History of OTC Birth Control
Of the 72.2 million American women of reproductive age, 64.9% use a contraceptive. About 10.5 million American women of reproductive age (15-49 years) used the birth control pill between 2017 and 2019. The Pill was the second most commonly used method of contraception in the United States after female sterilization (aka tubal ligation or “getting your tubes tied”).
The Pill is currently available by prescription only–with the exception of Opill (a progestin-only pill)–and a debate has emerged about whether the birth control pill should be available over-the-counter (OTC), which means the Pill would be available along with other drugs such as Tylenol and Benadryl in drug store aisles. Since 1976, more than 90 drugs have switched from prescription to OTC status, including Sudafed (1976), Advil (1984), Rogaine (1996), Prilosec (2003), and Allegra (2011). Read more background…
Pro & Con Arguments
Pro 1
Birth control pills are safer than many over-the-counter (OTC) drugs and common activities.
The Pill carries no risk of overdose or addiction and many women use the drug with no problem. About 10.5 million American women of reproductive age (15-49 years) used the birth control pill between 2017 and 2019. Of 141 countries for which data is available, 99 countries representing 80.29% of the global population have OTC birth control access. [1] [2] [3] [10] [120] [121]
Other OTC drugs carry more serious risks. Non-steroidal pain pills (NSAIDS) like ibuprofen can cause stomach bleeding. Sudafed can raise blood pressure. Tylenol can cause liver toxicity. Antihistamines like Benadryl can worsen glaucoma and kidney disease. Diet pills can cause irregular heart beats and raise blood pressure. [6] [7]
Eve Espey, Professor in the Department of Obstetrics and Gynecology at the University of New Mexico, stated, “Nonsteroidal medicines kill far more people than birth-control pills.” [6]
Further indicating the Pill’s safety: Plan B One-Step and other emergency contraception pills are available without a prescription and share the same active ingredient as daily birth control pills, levonorgestrel, but in a higher dose. The FDA has already indicated the safety of the drug by making Plan B available without prescription. [8] [9]
According to Bedsider, a nonprofit online birth control network run by doctors, “As medications go, the pill is very safe—safer than having a baby, driving, smoking, or taking daily aspirin.” Joe Speidel, Professor of Obstetrics, Gynecology & Reproductive Sciences at Bixby Center for Global Reproductive Health explains that pregnancy has a mortality rate about the same as car accidents–one in 8,300–while the risk of dying from birth control is about one in 1,667,000, about the same as dying from being struck by lightning. [4] [5]
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Pro 2
OTC birth control pills would increase access for low-income and medically underserved populations.
Twenty million women live in “contraception deserts,” places with one clinic or fewer per 1,000 women who need government-funded birth control from programs such as Medicare. In underserved communities, women could more easily find a local drug store for medication than a doctor’s office. 11-21% of sexually active low-income women studied were more likely to use the Pill if it were available OTC. [11] [12] [13]
Denicia Cadena, Policy Director for Young Women United in New Mexico, stated: “Our rural communities are most profoundly impacted by our state’s health care and provider shortages. Patients face three- to six-month wait times for any primary care and even longer for specialty care… 11 of the state’s 33 counties have no obstetrics and gynecology physicians.” [3]
Birth control can be difficult for many women to obtain, particularly teens, immigrants, women of color, and the uninsured. The National Latina Institute of Reproductive Health stated: “over-the-counter access will greatly reduce the systemic barriers, like poverty, immigration status and language, that currently prevent Latinas from regularly accessing birth control and results in higher rates of unintended pregnancy.” [3] [14]
Other medically underserved communities, such as LGBTQ+ people, are likely to be uninsured (16% of all LGBTQ people making less than $45,000 per year are uninsured), more likely to face economic barriers to healthcare (29% postponed necessary medical care and 24% postponed preventative screenings due to cost), and are more likely to face discrimination in the healthcare industry, resulting in less or no reproductive healthcare. [15] [16] [22]
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Pro 3
OTC birth control pills could lower the rate of unintended pregnancies, saving taxpayers billions of dollars.
