Birth Control

Minus the Doctor

Oral contraceptive pills in Pennsylvania should be sold over-the-
counter and through pharmacists.

The State of the Union

Pennsylvania drugstores offer over-the-counter medications like Advil,
Claritin, and Pepto-Bismol for consumers to buy without a doctors prescription.
Pharmacies sell both name-brand and generic versions, adult and child formulas,
and night and day varieties of many drugs. However, the birth control pill, rated
as a relatively safe drug which nearly all women can safely use, is missing from
pharmacy inventoriesi. Birth
control pills are proven to be [Contraception] is a basic
highly effective at preventing health care necessity.
unwanted pregnancies. However,
Louise Slaughter, Congresswoman
to obtain oral contraception, a
woman must schedule a visit with
a doctor, receive a physical
examination, and possibly commit to future visits before getting a prescription.
The lengthy, costly, and invasive process to start using birth control pills limits
womens ability to control their reproduction.
This issue brief seeks to recommend Pennsylvania legislatures deregulate
the distribution of oral contraception so it is available without a doctors
prescription. Because of the problems the current system causes and the success
of pharmacist-based prescription, and especially over-the-counter methods, the
push for deregulated sale encompasses a variety of arguments grounded in the
common belief that womens sexual health should be treated as a priority. Birth
control must be available both through pharmacists and over-the-counter to allow
women full control over their sexual health.
 2

Why now?
Birth control pills are up to 99.9% effective at preventing pregnancy, and
Sexually Active
Women & hundreds of millions of women have used the pill since it first entered the market.
Unintended However, there are still alarming statistics about the availability of birth control to
Pregnancy women of reproductive age. There are 61 million women in the United States in
their childbearing years (15-44). About 70 percent of them (43 million) are at risk
of unintended pregnancy; this means that they are sexually active and do not want
to become pregnant. Couples who do not use any form of contraception risk an 85
percent chance of unintended pregnancy in a yearii.
At risk The reasons women may choose to forego contraception vary. Some
(70%)
women object to the use of birth control for religious reasons, for others, it is too
expensive without insurance. Young women may be afraid to get birth control if it
means a discussion with her parents. It may be difficult for impoverished women
to get to a doctors office for a prescription. But for many, the issues plaguing the
current system of birth control distribution are the biggest barriers to taking the
pill.

Why use oral contraception?

Birth control pills, while marketed primarily as pregnancy prevention, also
boast a plethora of additional benefits. These include:
Acne relief
Reduced risk of bone thinning
Reduced risk of developing cysts in the breasts and ovaries
Reduced risk of certain cancers
Less painful menstruation
Besides purely medical benefits, women who have control over their
reproduction are a benefit to society. Research has shown a correlation between
legislation which allows women legal access to birth control pills and their
attainment of postsecondary education, employment, increased earning power,
higher wages, and more enduring marriages. Conversely, unplanned births are
linked to increased conflict and negativity in relationships and incidences of
depression and anxiety. Costs associated with unintended pregnancies are high,
ranging from daycare fees to health care bills; American taxpayers and the
 3

economy as a whole financially benefit from womens access to contraception. In

essence, it is in everyones best interest to offer birth control pills over-the-
counter and through trained pharmacists, thus increasing womens abilities to
acquire and take the pill.

Problems with the Pennsylvania model

Pennsylvania Costs
Model If a woman wants to start taking birth control pills, she must first meet
with a doctor or nurse to undergo a physical exam in order to receive prescription.
Medical offices may require women additionally undergo invasive and costly
Doctor procedures like pelvic and gynecological exams to receive birth control
prescriptions; however, men prescribed Viagra (generic versions of which are
sold over-the-counter) are not subjected to mandatory prostate and testicular
insurance. The cost of seeing a doctor is perhaps the biggest burden for women
trying to get a birth control prescription. In a country where 1 in 3 American
women either live in poverty or live on the brink of it and where two-thirds of
Pharmacist
minimum wage workers are female, it is difficult to finance doctors visits for
birth control prescriptions. Offering both prescription-based programs and over-
the-counter distribution would accommodate a spectrum of incomes, as over-the-
counter distribution tends not to be covered by insurance.
Receive birth Access
control pills There are 5,564 registered hospitals in the United States and 67,500
pharmacies. In Pennsylvania, there are only 177 registered hospitals. Statistically,
the likelihood of a woman living closer to a pharmacy than a hospital is much
more likely than the opposite. Besides the financial burden scheduling and
attending a doctors visit causes, the simple act of getting to a hospital or clinic
can be difficult. Studies have already proven patients are less likely to get to a
hospital and more likely to suffer medical complications if they live farther from a
hospitaliii. Allowing women to bypass a doctor and receive birth control in
pharmacies makes the entire process less complicated, therefore encouraging
Fill widespread use of contraception.
prescription
at pharmacy Besides financial burden, scheduling a doctors appointment becomes
difficult for women who live with disapproving parents or partners. Without
familial support, a privilege too often taken for granted, women face high barriers
 4

