In Indian country, uneven access to Plan B

A slender woman with long, dark hair stands silently flipping through a series of handwritten cards. "Afraid? Worried?" the first says. The questions go on. "Unprotected sex?" "Missed your pills?" "Condom broke?" "Raped?"

The simple, 40-second video, overlaid with an Indigo Girls soundtrack and available on YouTube, ends with the message, "You’re going to be OK" and the information that the morning-after pill is now available for free at Indian Health Service (IHS) clinics. The woman holding the cards smiles as the screen fades to black, "Native Sisters … love you." It's an important message to spread in a community that continues to struggle with accessing emergency contraception.

One of the women who helped produce the video, Micha Bitsinnie, a former community health worker (recently turned schoolteacher) at First Nations Community HealthSource, is trying hard to change that. She says that although the laws governing access to the morning-after pill have been loosened, not all Native American women know to ask for it — and when they do, they are faced with various barriers that hamper access.

The morning-after pill, also known as the emergency contraceptive pill or EC, is a form of birth control intended to disrupt or delay ovulation and prevent a pregnancy when taken within five days after unprotected sex. According to the Centers for Disease Control and Prevention, when taken within 72 hours, EC can reduce the chance of pregnancy by roughly 75 percent. Even minor delays drastically reduce the effectiveness of the pill, which makes it imperative that access be unfettered and timely. (About half of the 6.7 million pregnancies in the United States each year are unintended and the teen birth rate, although declining, is higher for Native versus non-Native women.) 

Around the country, EC costs anywhere from $30 to $65, but it's free for approximately 1.9 million American Indians and Alaska natives through IHS, which is a part of the Department of Health and Human Services' agency, through their 161 facilities in 35 states. 

Access to emergency contraception is especially vital in Native American communities because of the exceptionally high rate of sexual assault (more than one in three Native women is raped in her lifetime versus fewer than one in five for American women overall). Bonnie Clairmont, a victim advocacy specialist at the Tribal Law and Policy Institute, believes the "true number is higher, but that there is a real lack of baseline data." When she goes into Native communities, Clairmont says, women talk not about if, but rather when, they will be victimized.

Moreover, the community's struggle to access emergency contraception has been hard-fought and has made headlines over the past two years. In 2012, a Lakota activist, Sunny Clifford, launched a petition campaign to ask the head of the IHS to issue a formal directive allowing EC for Native American women 17 and older; to date, it has garnered almost 130,000 signatures. 

This past year has been one of mounting success for advocates of emergency contraception: In April, U.S. District Judge Edward E. Korman ordered one version of the pill, Plan B One-Step, to be made available for all ages without a prescription, overturning previous restrictions for girls 16 and younger. In June, the Food and Drug Administration (FDA) approved Plan B for unrestricted sale on the shelf. A spokeswoman for Teva Pharmaceuticals, which manufactures the pill, said Plan B would be available on shelves by August 1, though many pharmacies stocked it even earlier. 

With these court decisions — and the assurance of manufacturers that EC has been in stock for almost two months — why are Native American women still finding it so hard to access basic medication that is vital to their reproductive health? 

That's what Bitsinnie, a Diné (Navajo) woman, and a group of other health workers set out to address last July in an Albuquerque meeting. Then a community health worker who worked with women who had been raped, trafficked and abused — the very constituency that needed EC the most — Bitsinnie "had no idea that there was a new regulation passed and [that] Plan B was available for all ages" until she participated in this information session last year.

She soon found that she was hardly alone, and helped make the public-service announcement in an effort to "get the everyday person informed. We wanted to spread the word on Facebook and Twitter and Instagram."

Part of the reason people in her community weren't aware of the changing regulations, Bitsinnie said, has to do with the phrasing used by mainstream media. "We don't use the phrase 'emergency contraception' in our communities. We call it 'Plan B' or 'the morning-after pill,'" she said, so any reference to "EC" would likely have been a source of confusion.

Maya Torralba has known pregnant girls as young as 12. A member of the Kiowa Tribe of Oklahoma and a community wellness advocate in that state, she believes that if they or their parents or grandparents or someone knew about emergency contraception, the situation could be different. "A young woman in that position feels so alone," Torralba said. "Put the information up in the bathroom stalls at the library or get something on the radio — anything that's accessible to them."

The lack of information also has to do with the how rural, isolated and impoverished some Native communities are. There are no reservations in Oklahoma, but in Torralba's area there are seven tribes in one county and very high poverty levels. "That means lack of access to a cell phone or social media or cable and newspapers," said Torralba. "It’s a very 'survival' kind of environment. It's 'Where can I get the next meal for the kids? Can I pay the rent?'"

"For the most part Native women don't understand Plan B and don't know they need to ask for it within 72 hours of having sex," said Pamela Kingfisher, a Cherokee and member of the Bird Clan. "Everyone is convinced that it is an abortion pill." While EC prevents a pregnancy, mifepristone (previously known as RU 486) is taken to terminate an early-stage pregnancy. Kingfisher, who lives in Oklahoma and is an organization-development consultant, says women are under pressure from tribal bosses, husbands and other family members, churches and traditional Native practitioners not to attend meetings where emergency contraception will be discussed. "We are in the buckle of the Bible Belt here," she adds.

