Birth Control On Demand, Without Apology, and Over-the-Counter!

Posted on 5.15.2012 by Lily

Last month Amy and I went to CLPP, a 3-day reproductive justice conference filled with fabulous, progressive people working in all sorts of social movements. One of the workshops I went to was run by the OCs OTC Working Group, which is a coalition working to make birth control pills available over-the-counter.* This is a tough idea for a lot of people to swallow, including reproductive justice folks. But over-the-counter contraception actually makes a ton of sense.

In the US, hormonal birth control access has traditionally been tied to the annual pelvic exam and Pap smear. Women know that if they wish to prevent pregnancy pharmaceutically, they must jump through the Pap hoop. (How ‘bout that image?) But this connection is a mistake of history. No Pap result contraindicates the use of hormonal birth control; contraindications are found by taking a medical history and checking blood pressure. No exam necessary.

(Lest anyone think I’m saying Paps and well-woman exams are irrelevant, please be assured that I’m fully aware of their importance. Of course everyone needs regular check-ups, and the Pap is the best tool we have to prevent cervical cancer - although many practitioners still don’t follow the updated Pap protocols, which say that most women need a Pap only every 2-3 years rather than annually and no one needs one before age 21, period.)

Nor am I saying that birth control has no place in the doctor’s office. Over-the-counter access should ideally supplement, not replace, consultations with your provider. But providers should not be the gatekeepers between women and these needed medications. Clinicians will often withhold refills until patients come in for their appointments, which definitely affirms who has control over women’s bodies, but accomplishes little else - besides contributing to rates of unintended pregnancies and abortions, naturally. A cardiologist would not deny a patient their blood pressure prescription as punishment for blowing off a follow-up appointment. Birth control is no less important a medication, but it is firmly entrenched in the social and political arena of the War on Women and Our Bodies.

Not only is the pelvic exam medically unnecessary for birth control, but forcing women to go to a provider disproportionately hurts women who are young, low-income, uninsured, and/or undocumented, contributing to existing health disparities. Even women with great health insurance who can easily manage a yearly exam can face barrier access. Insurance plans involve all sorts of restrictions on contraception, like being allowed to get only one month’s supply at a time. When I was on the pill, I was obsessive about taking it at the same time every day, but I had a hard time remembering to get to the pharmacy each month. Being a typical Sunday starter, I often had to double up on the first Monday of the cycle because I’d only remembered that I needed my next pack when my college’s pharmacy was closed over the weekend. Many pill users are not unlike me - the beginning of the cycle is the most common time to miss pills, probably in large part due to the one-pack-a-month rule.

Moreover, monthly co-pays can be prohibitively expensive, though that should thankfully be changing in August due to new HHS regulations under the Affordable Care Act. Which brings me to another point: over-the-counter access to birth control should not replace prescriptions, as patients will still need the financial benefit of insurance coverage. But we should have the option to buy an emergency pack when needed.

One participant in the CLPP workshop worried that over-the-counter access would mean an increase in cervical cancer. A friend of hers had only gotten her Pap to get her birth control, and she subsequently discovered, and was able to treat, pre-cancerous cervical cells. It’s true that there may be some women who would fall through the cracks, but research has shown that most women see their gyn regularly whether or not they need prescription birth control. And let’s keep in mind that unintended and unwanted pregnancy is a serious public health concern too. Considering the number of women who would be better able to prevent pregnancy through improved access, I’m willing to bet that the public health benefits would outweigh any costs.

Besides, even if some patients do benefit from the contrived connection between birth control and the Pap smear, one thing still has nothing to do with the other. Paternalistic ideas about acting in women’s best interest should not set medical precedent, especially when they go against the evidence.

So what am I saying? Birth control should just be available on the shelf to anyone with a few bucks? What about the risks? How will women know whether it’s safe for them to take? What if they abuse it? (I love that idea - as though women who Rush Limbaugh considers “slutty” are getting high off synthetic estrogen and progestins.)

Well, here’s the thing. In much of the world, birth control pills are already either officially or de facto available over-the-counter. Public health awareness campaigns can help women determine whether they are good candidates. Blood pressure can easily be checked right there in the pharmacy; pharmacists have vast expertise which is underutilized in general and could definitely come in handy here. (Excepting those who use their power for evil in the form of so-called “conscience clauses,” but that’s a grievance for another time.)

With regard to risks, let’s compare contraception to some other medications that are far more readily available. Good ol’ acetaminophen (Tylenol) is responsible for some 450 deaths per year from liver failure. That may sound like a low number, but the danger lies in how innocuous it's generally thought to be when even the recommended dose can be toxic, especially when combined with just a small amount of alcohol. Deaths from NSAIDs, which include ibuprofen, aspirin, and naproxen, reach tens of thousands annually - similar to the number of US AIDS-related deaths.

In comparison, the miniscule number of deaths and serious complications resulting from birth control are always widely publicized complete with histrionic ads from personal injury lawyers, but are seriously overblown. A 2010 UK study found that women who had ever used oral contraceptives actually had a lower mortality rate than women who had never used them. Without minimizing the very real risks of hormonal birth control (particularly the progestin in Yaz/Yasmin), it’s safe to say that these medications are, both objectively and relatively speaking, extremely safe - especially when we remember just how commonplace their use is. Guttmacher estimates that over 10 million American women use the pill, and the death rate from today’s low-dose versions is so minimal I couldn’t even find a number while researching for this post. Eventually I found this statement from a university health center:

The most serious risk to pill users is the increased possibility of stroke or heart attack. However, among all women less than 35 years and among nonsmoking women less than 45 years, there are no significant differences in death rates from circulatory diseases between those who take the pill and those who don't. The number of such deaths in women in their early 20s is so small that accurate conclusions cannot be drawn.

Of course many patients experience other downsides to being on birth control, including mood changes, weight gain, and decreased sex drive. But the point is not that hormonal contraception is free from side effects and great for everyone. The point is that when considered alongside other common medications currently available on convenience store shelves, birth control is easily just as safe, if not arguably much safer. Considering their popularity, safety profile, and the high rate of unintended pregnancies, it’s a no-brainer to increase access to these medications however possible. Let’s start by getting rid of the prescription barrier!

*I use “over-the-counter” to generally mean available without a prescription. But there is an enormous functional difference between products that are truly over-the-counter - meaning they are located on the convenience store shelf like condoms and Tylenol, available to anyone who can pay - and those that are “behind-the-counter,” meaning they can be obtained only by request and often an ID check, such as Sudafed, cigarettes, and (outrageously) Plan B. If birth control pills were to become available without a prescription, they would likely be behind-the-counter at least initially. But sometimes progress happens in baby steps, and behind-the-counter birth control pills would surely be an improvement over prescription-only.