See original article in Scientific American
Here’s how to make newly approved over-the-counter birth control pills affordable and easy to get.
At a time of unrelenting attacks on reproductive autonomy, the Food and Drug Administration’s decision on July 13 to approve a birth control pill for over-the-counter (OTC) use is an important advance toward providing people with tools to control their fertility. This includes preventing unwanted pregnancy. Having Opill, a safe, effective, easy-to-use birth control option available without a prescription is essential, because it so difficult for many people to get prescription birth control in the U.S.
As researchers and clinicians specializing in reproductive health care, we applaud the FDA for following the science and joining the more than 100 other countries, including Mexico and nations in most of South America, most of Central Asia and parts of Africa, that already allow people to buy birth control pills without a prescription. But how much the FDA decision will affect people’s ability to manage their reproductive lives in the U.S. will depend on what we and Opill’s maker, Perrigo, do to get these progestin-only pills into people’s hands when they are finally available, sometime in early 2024.
Our current health care system and the widespread stigma around sex create many barriersfor people who want to avoid pregnancy. For some, the challenges in getting an appointmentwith a health care provider include the cost of a visit, a lack of insurance or an inability totake time off work. Being unable to see a clinician confidentially is another issue, particularlyfor minors or people in abusive or controlling relationships. The cost of a prescription cancreate another financial barrier. These barriers are even greater for those who facediscrimination and judgment because of their racial or ethnic identity, sexuality, genderidentity, disability, age, socioeconomic status or immigration status.
For example, youth report facing difficulties with scheduling appointments, a lack oftransportation and stigma from parents and health care providers. In a national survey ofyoung people, more than half reported that one or more of those barriers prevented themfrom getting birth control at all. Black and Latine people and those with low Englishproficiency also report being less likely to receive quality contraceptive counseling thatfocuses on their values and preferences. Black people specifically experience racism whenreceiving contraceptive care, including being pressured to use contraceptives. More than 50percent of Black people in one study reported having had discriminatory experiences thatreflected racialized stereotypes, such as being assumed to have multiple sexual partners.Transgender or nonbinary people who can become pregnant face discrimination and stigmaand sometimes have health care providers who lack training in providing gender-inclusivecare.
Having an over-the-counter birth control pill available removes many of these barriers forthose wishing to prevent pregnancy. The approval of the OTC Opill is therefore a bright spotin an otherwise bleak landscape for reproductive autonomy in the U.S. It is not enough tomerely have this medication approved, however, given the myriad barriers people faceaccessing and using any medication, including OTC medications. Government officials,health care systems and providers and advocates must make it easier to get Opill and anysubsequent over-the-counter birth control options by making these medications affordable, easily available, simple to use and able to be dispensed without stigma or gatekeeping. Thisway we can ensure that all people in the U.S. who wish to can use this pregnancy preventionoption.
Opill is a little different from other hormonal birth control pills, which typically combineprogestin and a form of estrogen. While combined pills stop ovulation, leaving nothing forsperm to fertilize, progestin-only pills primarily work by thickening the cervical mucus, creating a barrier to prevent sperm from entering the uterus or fallopian tube to fertilize anegg. Progestin-only pills are very effective at preventing pregnancy and are associated withfewer health risks than combined pills, particularly with regard to blood clots. Some peopletaking these pills may have more irregular bleeding than with combined hormonal pills, butside effects such as breast tenderness and nausea are less common.
Progestin-only pills are not new. Clinicians already prescribe them for people who haveunderlying health conditions that affect their ability to tolerate an estrogen-containing pilland for people who have recently had a baby. Making the pills over the counter won’t increasethe risk of someone with contraindications taking them. People can accurately identify therare circumstances when they should not use the progestin-only pill using a simple checklist.And when it comes to people’s record of taking birth control pills consistently, OTC pill takersare just as consistent, if not more so, than people using prescription pills. These data show usthat people of all ages are able to assess the risks and adhere to directions for taking birthcontrol pills without the additional need for a health care provider to screen or counsel, justas they do when buying pain or allergy medications over the counter.
Intentional efforts to ensure this method is available to all who wish to use it must includethese requirements:
The FDA and Perrigo must ensure information about correctly using the pill iswidely available, including what the potential is for side effects and how to managethem. This information needs to be understandable and in multiple languages.
The FDA and pharmacists must make the pills available on shelves rather thanbehind the pharmacy counter. Pharmacies must additionally set up home deliveryoptions to reduce marginalized peoples’ exposure to stigma and negative healthcare experiences.
Perrigo must make this pill affordable. State and federal legislators need tomandate that private and state-based insurance plans cover this medication, asthey do for other OTC medications, because over-the-counter medications can bemore expensive for consumers than prescription drugs.
The FDA must ensure that pharmacies and pharmacy employees do not createadditional barriers to accessing these drugs through inaccurate information orshaming, as has happened with over-the-counter emergency contraception.
The FDA, pharmacies, parents and society at large need to trust that young people,including adolescents, can make decisions about their health and ensure theiraccess to the pill by not limiting availability via age restriction or ID requirement.
As we celebrate this win for reproductive autonomy, we must not lose sight of the broaderfight. Everyone should have the ability to access the health care and medications they need tomanage their reproductive health as they choose. Expanding access to birth control pills is agreat step, but it is not enough. We must continue to work toward expansion of low-barrieressential health care access, including comprehensive sex education, access to the widebreadth of available prescription contraceptives and abortion care. As we watch the courtsbattle over mifepristone, an abortion medication known to be safe and effective, we hope thatthe FDA’s decision to approve Opill serves as a precedent and an inspiration to follow thescientific evidence in all aspects of reproductive health.
This is an opinion and analysis article, and the views expressed by the author or authorsare not necessarily those of Scientific American.
ABOUT THE AUTHOR(S)
Mai Fleming (she/her) is an Assistant Clinical Professor of Family and Community Medicine at the University ofCalifornia, San Francisco and a Fellow with Physicians for Reproductive Health. Her clinical and advocacy work focuseson community liberation and autonomy through the intersecting lenses of reproductive, racial, and gender justice. April J. Bell is an Assistant Professor of Family and Community Medicine, social epidemiologist, and researcher at theUniversity of California, San Francisco. She is the director of the Girlx Lab, which conducts innovative research inpartnership with Black girls to improve their sexual and reproductive health. Christine Dehlendorf is a family physician and reproductive health researcher at the University of California, SanFrancisco. She directs the Person-Centered Reproductive Health Program, which aims to advance reproductiveautonomy and well-being by conducting research and designing programs that center people's experiences andpreferences for sexual and reproductive health and health care, guided by an attention to the intersecting oppressionsand structural injustices that impact people's lives and health.