may also work by preventing implantation to the uterus’ might deter some women from using EC, leaving them no option to prevent unwanted pregnancy after unprotected sexual intercourse” (Li HWR, Resche-Rigon M, Bagchi IC, Gemzell-Danielsson K, Glasier A. Does ulipristal acetate emergency contraception (ella®) interfere with implantation? Contraception. 2019;100(5):386–390). It is notable that in Europe the language on LNG packaging was updated in 2015 to reflect this science. The American College of Obstetricians and Gynecologists (ACOG) reaffirmed in 2022 that evidence suggests EC is unlikely to prevent implantation and is ineffective after implantation (ACOG, 2022). As clearly stated by the ACOG, “Emergency contraception is sometimes confused- erroneously- with medication-induced abortion. Medication-induced abortion is used to terminate an existing pregnancy. All types of emergency contraception are effective only before a pregnancy is established, and, therefore, are not abortifacients” (ACOG, 2022).
IMPORTANCE AFTER SEXUAL ASSAULT: Almost 3 million women in the U.S. experienced rape related pregnancy (RPR) during their lifetime (Understanding Pregnancy Resulting from Rape in the United States. Centers for Disease Control and Prevention Violence Prevention. https://www.cdc.gov/violenceprevention/sexualviolence/understanding-RRP-inUS.html. Published June 1, 2020. Accessed July 4, 2022).This translates to an estimated 25,000 pregnancies resulting from sexual assault in the U.S. annually (Stewart FH, Trussell J. Prevention of pregnancy resulting from rape: a neglected preventive health measure. Am J Prev Med. 2000;19 (4) :228–9). As many as 22,000 of these pregnancies could be prevented by timely administration of emergency contraception (EC), thereby reducing the need of confronting decisions about abortion. Numerous professional medical societies, as well as The World Health Organization, endorse EC as an integrated aspect of post-sexual assault care. Nonetheless, barriers such as a lack of knowledge of oral EC’s mechanism of action confusing it with an abortion pill still exists for the point of care use of Emergency Birth Control.
A rape victim is often taken to an emergency care facility by the police or emergency transport team. Under these conditions, most women lack the time, information, and opportunity to inquire whether the healthcare facility provides EC. Nor should these victims be expected to do after sustaining the trauma. Moreover, in some rural settings, small hospitals or acute care centers may not provide EC, making it extremely difficult or even impossible for rape victims to access the care needed to avoid rape related pregnancy. This is an area where forensic nurses (SANEs) may fill the gap and provide quality care to victims. It is therefore imperative that SANEs/forensic nursing professionals have the education, training, and confidence in understanding the mechanisms of oral EC options.
NOT MIFEPRISTONE: In closing, the two oral Emergency Birth Control pills available as “morning after pills” are NOT abortion pills. There is currently only one type of oral abortion medication, called Mifepristone. This is to stop an existing pregnancy, something that neither Plan B nor Ella can do.