to schedule and arrive at a doctors appointment. Young women without health

insurance may be unable to finance the trip out-of-pocket, and those with their
parents insurance worry about the confidentiality of getting a prescription.
Additionally, women in abusive relationships may feel the pressures of
reproductive coercioniv, in which a partner tries to control a womans
reproduction by forcing her to become pregnant against her will. Allowing
women to purchase birth control through pharmacies offers a more discreet and
reliable alternative to infeasible visits to their doctors. With the widespread nature
of abusive relationships--whether familial or spousal-- reaching 60% of women,
easier access to birth control becomes a necessity.
Complications
Womens bodies are medicalized from birth, with natural processes like
menstruation, pregnancy, and menopause the subject of doctors attention and
societal criticism. In a world in which women are asked for the date of their last
period before receiving a physical exam and monitored by their healthcare
providers throughout their lives, complicating birth control prescriptions by
associating them with the medical system provides an unnecessary burden for
women. Over-the-counter and pharmacist-based systems drastically reduce the
number of steps women must take in order to receive birth control pills.

New & noteworthy prescription systems

Truly over-the-counter distribution of birth control is not yet available in

the United States, but legislators in Oregon, California, and most recently,
Maryland, have decided women can receive birth control without seeing a doctor;
these states offer pharmacist-based prescriptions. Internationally, especially in
developing countries, women can receive birth control in a variety of ways--
pharmacy is only one. Increased access to birth control through over-the-counter
methods is supported by interest groups, such as the American Congress of
Obstetricians and Gynecologists, a professional association of physicians
specializing in obstetrics and gynecology in the United States.
 5

Pharmacist-filled prescription in Oregon

Oregon Model
Currently in Oregon and California, women can get a pharmacists
prescription to receive birth control in lieu of a doctor. Both programs took effect
in early 2016. In order to prescribe oral contraception in Oregon, pharmacists
Pharmacist complete a training protocol. Women also answer a 20-question survey about
their health history. The birth control covered through a pharmacists prescription
is still covered under health insurance programs. Oregons program assumes an
age restriction of 18 years for women to receive a pharmacists prescription for
oral contraceptionv.

Receive birth Online prescription in California

control pills In California, women of any age can receive a prescription for birth
control through pharmacists, though problems emerged mid-2016 when too little
pharmacies implemented the systemvi. California Planned Parenthood initiated an
online, app-based prescription program called Planned Parenthood Direct - CA
which allows women up to 12 months of birth control without a doctors
progestin-only pills and select the quantity of pills they need, then proceed to take
a health questionnaire to be approved for the program. Although this program
requires payment, it allows women to order birth control from home--a pharmacy
PP Direct &
Nurx Model accessibility; many women commented that it was easier than scheduling a
doctors appointment.
Other companies began offering app-based distribution, such as Nurx.
Nurx offers a similar service to Planned Parenthood Direct - CA. Patients fill out
App
a questionnaire, which is stored in a HIPAA-compliant system, then forwarded to
doctors for review. Nurx does not publish data on its success, but boasted 70 sign
ups in a day when it first openedvii.
Some medical interest groups, such as the American Medical Association
(AMA), warn against the elimination of a doctor or trained pharmacist, citing that
Receive birth
control pills apps prioritize convenience over safetyviii. Medical screening for health problems
becomes difficult over computers, and researchers worry that women would be
less likely to seek medical care if they can get birth control online. Additionally,
women in poverty unable to afford buying birth control (which can range from
$20 to $50 per month) could not utilize the app system.
International systems
 6

Developing countries have been providing women oral contraception by

offering a number of distributors for women; these distributors largely fall under
the categories of community-based distributors, social marketing programs and
pharmacies. Community-based distributors target women at the village and
household levels and information about side effects, screen for possible
contraindications, and provide access to birth control pills. Social marketing
programs work to subsidize market prices of contraception to make pills more
affordable for local women. Family planning programs additionally pushed
pharmacies to stock oral contraception for women and train pharmacists to teach
women about birth control. Thus, the three-pronged approach focuses on
providing a variety of ways in which to educate women about birth control; with
three main goals:
1. Describe how to use oral contraception correctly
2. Educate women about potential side effects
3. Aid women in remembering to take the pills daily
The developing country model shows that eliminating the need for a
doctors prescription increases womens access to birth controlix.