54% of unintended pregnancies were associated with not using contraceptives and 41% with inconsistent use. Unintended pregnancies cost the US federal and state governments $21 billion in 2010, the newest numbers available at the time of publication, with the average cost-per-birth being $12,770 for prenatal care, labor and delivery, postpartum care, and 12 months of infant care ($20,716 for 60 months). The Guttmacher Institute estimated that $15.5 billion dollars could have been saved if the unintended pregnancies had been prevented. [1] [17]
Only 5% of unintended pregnancies have happened while the woman used effective birth control consistently. A study found that women who received a one-year supply of Pills were 30% less likely to have an unplanned pregnancy and 46% less likely to have an abortion. A study comparing Pill use between women who obtained Pills with a prescription from an El Paso, Texas, clinic and women who obtained Pills OTC from Mexico showed that the women who got Pills OTC were more likely to continuously use the medication. [1] [18] [19]
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Pro 4
OTC birth control pills could further lower teen pregnancy rates.
From 1991 to 2019, the nationwide teen pregnancy rate dropped 73% among 15- to 19-year-olds. Experts believe the drop is due increased contraceptive use and delayed sexual activity in teens. [20] [123]
Teens may be more likely to use OTC birth control because taking the Pill is a daily routine and is not tied to the emotional pressure attached to sex the way using a condom is. [21]
Krishna Upadhya, physician, stated: “Decades of research show that a majority of adolescents initiate sex before the age of 18 and that earlier use of contraception reduces the risk of teen pregnancy. Our review strongly suggests that giving teens easier access to various contraceptives will not lead to more sex but would result in fewer unwanted pregnancies… [and] any future over-the-counter pill has the potential to benefit teens.” [21]
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Pro 5
Making birth control pills OTC could lower the abortion rate.
In a survey of women seeking abortions, 72% said they were pregnant because they could not get the contraception they needed, and 32% reported an institutional reason such as the prescription requirement. These obstacles resulted in a 35% increase in contraceptives not being used. [22]
The American College of Obstetricians and Gynecologists stated: “The most effective way to reduce abortion rates is to prevent unintended pregnancy by improving access to consistent, effective, and affordable contraception… [and a] strategy for improving access to contraception is to allow over-the-counter access to oral contraceptive pills.” The Guttmacher Institute stated that “more and better contraceptive use” caused the 13% decline in abortion rates between 2008 and 2011. [23] [24]
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Pro 6
Making the Pill OTC would increase continuous use, leading to long-term health benefits.
Research indicates women who have access to OTC birth control pills are more likely to use the Pill continuously. Whereas women who have to go through a doctor to get a prescription are more likely to miss pills between refills or another doctor’s appointment. [19]
A majority of American women (54%) agree that having access to birth control has health benefits.[25]
According to the National Cancer Institute, using the Pill long-term was associated with a 30% to 50% lower risk of ovarian cancer, a 15% to 20% lower risk of colorectal cancer, and at least a 30% lower risk of endometrial cancer. [26]
Hormonal birth control pills also reduce or prevent anemia, irregular or heavy menstrual cycles, bone thinning, endometriosis, fibroids, acne, ectopic pregnancies, breast and ovarian cysts, premenstrual syndrome (PMS), menstrual migraines, pelvic inflammatory disease, and infections in the ovaries, fallopian tubes, and uterus. [27] [28] [29]
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Pro 7
Women are responsible and knowledgeable enough to care for their own bodies.
Alison Block, physician, said: “My main philosophy as someone who provides reproductive health care is to trust women to make their own decisions. The idea that they have to [have a] conversation with a doctor to decide which method is best for them seems overly paternalistic and unnecessary.” [30]
Often, doctors will only prescribe birth control pills once a patient has visited and had a pelvic exam. However, Pap smears are now recommended every three years instead of every year, and only after a woman has turned 21. Nancy Stanwood, MD, obstetrician and Board Chair of Physicians for Reproductive Health, stated, “We were holding pregnancy prevention hostage to cancer screening [Pap smears]. They’re both worthwhile goals, but one should not be held hostage to the other.” [31]
Women can sort out for themselves whether hormonal birth control is right for them. In one study, 98% of women matched their doctors’ medical evaluations about whether they could use hormonal birth control. The women were more cautious about contraindications (medical reasons not to take a drug) such as headaches, smoking, and potential pregnancy than their doctors were. The Border Contraceptive Access Study found that women who got the Pill OTC from a pharmacy in Mexico were adequately self-screening for contraindications. [32] [33]
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Pro 8
Most women want OTC access to birth control pills and say it would improve their lives.
