Alison Edelman

[Cost-effectiveness of increased access to emergencycontraceptive pills: probably not] Response to Letter to the Editor.

We thank Raymond et al. for their interest in our recent article on the cost-effectiveness of ulipristal acetate (UPA) versus single-dose levonorgestrel (LNG) for emergency contraception (EC). We agree that no study has yet demonstrated a meaningful population-level reduction in pregnancy rates with LNG EC use even with advanced provision. However the studies provided in the response have their own significant limitations and none definitely evaluates the use of EC at a population level. Nevertheless the safety and efficacy of EC for pregnancy prevention for individual women is well established. All models have assumptions and limitations. Our decision tree model is based on the correct and timely utilization of EC. We recognize that there are additional confounding factors when EC is used in real life. For example EC has decreased efficacy among women who have further acts of unprotected intercourse in the same cycle. In addition LNG and possibly UPA appear to have decreased efficacy in women with a body mass index of >or=30 kg/m2 . These same confounders and others are present in the studies evaluating the efficacy of EC. When comparing LNG to UPA UPA will prevent significantly more pregnancies after unprotected or inadequately protected intercourse. This translates to a cost savings at the individual level and we have modeled the potential savings at the population level. We believe that over-the-counter status for UPA should be pursued as it has the potential to decrease unintended pregnancy and the associated downstream outcomes and health care costs. Reduction of unintended pregnancy is critical for both the health of individual women and society. EC is an underutilized option to reduce unintended pregnancy especially UPA. Policy changes that reduce barriers to EC use are likely to be helpful in promoting effective use. We await future well-designed studies that can examine these questions at a population level. (full-text) Copyright