Objections

Some doctors hesitate to endorse over-the-counter distribution on the basis

of womens health. Although the idea of prescription-based distributions tend to
have bipartisan congressional support, medical groups believe that birth control
prescriptions should remain in the hands of doctors. The AMA publically stated
that a valid relationship needs to be established between the doctor and patient
before women acquire prescriptions, preferably in person or on a phone or video
call. However, in terms of doctors necessity in the context of acquiring birth
control, the medication in question is considered a relatively safe drug.
Complications may arise for women over 35 and smokers, at high risk of blood
clots, extreme diabetes, etc.x. However, women can make an educated choice to
use birth control. Information about the small risks associated with taking the pill
is available widely. Women can buy Advil without a prescription, even though the
pain relief is not recommended for women recovering from heart bypass surgery,
women with asthma, diabetes, etc. While Advil and oral contraception are slightly
 7

different drugs, there is no reason why one is much easier to obtain than the other
considering they have similar health risks.
The proposal is feasible. To offer over-the-counter birth control access and
pharmacy-based prescriptions would not result in an overwhelming increase in
funding; in an over-the-counter system where women pay for their own
medication, insurance companies would gain monetarily. The cost of training
pharmacists is minimal; Oregon developed a web-based, state-developed
curriculum to instruct distributors. Private companies supplying birth control
(Planned Parenthood, Nurx, etc.) reduce costs as well because they do not require
government funding. The project demands little financially, though it reaps
widespread social implications.

Support for prescription-based systems

Easier access to birth

control is not a partisan issue. A The College supports access to
group of Senate Democrats led by comprehensive contraceptive
care
Sen. Patty Murray, a Democrat
from Washington, endorsed a bill
to allow birth control pills to be approved by the FDA without a prescription and
covered through health insurance.
"I believe strongly that women should be able to get the comprehensive
health care they need when they need it, without being charged extra, without
Sen. Murray asking permission and without politicians interfering," Murray said.
Republicans also unveiled a GOP proposal to make birth controls
available without a doctors prescription, according to Senator Cory Gardner, a
Republican from Colorado.
The American College of Obstetricians and Gynecologists promotes easier
access to oral contraception. It publically stated that The American College of
Obstetricians and Gynecologists (the College) supports access to comprehensive
contraceptive care and contraceptive methods as an integral component of
womens health care and is committed to encouraging and upholding policies and
actions that ensure the availability of affordable and accessible contraceptive care
Sen. Gardner
and contraceptive methods, the College said.
 8

"... Pharmacist prescribing laws are not the same thing as over-the-counter
access. Requiring a pharmacist to prescribe and dispense oral contraceptives only
replaces one barrier a physician's prescription with another. This is not
going to allow us to reach women who remained underserved by the current
prescribing requirements, the College said.

Next steps

Pennsylvania legislators must approve birth control for full over-the-

counter sale and pharmacist-based prescriptions. Women and society as a whole
benefit from increased access to birth control. Current methods in Oregon,
California and the developing world show the possible routes for successful
implementation of over-the-counter programs in Pennsylvania. It is not enough
for birth control to be theoretically available if it is not practically accessible.
Over-the-counter sale and pharmacist-based prescription systems allow women
with different incomes, schedules, and lifestyles to receive life-changing
medication.
 9

Endnotes
i
Chin-Quee, Dawn S., et al. Over-the-Counter Pill Provision: Evidence from
Jamaica. Studies in Family Planning, vol. 37, no. 2, 2006, pp. 99110. Web. 03
Apr. 2017.
ii
"Contraceptive Use in the United States." Guttmacher Institute, Sept. 2016.
Web. 15 Apr. 2017.
iii
Buchmueller, Thomas C., et al. "How Far to the Hospital? The Effect of
Hospital Closures on Access to Care." Journal of Health Economics, vol. 25, 28
Oct. 2005. JSTOR. Web. 14 Apr. 2017.
iv
Chamberlain, Linda, and Rebecca Levenson. Addressing Intimate Partner
Violence, Reproductive and Sexual Coercion. Futures Without Violence. The
American College of Obstetricians and Gynecologists. Web. 03 Apr. 2017.
v
Belluck, Pam. "Birth Control without Seeing a Doctor: Oregon Now, More
States Later." The New York Times, 4 Jan. 2016. Web. 15 Apr. 2017
vi
Karlamangla, Soumya. "Women in California Can Legally Get Birth Control
without a Prescription, but for Many, It's a Struggle." The LA Times, 31 Oct.
2016. Web. 15 Apr. 2017.
vii
Kelly, Heather. "Birth Control on Demand -- No Doctor's Office Required."
CNN, 21 Jan. 2016. Web. 15 Apr. 2017.
viii
Editorial Board. "Need a Birth Control Prescription? Theres an App for That."
The Washington Post, 21 Aug. 2016. Accessed 15 Apr. 2017.
ix
Allina, Amy, and Francine M. Coeytaux. Over-the-Counter Distribution of
Oral Contraceptives. Reproductive Health Matters, vol. 2, no. 3, 1994, pp. 34
39. Web. 03 Apr. 2017.
x
How Safe Is the Birth Control Pill? Planned Parenthood. Web. 15 Apr. 2017.