By Michaela McDonald
*McDonald is a Maternal and Child Health MPH student at the University of Minnesota.
Women in the United States face numerous barriers to using oral contraception (OC), such as cost, a doctor’s requirement of an annual exam to renew a prescription, and restrictions that limit many women to only one pack of pills at a time, requiring a monthly trip to the pharmacy. These and other problems of access are some of the most significant reasons women don’t use birth control consistently, and inconsistent use of contraception is a major factor in unintended pregnancies. There is a growing perception that offering oral contraception as an over-the-counter (OTC) medication might be an answer to some of these problems of access.
There are many issues to consider when contemplating a shift from prescription to OTC for oral contraception. A significant issue is access. Will making oral contraception available OTC make it more accessible to the 10.7 million American women using it as a method of contraception? Certainly, it is easier to go to a pharmacy than a doctor’s office, and the American College of Obstetricians and Gynecologists endorsed the idea in December 2012. In a Committee Opinion paper, ACOG declared that oral contraceptives have low rates of serious complications, and pharmacists can be appropriately trained to screen women for contraindications. In addition, ACOG asserts that pelvic exams and STI screenings are not medically necessary to prescribe OC, and the traditional coupling of screenings with an annual OC prescription is inappropriate.
While 10.7 million American women use oral contraception, there are many more women who might if it were offered over the counter. There are 43 million women of childbearing age (15-44) in the US who are at risk for unintended pregnancy. This means that they are sexually active and do not wish to become pregnant. Ten percent of those women (4.3 million women) are not using any kind of birth control, while 8.4 million women use less effective methods (male condoms, female condoms, withdrawal, cervical cap, and others). Some of these 12.7 million women would not choose to use oral contraception if it were offered over the counter, but many might. The current requirement of an annual exam is too much for some women, whether they feel it is unnecessary, they cannot take the time, or they don’t want to have a pelvic exam. If offering OC over the counter would lead to more of those 12.7 million women using a more reliable method of birth control, leading to fewer unintended pregnancies, it is worth considering.
A common reason for discontinuation of OC use is dissatisfaction with side effects. These are not rare, life-threatening side effects, but OC has other side effects that many women find undesirable for a variety of reasons. However, offering OC over the counter does not prevent a woman from discussing other options with her primary care provider. For women who are dissatisfied with the effect OC has on their wellbeing, there is still the option of making an appointment with a physician to discuss other OC options or other birth control methods that might suit their needs better. But for women who are satisfied with OC, accessing it OTC is a much easier option.
These are compelling reasons to shift OC to being offered over the counter, but there are some significant arguments against this change. One is the staggering inconsistency in laws regulating pharmacists in the United States. The National Conference of State Legislators has compiled the different laws regulating health care “conscience clauses” and there are many laws that allow health care providers (which frequently includes pharmacists) wide latitude to refuse to dispense medication, provide information, or perform a medical procedure based on religious or ethical objections. There is only one state which provides any sort of protection for women seeking medication to which a pharmacist might have an objection. California law states that a woman must be able to access her prescription in a timely manner for a pharmacist to be able to refuse to dispense it, but no other states have explicit protections for how women should get their prescriptions filled after being turned away from a pharmacy. This is a problem of access that would not change by making oral contraception available over the counter. This is a huge potential barrier in rural areas, where the closest pharmacist willing to fill a “morally objectionable” prescription could be prohibitively far away. While the idea of finding a pharmacist willing to consult and then sell OC over the counter is not hard to imagine in an urban area, it could be a different story in small rural communities. And a pharmacist who refuses to dispense prescribed OC would likely not be a reliable source of information about over the counter OCs.
Additionally, so much about medical care is changing rapidly as different provisions of the Affordable Care Act go into effect. OTC medications are not covered by insurance co-payments, and the ACA stipulates that for an OTC medication to be reimbursed through a flexible spending account or health savings account, one must have a prescription for the OTC medication. This would be a significant step backward for women’s access to OC. The ACA made OC much more accessible by mandating that it be covered by insurance plans as preventive care, meaning that many women can now get most kinds of OC without any out-of-pocket expense. That benefit might disappear if oral contraception were made available OTC, barring a special exception to the FSA rule (such as the current exception made for diabetes treatment and monitoring supplies, which qualify for an FSA without a prescription) or a new mandate about OTC medication being covered by insurance.
Like most issues related to health, access problems with oral contraception are complicated. There is no perfect solution, but making oral contraception available over the counter would most likely increase access and use of OC. There are limitations to the benefits of this approach, but they are not insurmountable, and could be improved by new legislation or local education campaigns. In addition, insurance companies could expand their coverage for OTC oral contraception, removing that barrier. With over 10 million using oral contraception, and nearly 13 million who might use OC if it were offered over the counter, there needs to be a serious conversation about how access and use can be made easier, and considering making it available over the counter should be a part of that conversation.