Torralba is also familiar with local attitudes toward EC. "There's an abstinence-only curriculum in the school systems," said Torralba, who started the Anadarko Community Esteem Project for young women in her community. "There are religious factors. And when it comes to Native American women, there just isn't enough information out there. We're a minority that is invisible. If you're not told by your aunty or grandma or mother, there's nothing."

"Last year we started meeting with women in our communities throughout South Dakota, New Mexico and Oklahoma," said Charon Asetoyer, a member of the Comanche Nation of Oklahoma, and co-founder and CEO of the Native American Women's Health Education Resource Center (NAWHERC). Asetoyer and Kingfisher have been on a grassroots mission to educate women about emergency contraception and their rights to access it. They've compiled an EC tool kit, which they hand out at pow-wows, conferences and other gatherings around the country. (A digital version will be available soon.) And they're the ones who coordinated the outreach session for health care workers that Bitsinnie attended in July.

NAWHERC released a report last September that found that of the 63 IHS pharmacies contacted in a phone survey, roughly 43 percent did not carry the drug at all, about half carried it but required a prescription, and just 11 percent offered it over the counter — an option that has been legal since the FDA approved it for women 18 and older in 2006.

Torralba, Bitsinnie, Kingfisher and Asetoyer were among 60 women who contributed to a 2012 roundtable report on the accessibility of Plan B as an over-the-counter product at HIS facilities, which was a powerful education tool for the women. "I was already counseling young women and I didn't know we had access to it," Torralba said. "After that roundtable, I let people know when and where they could get it." 

Lack of information and confusion between EC and the abortion pill aren't the only barriers to Native women exercising their reproductive rights. Twenty-two percent of American Indians and Alaska Natives live on lands classified as "reservations." On these reservations, Clairmont believes problems accessing emergency contraception are part of a larger deficiency of family planning resources. She notes a lack of providers and an inadequate number of IHS clinics plus the assumption in many tribes that a woman's primary duty is to have children. She says that women who take leadership positions and advocate for family planning resources are often assumed to be promoting abortion and are ostracized from the community for doing so. This is what happened when, for example, the Oglala Sioux Tribal Council fired President Cecelia Fire Thunder, who tried to open an abortion clinic on Pine Ridge Reservation in South Dakota. 

"I don't want to say all reservations lack good access to family planning," Clairmont explained. "But those I've visited are seriously lacking."

Part of the reason for this is political. "A lot of tribal leadership aren't supportive of health programs for women," said Clairmont. "Some have bought into a kind of paternalism and don't see the importance of allocating resources to family planning. We're struggling within our own tribes with women's sovereign status to control their own bodies."

The situation is much worse for women who have been sexually assaulted. Clairmont said that in tribal communities there is still a lot of scrutiny and victim blaming, not to mention fear of retaliation. Though there have been improvements, Clairmont said, very few tribes have comprehensive services for rape victims. "Only a small percentage have the capacity to provide forensic exams and emergency contraception. It's a really sad situation for Native women who are raped. They have to go outside the reservation to get services and they shouldn't have to."

Going off the reservation to the closest pharmacy stocking EC isn't always easy. Depending on her location, a woman might need to travel many miles. She would require a means of transportation, time, money. The average price of Plan B is $48 and the average price for other brands is $40, whereas it is free at IHS clinics.

There's also the issue of anonymity at IHS facilities. "When you're there you can see relatives," said Torralba. "The pharmacy window is right there in the waiting area." She explains this lack of anonymity might deter young women interested in emergency contraception. Long wait times are a factor as well. A 2005 report by the Government Accountability Office reported average wait times of two to six months at some facilities for primary care services such as women's health care, physicals and dental care and a 2010 GAO study confirmed that the situation didn't improve much in the years immediately after. Even once you have an appointment, Torralba and Bitsinne both noted their and others experiences of spending a substantial portion of the day waiting to be seen — a problem for those unable to take off work, say, or for teenagers who can't get out of school. 

It's young people to whom Asetoyer and Kingfisher have turned their attention since Plan B was approved for sale over the counter to all ages in June. Back in February, Asetoyer represented the Native American Community Board in filing a Freedom of Information Act (FOIA) request for the policies governing EC access at IHS facilities. 

The FOIA request stated that only 10 percent of IHS unit pharmacies made Plan B available over the counter, that 37.5 percent of pharmacies only offered an alternative, prescription EC; and that the remaining pharmacies — approximately 53 percent — had no form of EC available at all. But the IHS has yet to respond to the FOIA request about their official policy.

Just last week, though, the Indian Health Service announced that their facilities have been given a "verbal directive to provide Plan B to women 17 years and older at pharmacy windows without a prescription." However, no official policy has been released. Alexa Kolbi-Molinas is the American Civil Liberties Union attorney who worked on the FOIA request. She says "more data is needed now to determine if IHS facilities are making Plan B available to all women without a prescription" — which is exactly what Asetoyer and fellow advocates are currently collecting. They are asking clinics across the country if they provide emergency contraception without age restrictions.

"If we find ones that say yes," Asetoyer says, "we'll see if we can find women to go in and test it out."

Asetoyer says the IHS has had enough time to get organized. "The IHS hasn't lifted that ban on age restrictions. They aren't in compliance with FDA regulations. We're still waiting for a policy. We are the only race of women being denied access to Plan B upon request."