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The Supreme Court ruling in the Hobby Lobby case raises at least two questions: How will it affect access to contraception, and what do the drugs and devices the company objected to on religious grounds actually do?
A growing body of evidence shows that it is already hard to obtain certain kinds of contraception, and the ruling seems likely to increase barriers. A significant number of pharmacists — 6 percent in one study — say they would refuse to dispense oral contraceptives or other medications to patients for moral reasons if they were permitted to do so.
This dynamic played out in a recent study by a health services researcher, Tracey Wilkinson, who had callers pose as adolescents to see if pharmacies had emergency contraception and would dispense it – legally – to them.
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The first key finding was that in about 20 percent of pharmacies, no emergency contraception, like Plan B, was available at all. Even when it was, however, almost 20 percent of the time adolescents were told, incorrectly, that they couldn’t have it under any circumstances. They were told this significantly more often when calling pharmacies in low-income neighborhoods.
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Various models of IUDs, circa 1960 to 1994. Inserted into the uterus, they provide long-lasting and effective birth control, but they are not without controversy. Credit Image by Robert Estall/Corbis
As part of the study, Dr. Wilkinson also had physicians call the pharmacies. Misinformation was given to them only 3 percent of the time. For some reason, those in the pharmacies were more likely to make it harder for the patients themselves to get the emergency contraception they could legally obtain.
If other family-owned corporations choose to emulate Hobby Lobby and win an exemption from the Affordable Care Act’s requirement for broad coverage of contraception, cost will become a higher barrier for more women. Emergency contraception costs, on average, $45 without insurance.
The cost of an IUD, one of the most effective forms of birth control, is considerable. It requires a visit to the doctor, and a procedure to have the device put in place. Medical exams, insertion, and follow-up visits can run upward of $1,000. Without insurance coverage, it’s likely that many women will be unable to use them.
The reason that contraception is covered at all is that the A.C.A. says that important preventive services must be covered by insurance. After an extensive review made at the request of the government, the Institute of Medicine made eight recommendations for such services, including “a fuller range of contraceptive education, counseling, methods, and services so that women can better avoid unwanted pregnancies and space their pregnancies to promote optimal birth outcomes.â€
The owners of Hobby Lobby told the Court that they were willing to cover some forms of contraception but believed that the so-called morning-after pills and two kinds of IUDs can cause what they believe to be a type of abortion, by preventing a fertilized egg from implanting in the uterine wall or causing an already implanted egg to fail to thrive.
As colleagues have noted, the scientific consensus is against this idea, and it’s worth reviewing some basics here. Even without contraception, fertilized eggs often fail to implant naturally.
Intrauterine devices are not often discussed in the lay media. That doesn’t mean they are uncommon. More than 15 percent of all women worldwide who are married or living with a partner use IUDs at the primary measure of birth control. Use in North America is lower, at around 2 percent.
IUDs come in a number of forms. They can be inert, or have copper or hormones embedded within them. Most scientists believe that they interfere with the ability of sperm to get to an egg in time to fertilize it before they die.
Research does not support the idea that they prevent fertilized eggs to implant. The journal Fertility and Sterility published a study in 1985 that followed three groups of women for 15 months. One group had an IUD, one group had their tubes tied, and one group was trying to get pregnant. They then measured hormone levels to see if fertilization occurred. It did so only in the group trying to get pregnant.
Another study found that a telltale sign of fertilization — a surge of the hormone human chorionic gonadotropin — occurred in only 1 percent of 100 cycles in women using IUDs. This would be consistent with the failure rate of IUDs in general. In other words, IUDs do not appear to work by aborting a fertilized egg.
Emergency contraception, which is really just a large dose of the hormones in a birth control pill, works in a similar manner. The pills can thicken the mucus in the cervix to make it difficult for sperm to reach the egg, and they prevent ovulation from occurring in the first place. Because the doses of medication are very short-term, they probably cannot affect the uterine lining in such a way as to affect implantation.
Moreover, the fact that both of these forms of contraception can fail, and allow pregnancies to occur, provides evidence that if a fertilization occurs, it can move on to implant and grow.
Regardless of the data, or lack of it, many still believe that these forms of contraception are different than others. Today, the Supreme Court gave those beliefs weight. This seems likely to make it harder for women to get contraception in the future.
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