62.2% of women surveyed indicated that they were in favor of OTC Pills. The same survey found that 28% of women using no birth control and 32.7% of women using a less effective form of birth control would use OTC Pills, a market of about 11 million women. 78.7% of women said it was “extremely or quite important” that birth control be easily obtained. [25] [34] [35] [36]
62.5% of women surveyed said birth control reduces stress, 56.3% said it helps working women continue to work, 49.0% said it helped women get an education, and 48.7% said it led to more stable relationships with partners. [25]
Research supports these women’s conclusions, because state laws that allowed early access to the Pill (17 or 18 years old, instead of 21) are linked to higher women’s college graduation and employment rates, increased earning power, narrowed gender pay gap, and longer lasting marriages. [37]
OTC birth control pills would also be more convenient, eliminating the need for a woman to make a doctor’s appointment, take time off work, and rearrange her schedule.
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Pro 9
OTC birth control pills would be more affordable.
Moving the Pill over-the-counter would eliminate the insurance companies as middle-man between women and the Pill, thus making the drugs less expensive.
Jeffrey A Singer, Senior Fellow at the Cato Institute, noted that moving birth control to OTC status could make the Pill less expensive by selling the drug directly to consumers rather than through third-party insurance companies that inflate the prices. [38] [124]
Getting birth control by prescription has several associated costs that would be eliminated with OTC status, including co-pays for doctor’s visits, time taken off work to go to the doctor, childcare, and other related costs. [38] [124]
Uninsured women may also save money by eliminating the insurance companies as middle-man. Uninsured women, about 11% of US women ages 19 to 64, paid $370 on average for a year’s worth of Pills (about $30.83 per month), which was 68% of their total healthcare spending for the year, and about 51 hours of work for someone making the federal minimum wage of $7.25 an hour. Those numbers don’t include what an uninsured woman pays for the doctor’s visit and associated costs (time off work, childcare, etc), which could also be saved by popping into a pharmacy on her regular errands. [39] [40] [124]
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Con 1
Over-the-counter (OTC) birth control would raise the cost of the drug.
Making birth control pills OTC means they would no longer be covered by insurance and women would have to pay for them on their own. With the Obamacare birth control mandate, insured women, who account for 89% of American women, can access free birth control. The National Women’s Law Center estimated that 64.2 million women had birth control coverage with no out-of-pocket cost. [45] [46] [125] [126]
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Stuart O. Schweitzer, UCLA Professor of Health Policy and Management, stated that OTC is “more expensive to consumers than a prescribed drug that’s covered by insurance.” Before Plan B emergency contraception went OTC, the drug cost about $12 for the brand name and $5 for the generic for women using Medicaid. After the drug became OTC, the cost increased to $50 for the brand name and $41 for the generic. Kelly Cleland, Research Specialist at Columbia University stated, “When the generics [of Plan B] were about to go onto the shelves I thought there might be a price war that would push the cost down. But that really hasn’t happened, and I don’t see a sign that it will.” [47] [48]
Con 2
OTC status for birth control pills could result in more unwanted pregnancies.
The birth control pill is not the most effective form of birth control. Among birth control methods, the Pill ranks seventh in effectiveness. Typical use of the Pill results in nine unintended pregnancies out of 100 women after one year of use and increases steadily to 61 unintended pregnancies out of 100 after ten years of typical use. [49]
Meanwhile, typical use of copper IUDs results in eight unintended pregnancies per 100 women after ten years of typical use, female sterilization results in five, the Levonorgestral IUD and male sterilization result in two, and hormonal implants result in just one. [49]
Robin Marty, health writer, noted that because the more effective options “would require a doctor’s visit and the Pill would just require a trip to the store, women may be inclined to use less effective contraception for the sake of convenience.” [50]
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Con 3
Teens are not knowledgeable enough to have access to OTC birth control pills.
