Is Over-the-Counter Birth Control Really a Good Idea?
If you’ve been seeing tweets and headlines about over-the-counter birth control lately, you might be really excited. The idea behind OTC birth control is that you’d be able to pop into a retailer like a drugstore and pick up contraception without needing a prescription from a pharmacist or doctor. As we are huge fans of the idea that everyone who wants birth control should be able to access it, we honestly understand all the buzz. Hell yes to making contraception easier to get...right?
Like most things that seem 100 percent excellent, there’s actually a lot more to consider when it comes to deciding if over-the-counter birth control should become a reality across the United States. What would over-the-counter birth control really look like in practice? Would it be a good idea for most people? How do the arguments against it hold up? Here, experts answer these questions and more.
For starters, what kinds of birth control could be sold over the counter?
When it comes to over-the-counter birth control, the only really feasible options are hormonal methods like the pill, the patch, and the ring, Emily Stewart, vice president of public policy at Planned Parenthood Federation of America (PPFA), tells SELF. (This is in addition to barrier methods that are already available over the counter, like the internal condom, external condom, diaphragm, and contraceptive sponge.) Over-the-counter birth control wouldn’t be possible for methods that require insertion or administration by someone like a doctor, such as IUDs, the arm implant, and the birth control shot. No matter how smart and determined you are, it’s best to leave some things to professionals.
So in the most likely scenario, over-the-counter birth control would probably include moving the birth control pill (and maybe just that method) onto store shelves. Oral contraceptives are the most popular reversible method of birth control in the United States, according to the Centers for Disease Control and Prevention (CDC), and they are actually already legally available without a prescription in dozens of countries. “The expectation is that the [Food and Drug Administration] would first get an application [for OTC status] from an oral contraceptive manufacturer,” Stewart says. It would then take years of safety and efficacy testing in order for the FDA to approve selling an over-the-counter birth control pill.
What are the possible benefits?
Organizations like PPFA, the American Academy of Family Physicians (AAFP), and the American College of Obstetricians and Gynecologists (ACOG) have released statements supporting over-the-counter oral contraceptives because of the positive impact they could have on people with vaginas.
First, there’s the obvious preventing pregnancy thing.
“Improving access to contraception has public health benefits [because] it could help reduce the rate of unintended pregnancies in the United States,” Sarah Horvath, M.D., who also has an M.S. in health policy and is a Darney/Landy Fellow at ACOG, tells SELF.
According to a 2016 study in The New England Journal of Medicine that tracked pregnancy rates from 2008 through 2011, 45 percent of U.S. pregnancies were unintended in 2011. This was a significant decline from 51 percent of unintended pregnancies in 2008. The study authors attribute some of that reduction to an increase in birth control use, particularly in long-acting reversible contraceptives (LARCs) like IUDs which wouldn’t be available over the counter. The takeaway is still that increasing contraception access would likely help bring down the unintended pregnancy rate.
Hormonal contraception offers other possible benefits besides preventing pregnancy. The estrogen and progestin in these birth control methods can help regulate periods, manage pain from conditions like endometriosis, tame menstrual migraines in some people, and so much more. (Here’s a ton of information about the various potential benefits from hormonal birth control pills in particular.)
No matter the reason someone wants to use birth control, experts argue that making more methods over the counter would vastly increase accessibility. For instance, someone who doesn’t have insurance for doctors visits or who lives in an area with limited health care access could have an easier time securing contraception, Dr. Horvath says.
Even if you happen to have great insurance it can be tough to get an appointment to see a doctor. If you need that appointment in order to get a prescription for the pill, an over-the-counter version would slash that waiting time. “Making oral contraceptives available over the counter empowers women to control the timing of initiation, rather than waiting for an appointment,” Dr. Horvath says.
Over-the-counter status could also help people stay on the pill or use it most effectively, Dr. Horvath says. Sometimes people can’t get a prescription refill on time or have a gap in their insurance coverage, so they don’t take their birth control regularly, which makes it less effective.
Ultimately experts view being able to get birth control over the counter as a matter of basic health care access and reproductive autonomy. “Women know what is best for them; they know what is best for their health,” Stewart says. “We've been advocating for decades for all sorts of ways to support and offer them choices,” like making hormonal contraceptives available over the counter.
Would it be safe to sell birth control over the counter?
