From American Idol to Plan B: a call for a shift in priorities.

This month marks the 1-year anniversary of “behind-thecounter” provision of emergency contraception in the United States. For years, the hope that emergency contraception would make a significant dent in unintended pregnancy rates fueled women's health advocates, policymakers and donors to create programs and products to promote this “second chance” contraceptive option in the United States and abroad [1]. The level of progress leading up to the current behindthe-counter status granted by the U.S. Food and Drug Administration (FDA) in August 2006 has been tremendous. The United States now has a highly effective, dedicated emergency contraceptive product — Plan B® — marketed by a U.S. pharmaceutical company. Previously, women had to punch the correct dosage out of regular pill packs or take a large number of minipills, all without official product labeling or instruction. In addition, American women are more aware of this option than ever before. Some 64% of reproductive-age women surveyed in 2004 said that there was something women could do to prevent pregnancy following sex, and 75% of those women mentioned emergency contraception [2]. Even before the FDA decision, women were able to obtain emergency contraception directly from pharmacists in 10 states [3,4]. Recently released sales data indicate that women are purchasing more Plan B than ever before: sales are expected to total about $80 million in 2007, almost double the sales in 2006 and eight times the total in 2004 [5]. Even with this progress, advocates are well aware that we have not yet arrived at a place where the full impact of emergency contraception on reducing unintended pregnancy can be realized in the United States. This was made clear by an analysis of studies conducted prior to the advent of behind-the-counter access. Although increased access to the pills enhances use, it has not been shown to reduce unintended pregnancy rates at the population level [6]. Yet, since clinical trials have demonstrated that using emergency contraceptive pills can reduce pregnancy risk following a single act of unprotected intercourse, we are left trying to understand the disconnect between their known efficacy at an individual level and a lack of effect at a population level [7]. One reason may be that women underestimate their risk of pregnancy and consequently fail to use emergency contraception when it is most needed. The review authors