The Morning-After Pill Wasn’t Meant to Be a 'Plan B'. What Happened?

Once something traumatic happens to you, it’s easy to go fling yourself down a rabbit hole, trying to understand it from every angle. When I used the morning-after pill once and it didn’t work, I wanted to know why. So I interviewed researchers, experts, campaigners and academics and uncovered a bigger story altogether: the way that we use the morning-after pill (MAP) in its current form is very far away from its intended purpose. It was, in fact, meant to be used as a regular form of contraception, not just “for emergencies”.

To understand how we ended up here, we need to go back a century and a half. As you often find when you dig into issues related to women's reproductive health, outdated ideas relating to morality rather than medical science underpin a lot of today's legislation. “So much of how we treat contraception as a society can be traced back to Victorian views about women’s sexuality, and its intrinsic sinfulness,” Dr Anne Hanley, a lecturer in the History of Medicine at Birkbeck University, tells me. “The stigma related to MAP [the morning-after pill] is part of a longer association between women and a lack of responsibility; that women can’t be trusted to understand what’s best for their own bodies or to take the steps required to get the best care for themselves.”

You have to go back to 1861 to uncover the framework that still shapes women's reproductive rights in the UK. In particular, to something known as the Offences Against the Person Act (OAPA). Under this law, abortion was criminalised, carrying a life sentence for any patient or medical practitioner found to have had or performed one. It wasn’t until 1967 that abortion as we know it today was made legal in the UK via the Abortion Act, but only under certain circumstances, and with written consent of two medical practitioners. The Act fell short of decriminalising abortion entirely.

That's still the case everywhere in the UK bar Northern Ireland. The wording is important because it explains the separation between what is considered a “contraceptive” versus an “abortive” intervention, and why this matters. To translate some fairly dry terms, disrupting an “established pregnancy” (ie: implanting a fertilised egg) is considered “abortive” under UK law, but preventing fertilisation first is “contraceptive”. Even though the morning-after pill works to precent conception (so is classified as a contraceptive), the fact that it is taken post-coitally confuses many people, who assume that this means it’s abortive. It isn't.

As Ann Furedi, chief executive officer of the British Pregnancy Advisory Service (BPAS), argues in her 2011 essay Britain: Contradictory Messages about Sexual Responsibility, this led to “uncertainties about whether its use is a ‘good’ or ‘bad’ thing” morally speaking." It also led to a case in the High Court in 2002 brought by the Society for the Protection of Unborn Children (SPUC)" – a pro-life, anti-abortion group – "who argued that the morning-after pill is not a contraceptive but an abortifacient, which causes miscarriage."

She continued: “Accordingly, SPUC argued, its use should comply with the abortion law,” But, in fact, the High Court ruled against SPUC, ruling instead that "prescription, supply, administration, or use of the 'morning-after pill' could not involve the commission of such an offence since it works prior to implantation and as such prevents pregnancy”. Basically: chill, the morning-after pill prevents pregnancy but doesn't actively abort fertilised eggs.

Oral contraception was made legal in the UK for married women in 1961 and for unmarried women in 1967 via a GP. “When oral contraception was first introduced in the United States and in Britain, there was a big fear that it would promote promiscuity,” Dr Anne tells me. Unwanted pregnancy, she says, had long been used as “a deterrent for sexual immorality and vice”, and many self-appointed gatekeepers of morality couldn't handle the prospect of this being turned on its head.

In the following decades, as Clare Murphy, director of external affairs at BPAS, and Verity Pooke, a PhD candidate at the University of Kent, found in their research paper into the morning-after pill, scientists began to research the idea of a pill to be taken after unprotected sexual intercourse to prevent pregnancy, intending for this to be an additional contraceptive option to be used regularly. It would, it was hoped, provide another option for women and reduce their exposure to daily doses of hormones, and any potential physical and mental health implications of this. And yet, somewhere along the way, it got lost.

By the time it was first launched in Britain in 1984, the messaging around its use had changed dramatically. It was only available on prescription at that time, and the NHS’s advice, still applied now, was to use it in the event that another form of contraception has failed, rather than as a regular option. In the US, this idea is even reflected in its name, Plan B, ostensibly for when “Plan A” (ie. other forms of contraception) has failed.

John Major's Tory government initiated an effort to bring down the rate of unintended pregnancies (especially among teens). As a result, pharmacies made the morning-after pill available without a prescription from 2001. Sadly though, as Ann Furedi reflects, “the tragedy of the provision of emergency contraception in the UK is that the extension of access into pharmacies did not become a means to normalise its use”. Instead the morning-after pill “has remained shrouded in stigma, a product that women really 'shouldn’t' need”. It also meant that the price could be set by pharmacies, and that brands of medications would be free to advertise the product, which in the UK is not the case for prescription medicines.

And guess what? Even this became influenced by skewed morality. “The price of the non-prescription retail product was also deliberately set high to discourage women from regular use,” Murphy and Pooke found. Remember when Boots controversially declined to lower the consumer cost of the morning-after pill after a BPAS campaign to so they wouldn’t be accused of “incentivising inappropriate use”?

There’s a lot to unpack here, but part of the problem seems to rest to do with the regulators that determine usage of different medicines, says Jesse Olszynko-Gryn, a lecturer in History of Health and Wellbeing at the University of Strathclyde. “Regulatory apparatus controls how medicines are used and by whom,” he says, “which is especially evident with reference to controversial reproductive technologies.” This means that, as he says, “non-medical factors, including the influence of lobby groups, can determine how access is managed” and that something like the morning-after pill ends up reflecting not medical science but “broader social and cultural factors.”

“Historical inertia can also play a major role,” he says. “Heated public debates that kicked off in the 1960s are still influencing health policy today.”

Against this backdrop, pharmaceutical companies are reluctant to promote morning-after pill in their marketing. That doesn’t help. The result? Misinformation – that it should only be used “in emergencies” – is rife.

The sad truth is that this limits women’s choices, and in extreme cases, contributes to a situation where one-third of British women will have an abortion in their lifetime. And with public funding cuts under the Tory government since 2014 that have hit women’s health services hard, it’s difficult to see this improving any time soon, although it needs to. We have to accept that people should be able to make informed contraceptive choices, Ann Furedi concludes. “What we have learned from our experience in the UK is that we cannot rely on pharmaceutical companies to lead the development of this more permissive and sex positive perspective.” If we do, we risk never moving on from the 1800s.

@RoseStokes