The American College of Obstetricians and Gynecologists stated, “adolescents need special attention at every visit for contraceptive services, including comprehensive counseling about sexuality, sexually transmitted disease and emergency contraception.” [51]
Some teens may mistakenly believe that they are at a lower risk of pregnancy just because they have access to OTC birth control, even though they may be taking it incorrectly. This lack of knowledge, combined with increased sexual activity due to mistaken confidence in the inability to get pregnant, could lead to more teen pregnancies. [52]
Peter Arcidiacono, Professor of Economics at Duke University, and his co-authors found that “increasing access to contraception may actually increase long run pregnancy rates even when short run pregnancy rates fall” because teens take readily-available contraceptives for granted and are therefore more likely to ignore availability and have sex without contraceptive protection. [53]
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Con 4
Women who take birth control pills without medical supervision can put themselves at risk.
Jennifer Ashton, gynecologist, stated, “It’s generally accepted knowledge that the overall health literacy of the lay population is about at the 7th-grade level,” adding that even with one-on-one counseling and explanations about how the Pill works, patients are still confused. [54]
Birth control pills do have serious and sometimes fatal contraindications, meaning not every woman should take them. When a drug is OTC, 49% of people get information about the drug from mass media, and only 27% contact their doctors with questions about OTC drugs. This lack of communication and lack of awareness of contraindications can put women at risk. [56]
Contraindications for birth control pills include women over 35 years old, and women who smoke, have a history of diabetes, heart disease, blood clots, cancer, stroke, liver disease, high blood pressure, migraines (and migraines with aura), and/or bladder disease. [57] [58]
Poppy Daniels, obstetrician-gynecologist, called OTC birth control without doctor involvement “ridiculous” and “absurd,” and stated, “My concern is that you’re basically taking women who have no counseling, no family history, no risk assessment, and they’re just getting [hormonal birth control] with no guidance. Why would you take that risk?” [59]
If the Pill is prescribed, the doctor or pharmacist can tell the patient about any possible interactions and prevent bad drug combinations. Drugs that can interfere with birth control pills include the antibiotic rifampin, many anti-HIV drugs, some anti-fungal medications, some anti-seizure drugs, the stimulant modafinil, many drugs to treat epilepsy, some medications for bipolar disorder, and many herbal remedies including flaxseed and St. John’s wort. [60] [61]
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Con 5
Tying prescription birth control to a visit with a medical professional results in additional screenings, tests, and conversations that promote overall good health.
When the Pill is available by prescription only, a doctor usually requires a well-woman exam every one or three years in order to obtain or maintain a birth control prescription. The examination generally includes a pap smear (the test for cervical cancer that may be combined with HPV screening), a breast exam, and pelvic exam that, among other things, screens for ovarian cancer and STIs. Additionally, these yearly exams are a good opportunity to check in with the doctor about general wellness and other preventative screenings. [54]
Further, at least 14% of women on the Pill are using the drug exclusively for noncontraceptive reasons, such as acne and irregular menstrual cycles. That’s at least 1.5 million women who could be self-diagnosing medical conditions in a drug store aisle without medical help. [62]
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Con 6
OTC status for birth control pills would decrease privacy.
If birth control pills were available on pharmacy aisles, purchases would be public and subject to the judgment and gossip of anyone in sight. Many people may prefer to keep their contraceptive use between them and their doctors.
Olivia Alperstein, Communications and Policy Associate at Congressional Progressive Caucus Center, stated “The concept of over-the-counter birth control ignores the grim reality that not all people can just go to a pharmacy and easily purchase birth control. Some face religious and social backlash for buying pills in full view of their pharmacist and people from their community.… Some are young and under a certain state’s law can’t purchase birth control without a parent’s consent. Some are transgender or gender-nonconforming.… The list goes on.” [63]
59% of sexually active teen girls would rather stop getting all reproductive health care services than have to tell their parents about their contraceptive use. But, 99% of those teens would continue having sex. Teens want their contraceptive use kept private and accessing birth control in the middle of a pharmacy where they might run into a neighbor or teacher could stop some teens from preventing pregnancy. [64]
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Con 7
Drug manufacturers are unlikely to make the Pill OTC, so improved access has to be accomplished through other means.
