As the Republican-controlled Congress and White House fight over just how radically to reduce access to basic, vital reproductive health care, advocates are drawing on new research and partnerships to build momentum for over-the-counter (OTC) birth control pills.
Already, people in 100 countries can access birth control pills without a prescription. Advocates participating in the “Free the Pill” campaign are aiming for the United States to be next. Despite increased access to contraception through the Affordable Care Act (ACA), there are still millions of uninsured people who must pay out of pocket for both the provider visit and a prescription, along with those in rural communities who simply cannot access birth control at all.
Denicia Cadena, policy director of New Mexico-based Young Women United, described on a press call last week what some residents in her state go through just to obtain a prescription.
“Our rural communities are most profoundly impacted by our state’s health care and provider shortages,” Cadena explained on the call. “Patients face three- to six-month wait times for any primary care and even longer for specialty care. Specifically, we have two counties—Harding and Hidalgo—with no primary care doctors, while 11 of the state’s 33 counties have no obstetrics and gynecology physicians.”
Because of this shortage, people must plan weeks or months in advance, take off work, schedule child care, and travel just to obtain what will likely be an out-of-network appointment. “These barriers that limit access to health-care services and contraception disproportionately burden people living in rural communities, low-income people, people of color and indigenous people, and immigrants,” added Cadena.
“An OTC birth control pill would give women more control over their lives,” Ibis Reproductive Health Vice President for Development and Public Affairs Britt Wahlin said on the press call. “Women want it, doctors and leading women’s health groups are on board, and now we are partnering with HRA Pharma to support the research needed for HRA Pharma’s submission of an application to the Food and Drug Administration—the FDA—for an OTC progestin-only pill. This means that an OTC birth control pill is literally on the horizon.”
Dr. Daniel Grossman, director of Advancing New Standards in Reproductive Health and a professor at University of California, San Francisco, broke down the medical criteria met by the progestin pill that should allow it to bypass the physician and pharmacist gatekeepers.
“The pill has been around for almost 60 years and it is one of the safest and best-studied medications on the market today,” Grossman said on the call. “In fact, it’s so safe, effective, and simple to use that I believe the pill meets the FDA criteria for over-the-counter sale. There is no risk of overdose with the pill, nor is it addictive. Women determine on their own if they are at risk of unintended pregnancy and need to use contraception.”
Dr. Krishna Upadhya, an assistant professor at Johns Hopkins Medicine, contrasted the safety of the pill with the safety of carrying a child to term. “As with any medicine, there are potential risks, but they are uncommon and especially rare for women under 35 years old. And when compared to pregnancy and childbirth, the risks of birth control pills are minute,” she added. “Progestin-only pills, which will likely be the first type of birth control pill to apply to make the switch to OTC status, are safe to use for virtually all women. They don’t contain estrogen, which means there are no risks for women who typically are disqualified from taking estrogen: those who are over 35 and smoke, are breastfeeding, or have certain health conditions like migraines, blood clots, or heart disease.”
Those who are wholly able on their own to determine whether they need birth control for pregnancy prevention or its other side effects—such as reducing acne, painful menstrual cycles, and the likelihood of developing breast and ovarian cysts, infections, iron deficiency, and endometrial and ovarian cancers—include individuals of several marginalized groups that will continue to face roadblocks whether or not the ACA remains law and the least destructive budget is passed. Putting the pill on the shelves within their reach would undoubtedly save and greatly improve lives.
Anyone who has ever realized they needed to renew on a holiday, or had their medication lost or damaged while traveling, can appreciate the anxiety-reduction of being able to simply stop into a store and pick up a new pill pack.
Perhaps the group most in need of this advancement, though, are those without the power or the papers to simply see a doctor whenever they wish: undocumented people and youth who for whatever reason cannot access contraception through a parent or guardian. While the Free the Pill campaign envisions OTC birth control being covered by insurance to prevent additional costs, far too many of those who are without insurance are currently completely without access.
Contraception “is too hard to get for too many people: for low-income people, for teens, for immigrants, for the uninsured, for women of color who disproportionately experience health disparities,” said Wahlin, who explained that there is work to do while advocates push to get OTC contraception onto the shelves.
“Three states now have laws requiring insurers to cover OTC contraception like emergency contraception without a prescription and some insurance companies have begun to do this on their own. But it is critical that we continue to get more states and more insurers to cover OTC contraception so that when the FDA approves an OTC progestin-only pill, all women will benefit.”
And folks who can get pregnant are ready and waiting for this advancement.
“In a nationally representative survey of U.S. women, 37 percent said they would be likely to use an OTC pill, and almost two-thirds said they supported OTC access,” said Grossman, who explains that though the FDA will require additional research on which particular product will be the first to the shelf, he is confident that approval is “in the not-too-distant future” thanks to existing studies he cited on the press call. “Twenty-eight percent of women using no contraceptive method (but having sex and reporting they did not want to get pregnant) and 33 percent of those currently using a method less effective than the pill said they would be likely to use an OTC birth control pill if one were available.”
An Ibis modeling study estimated that OTC pills could reduce unintended pregnancy by as much as 25 percent—what should be considered a win for everyone.
In an era where sexual health education is being reverted to the ineffective abstinence-only approach and the president’s budget seeks to dismantle youth programs, pediatricians like Upadhya are speaking up on behalf of their patients who are minors.
“As a pediatrician who specializes in taking care of adolescents, I am keenly aware of the negative consequences for young people when they face barriers to contraception,” said Upadhya. “It’s very important to me that any potential birth control pill that becomes available over the counter is not restricted based on age. All too often, adolescents who are anticipating or experiencing the start of intimate relationships don’t have access to a health-care provider who is comfortable talking to them about sex, and many are also afraid to raise the subject with their parents, resulting in unnecessary risks to their sexual and reproductive health and well-being.”
Upadhya reminded advocates that easier access to contraceptives does not lead to teens having sex before they’re ready; it simply makes them less likely to deal with unplanned, unintended pregnancy.
“It is crucial that we provide all youth with the information and tools they need to prevent unwanted pregnancies,” said Upadhya. “There is no reason for teens to be treated differently when it comes to OTC access to birth control than other women at risk for pregnancy. Pills are just as safe and effective. In my view, withholding access to a safe contraceptive option based on concerns about age reinforces stigma around teen sex that puts teens at unnecessary risk.”
Hopefully, the placement of the pill on drugstore shelves can reduce stigma not just for teens, but for everyone. One of the fastest ways to normalize a medication is to make it available without restrictions beyond the disclaimers printed on the packaging.