Experts agree that over-the-counter birth control pills would generally be safe, with the benefits outweighing the possible risks.
As ACOG points out, no drug is risk-free. Even some of the most commonly used over-the-counter medications such as acetaminophen and aspirin can cause negative health effects in some people. But serious side effects of hormonal contraceptives, especially birth control pills, are very rare. “We have decades of evidence showing [their] safety,” Dr. Horvath says. “So we know that they are safe enough to be made available over the counter.”
One of the biggest safety concerns around hormonal contraceptives is the increased risk of deep vein thrombosis (also called venous thromboembolism), a type of blood clot that can lead to a pulmonary embolism, which is when a blood clot travels and blocks the lungs’ blood supply. Estrogen appears to increase how easily blood clots, so all forms of estrogen-based contraceptives are associated with an increased likelihood of deep vein thrombosis, according to the American Heart Association (AHA). But research has found this risk to be low overall, according to ACOG. (The risk is highest with the patch, which delivers about 60 percent more estrogen than the typical birth control pill.) And for perspective’s sake, the risk of getting a blood clot is actually much higher in pregnancy and the postpartum period than it is on hormonal birth control.
Although the risk of hormonal birth control causing serious side effects like deep vein thrombosis is low, it does increase with certain risk factors like smoking, poorly controlled high blood pressure, and a history of stroke, according to the Mayo Clinic. All of these factors are things that doctors typically discuss with patients before prescribing them birth control pills, which is why some people worry that eliminating that doctor visit could be problematic.
A practical way around this, as proposed by ACOG, is the use of a simple medical checklist to help people screen themselves for increased risk of serious side effects. “Evidence has repeatedly shown that women are capable of effectively self-screening for any possible contraindications,” Dr. Horvath says.
Take this survey published in The American Journal of Obstetrics and Gynecology in 2008, in which researchers conducted an experiment on 1,271 people aged 18 to 49 who were recruited at three shopping locations in El Paso, Texas. First researchers asked the participants if they thought they were medically eligible for combined oral contraceptives. Next the participants were provided with a simple medical checklist to self-screen for contraindications, then asked again if they thought they were medically eligible. Finally researchers tested the accuracy of those self-screenings with nurse-practitioner evaluations and blood pressure measurements. Results from the first screening—when participants didn’t have the medical checklist—weren’t great. Only 56 percent of those with contraindications said they had them. But the medical checklist gave enough information to help most of the participants accurately gauge their eligibility. After looking through the checklist, 83 percent of people identified as having contraindications by the nurse practitioners and blood pressure test realized that they had them.
Still the industry consensus is that the progestin-only pill (also known as the minipill) would be the first type of birth control people could get over the counter. Since it contains no estrogen the chances of serious side effects like blood clots are much lower. But the minipill is slightly less effective than the combined version, according to the Mayo Clinic. This is in part because it has a much less forgiving regimen than combined pills; you have to take the minipill within the same three-hour time frame every day in order to use it perfectly, ACOG says.
But would this make people less likely to use more effective methods of birth control?
One concern that some people have about over-the-counter birth control is that it could almost be too convenient in a sense. If birth control like the pill becomes available over the counter, would that easy accessibility make some people less likely to opt for more effective birth control methods, like IUDs? Sure, it could happen. But experts generally believe that the benefits of making some birth control available over the counter would still be worth it.
Depending on the specific type of IUD, failure rates are estimated to be between 0.2 and 0.8 percent, meaning that fewer than one person out of 100 will become pregnant within the first year of using an IUD. Birth control pills have an overall failure rate of 0.3 percent with perfect use, again meaning that fewer than one person out of 100 will become pregnant within the first year of using birth control pills perfectly. But perfect pill use is pretty hard to manage; it means taking it correctly every single time—no taking it too late or forgetting allowed. When we’re talking about typical use (which includes mistakes like forgetting to take a pill), the failure rate rises to 9 percent, or nine out of every 100 people who mess up taking their birth control pills in some way get pregnant within the first year of use. The benefit to a LARC like an IUD is that user error can’t skew the failure rates the way it can with birth control pills.
In their committee opinion on OTC birth control, ACOG addresses this by explaining that improving access to LARCs and expanding access to over-the-counter birth control shouldn’t be mutually exclusive. It’s possible to support both causes. If the medical establishment refuses to make birth control over the counter because those options aren’t as effective as LARCs, a lot of people who would benefit from OTC birth control would miss out on that protection.