Drug makers to date have little interest in going through the process to make a drug over-the-counter because it can take a long time and the costs are significant. Only the drug manufacturer can initiate this process with the FDA, which decides on the prescription or OTC status of a drug based on applications submitted voluntarily by the manufacturers. Lawmakers cannot change the status of a drug from prescription to OTC. Further, any decision involving birth control can be politically controversial. [30] [65]
Instead, some states are making birth control available without a prescription, but not over-the-counter. In those states, a pharmacist is required to ask the patient a few questions, notes blood pressure and weight, and dispenses birth control from behind the pharmacy counter. Many states including California, Maryland, Tennessee, and Washington allow birth control without a prescription. California, Maryland, and DC even allow 12-month supplies to be dispensed at once, which has been found to reduce unintended pregnancies by 30% and the odds of an abortion by 46%. The birth control in these cases is covered by insurance. A study found that 68% of women would use birth control if it were available via a pharmacist and 63% agreed the pharmacist consultation was an important step. [66] [67] [68] [127]
Women in some states can access birth control via an app or website from private companies. Insurance covers some of these prescriptions, and all that is generally required is a brief consultation to assess risks and appropriate medication, sometimes by video chat. Some services deliver the birth control to the patient, eliminating the need to stop by a pharmacy. [69] [70] [71] [72]
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Con 8
OTC birth control pills would decrease birth control choice and access.
Vanessa Cullins, obstetrician-gynecologist, noted that there were over 40 brands of birth control pills and “not every formulation will go over the counter.” By making only a few choices available OTC, women are more likely to follow the path of least resistance and choose those available at a drug store rather than by prescription, even if it isn’t the right variety of birth control for them. [73]
The FDA-approved contraceptive methods that would not be available over-the-counter include IUDs (both copper and with progestin), the implantable rod, and shots such as Depo-Provera, plus sterilization procedures, all of which the FDA stated are more effective than the Pill. [74]
Journalist Sarah Elizabeth Richards noted, “Women visiting their pharmacists won’t have access to the most reliable forms of birth control on the market because those methods, such as implantable rods or intrauterine devices (IUDs), will still require a trip to a doctor’s office.” [75]
And, even within birth control pill brands, choice will be limited. Most effort is focused on making the progestin-only (also called POP or minipills) OTC, rather than the estrogen and progestin pills (also called combination pills). Only about 0.4% of American reproductive-aged women take progestin-only birth control pills, or about 2% of all women who take the Pill. [76] [77]
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Con 9
Making the Pill OTC would increase the use of hormonal drugs that may disrupt and damage the body.
The FDA notes the side effects of the Pill include changes in sexual desire, bleeding between periods, sore breasts, headaches, and nausea. Some medical practitioners believe that pharmaceutical contraceptives in general are harmful because women are not as aware of their bodies or their natural cycles when taking synthetic hormones. [74] [78]
Holly Grigg-Spall, health author, stated, “Health problems caused by hormonal contraceptives can appear a few months, a few years or longer into use as each woman processes the synthetic chemicals differently. Yet all women will be changed by these drugs. As a woman’s body changes so does her reaction to the pill. The pill’s repression of vital bodily functions that leads to ill health can build in such a way that years later a woman becomes very sick but can not make the connection.” [78]
Lara Briden, a naturopathic doctor, emphasized these concerns are bigger for teens: “Making hormones is not easy. It requires regular ovulation, and that can take a few years to become established. That’s why the early years of menstruation are exactly the wrong time to take hormonal birth control.” [79]
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| Did You Know? |
|---|
| 1. The FDA approved Enovid, the birth control pill on May 9, 1960 for contraceptive use, making it the first FDA-approved contraceptive drug and the first FDA-approved drug that does not treat an illness. [90] |
| 2. Typical use of the Pill results in nine unintended pregnancies per 100 women after one year and increases steadily to 61 unintended pregnancies per 100 women after 10 years of typical use. [49] |
| 3. 60% of American women use some sort of contraception. [1] |
| 4. 17.1% of American women aged 15-44 use birth control pills compared to 8.8% of women worldwide using hormonal birth control pills. [2] [116] |
| 5. Plan B, the emergency contraception that uses the same active ingredient as the Pill, was made available over-the-counter in 2006. [101] |
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