By Tali Woodward

UNDER A NEW state law, California pharmacies may dispense emergency contraceptive pills – the only birth control method that's meant to be used after sex – without a doctor's prescription.

And if a local pharmacist gives you ECPs tomorrow, chances are good your medicine will have the name "Dr. Dick Fisher" typed on the prescription label.

Fisher is just one of the local health care advocates who are aggressively working to teach people about this little-used contraceptive method and to help them get it. A loose coalition is making the Bay Area a model that may transform the contraceptive landscape nationwide – with a method that's been around for decades.

As early as the mid 1960s, doctors and pharmacists knew that large doses of birth control pills, taken after sex, could greatly diminish the chances of pregnancy. Although some discreetly urged patients to use birth control pills for this off-label purpose, the Food and Drug Administration didn't approve the method for emergency use until 1997. It approved Preven, the first pill specifically packaged as an emergency contraceptive, a year later, and Plan B, a competing pill, soon after that.

Still, in 2000 the Kaiser Family Foundation found that only 2 percent of American women had ever used ECPs. Experts say that's because many women don't know about them – and that even if they do, they often find ECPs difficult to get. They argue that better access to the pills could go a long way toward diminishing the roughly three million unintended pregnancies that occur in the United States each year.

The state law that went into effect Jan. 1 allows certain pharmacists to give out ECPs "behind the counter," or without an individualized prescription. The pharmacist must first complete a training course and obtain "protocols" for dispensing the drug from a doctor who's willing to act, effectively, as a sponsor.

So far more than 650 pharmacists have completed training statewide. And San Francisco, where most Walgreens pharmacies are already offering ECPs, is setting a standard for the rest of the state. According to the Pharmacy Access Partnership, an Oakland-based nonprofit that's helping to link drugstores with doctors, at least 75 percent of the participating local pharmacies are being sponsored by Fisher and Dr. Glenda Newell, the assistant medical directors of Planned Parenthood Golden Gate.

'Timing is important'

Sometimes called the "morning-after pill," emergency contraception may actually be taken up to 72 hours after intercourse. However, the drug is most effective when administered the first day. "Women often need it when doctors are not available," Fisher said, adding that women are more likely to have sex over the weekend, when doctors' offices are closed. "Timing is important."

On some weekends Fisher's organization, which covers six Bay Area counties, has gotten as many as 300 calls from women trying to get their hands on ECPs, said Carla Eckhardt, Planned Parenthood's vice president of medical services. Fisher's willingness, she said, "to do the protocols, to put his license on the line, is the sign of a leader." She emphasized that the liability is low since ECPs are so safe and said that "it just made natural sense for us to take the lead."

"We definitely have women call [for ECPs] all the time, and we can't always see them," said Carlina Hansen, the director of the Women's Community Clinic, a free health center in Hayes Valley. "This is a huge thing for our clients." Many women seek emergency contraception after a condom slips or breaks, they've forgotten to take their birth control pills, or – in the worse cases – they've been sexually assaulted.

Political organizing by the Pharmacy Access Partnership and clinical work by researchers and doctors at UC San Francisco also played a big part in getting the legislation passed.

"Contraception is controversial, and it's mainly a private thing," said Dr. Tina Raine, a UCSF professor who heads the New Generations Health Clinics and is overseeing ongoing clinical trials of emergency contraception. "To bring this matter to the forefront takes a lot of work."

Dr. Felicia Stewart published two landmark papers in 1992 that helped jump-start the efforts to promote ECPs and was in charge of national family planning policy under President Bill Clinton. Now she's the codirector of UCSF's Center for Reproductive Health Research and Policy. She told us the effort to promote ECPs highlights the primary contraceptive issue in the United States, "the severe financial and practical obstacles that women face in getting contraception."

"If you need birth control in any other developed country, it's free [regardless of income level]," Stewart said.

Continuing education

Dr. Philip Darney, the chief of obstetrics and gynecology at San Francisco General Hospital, has been a vocal advocate of ECPs and is now providing protocols to pharmacies here and in the Central Valley. Right-wing opposition must always be contended with, Darney said, citing Wal-Mart's refusal to carry ECPs. (Wal-Mart says this was a business decision, but the company has never before banned a drug from its stores.) "But it's easier to do what we view as good work in San Francisco," Darney added, in part because "women themselves have a higher degree of awareness about reproductive rights in this area."

Jane Boggess, a UC Berkeley-trained anthropologist who ran the state's Office of Family Planning and now heads the Pharmacy Access Partnership, is under no illusions that the work is complete. She emphasized that efforts to promote ECPs are neither run nor funded by the government and noted that of all the political and practical hurdles, educating the public about ECPs may prove the most challenging.

"Functionally, it's a new method," she said, explaining that some clinicians are hesitant to promote it because it seems to contradict their typical advice about using more traditional methods of contraception, particularly those that protect against sexually transmitted infections. Boggess added that large, chain pharmacies are unlikely to stock ECPs – much less have a pharmacist trained to dispense them – if few customers request them. Some people also conflate ECPs with RU-486 (or Mifeprex), the drug that can induce abortion, although ECPs do not affect established pregnancies (see "Emergency Contraceptive Pills – a Primer").

Pharmacists are steadily signing on to distribute ECPs, but practical concerns persist. For one, when the pharmacist who is trained to distribute the drug is not at work, a customer has to be sent elsewhere. Pharmacies must also have appropriate space in which to privately review the state's mandated fact sheet with the patient.

At least 10 other countries enable women to get emergency contraception at a pharmacy – sometimes over the counter. The FDA has been petitioned to do the same in the United States but has requested more data. "There isn't any medical reason that it shouldn't be [over the counter]," Stewart told us.

In the meantime, states including Alaska, Hawaii, and New York are moving to mimic the arrangements that allow pharmacists in California and Washington to give out ECPs. Sen. Patty Murray (D-Wash.) and Rep. Louise Slaughter (D-N.Y.) introduced a bill March 6 that would direct $10 million toward educating the public about ECPs. And a private campaign to that effect – called "Back Up Your Birth Control" – started March 20. In line with the advice some doctors have been giving for years, the campaign encourages women to ask their doctors for an advance prescription so they can easily get ECPs whenever they need them.