To make their point, ACOG cites a 2006 study published in the journal Contraception, in which researchers surveyed 811 women aged 18 to 44 who were at risk of unintended pregnancy. Sixty-eight percent said they would take advantage of OTC hormonal contraceptives (including the pill, the patch, the ring, and emergency contraceptives), and of those respondents, 41 percent weren’t using any form of contraception. Even though LARCs would offer better protection against pregnancy, having people who need some form of birth control able to access it more easily is still a win.
“Theoreticals about decisions women will make in that scenario shouldn’t play a major role in limiting their choices here,” Stewart says.
Will people stop getting health screenings if they don’t need to see doctors for BC?
Another oft-cited concern is that if people don’t need to see their doctors to get birth control prescriptions, they will skip their regular ob/gyn appointments and miss out on all the important health services that usually happen during those visits. But the evidence suggests otherwise.
A 2018 study published in the journal Women’s Health Studies surveyed 2,026 sexually active women aged 18 to 44 and 513 teenage girls aged 15 to 17 who didn’t want to be pregnant. Eighty-five percent of respondents reported that even if they were taking an over-the-counter progestin-only pill, they would continue to get their recommended preventive screenings.
Prior research shows there’s good reason to take them at their word. A study published in the journal Contraception in 2012 compared over 500 U.S. residents who obtained over-the-counter oral contraceptives at pharmacies in Mexico to over 500 U.S. residents who obtained their birth control pills from U.S. family planning clinics. They found that the vast majority of over-the-counter pill users still reported getting key preventive screenings for cervical cancer (91 percent), breast cancer (almost 90 percent), and sexually transmitted infections (72 percent).
Would over-the-counter birth control be more expensive?
Many experts believe the most worrisome potential implication in making birth control over the counter is higher costs.
Currently the Affordable Care Act (ACA) mandates that employer-based health insurance covers prescribed birth control without a copay—specifically at least one FDA-approved form of each category of contraceptives. (While the Trump administration weakened this mandate, it still largely stands. As SELF previously reported, the Department of Health and Human Services estimates that the new exemptions allowed by the Trump administration will have a relatively small impact, applying to 200 or fewer employers and somewhere between 6,400 and 127,000 people who can get pregnant.)
Since the ACA mandate only applies to prescription drugs, insurance companies wouldn’t have to cover over-the-counter birth control. While some would argue that this doesn’t matter much because birth control would become inexpensive if it moved over the counter, there’s no reason to assume this would actually be the case. In fact as the Guttmacher Institute points out, the best case study we have—emergency contraception—suggests otherwise as it has remained costly even though it’s been over the counter since 2006 (for those 17 and older; it became over-the-counter for everyone in 2014).
So this shift could essentially knock down one barrier to access (the need for a prescription) while erecting another (out-of-pocket cost). Making birth control obtainable without a prescription isn’t helpful if it also makes it more difficult for people to afford it.
“Women should not have to trade affordability for access,” Dr. Horvath says. “Any effort to make birth control available over the counter should address affordability by ensuring the same level of insurance coverage as prescription birth control.”
Stewart agrees that this point is essential to any policy conversation about making birth control available over the counter. “The most important thing we have to do is make sure the ACA birth control benefit still applies to any [form of] birth control,” she says.
Fortunately there’s a possible solution to the cost problem. An effort to prevent a cost/convenience trade-off is already underway. In June Democratic lawmakers in the House and Senate introduced a preemptive measure to uphold birth control accessibility across the board. The Affordability Is Access Act would ensure that if the FDA does permit oral contraceptives to become available over the counter, the cost will still be covered by insurance. It also makes no mention of a minimum age required for purchase unlike other OTC birth control bills that would only make it accessible to people 18 and up. (Though the price could potentially still be out of reach for those who don’t have insurance, family planning centers like Planned Parenthood and community health clinics would possibly offer contraception on a sliding scale, as many do now.)
For many people, this scenario would truly offer the best of both worlds. It would allow people who currently don’t have insurance or easy access to medical care to get birth control over the counter without taking anything away from those currently getting certain kinds of birth control for free thanks to the ACA. That could mean a free and convenient birth control option for everyone, and it’s hard to think of a more ideal scenario. This, Stewart says, should be “a part of basic health care.”
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Originally Appeared on Self
