To Decrease Unintended Pregnancies, Decrease Monetary and Nonmonetary Barriers to Hormonal Contraception.

Approximately half of all pregnancies in the United States are unintended, a proportion that has actually increased over the past decade. Most unintended pregnancies occur among women who either use no contraceptive method or inconsistently use a method. Hormonal contraceptive methods (oral contraceptive pills, the patch, the ring, and injectables such as Depo–provera) are both safe in the vast majority of patients and effective, between 91% (with typical use) and 99% (with perfect use). Thus, when women have fewer barriers to using hormonal contraception, they should experience lower rates of unintended pregnancy. Yet, as Grindlay and Grossman show in their article in this month’s journal, many women indicate they have difficulty accessing hormonal contraception in a timely manner. These methods currently require a prescription from a physician or other ancillary provider, such as a nurse practitioner. Although 14% of women in the study cited cost or lack of insurance coverage as an impediment, just as many described nonfinancial difficulties such as finding a physician, making an appointment, getting time off of work or school to attend appointments available only during business hours, and transportation problems. Perhaps not surprisingly, the burden of these obstacles falls most heavily on groups already at higher risk of an unintended pregnancy: younger, lesseducated minority women, many of whom with incomes below 200% of the poverty line or lack health insurance. Native Spanish speakers also reported increased difficulty obtaining a prescription, likely due to language or other cultural barriers encountered when interacting with the medical system. In California and Oregon, recently enacted legislation will soon allow pharmacists to dispense these medications after women fill out a questionnaire regarding their health histories, although Oregon’s law will still require adolescents under age 18 to obtain their first prescription from a physician. The American College of Obstetricians and Gynecologists (ACOG) advocates going even further, allowing for hormonal methods of contraception to be available over the counter, without any intermediaries. Both of these measures would address a common problem with daily or weekly hormonal contraception: resupplying. In the Grindlay and Grossman study, 18% reported difficulty obtaining a refill in a timely manner due to barriers such as getting to a physician’s office for another prescription. For medication that must be taken continuously to have maximum efficacy, even a day or two without a refill can lead to an unintended pregnancy. Evidence indicates that greater accessibility will lead to greater adherence, and thus greater efficiency. Despite the support of professional organizations, individual medical professionals have opposed access to hormonal contraception outside of a formal doctor–patient relationship. Many objections center around using the need for a new prescription as a reason to bring otherwise healthy women to a clinic for an annual visit, which might also include screening for sexually transmitted infections (STIs) and cervical cancer, as well as counseling regarding birth control options. Yet, STI and cervical cancer screening are not medically required to provide hormonal contraception safely, and cervical cancer screening is now recommended at much greater intervals than 1 year for most women. Although screening and preventative counseling are worthy goals, contraception should not be held hostage to a physician’s visit intended for other purposes. Studies also indicate that women who obtained contraception over the counter (in Mexico, for instance) still visited a physician for Pap tests and other preventative health needs at the same frequency as women who used these physicians as their source of contraception. Another barrier frequently cited to obtaining hormonal contraceptive prescriptions is discomfort and embarrassment associated with pelvic examinations. Up to a third of practitioners require a pelvic examination before dispensing hormonal contraception—examinations that are not medically necessary for this purpose. This demand for a pelvic examination may arise, in part, out of practitioners’ fears regarding liability and the responsibilities inherent in the doctor–patient relationship to examine and identify gynecological pathology whenever a patient presents to them for any reason. In this instance, removing a formal physician–patient relationship might actually work to increase access to hormonal contraception, as can provide education regarding what is and is not required to meet the standard of care when prescribing hormonal contraception. Safety concerns have also proved unfounded. Although many objections center around the increased risk of venous thromboembolic events (VTEs) with hormonal medication, as ACOG rightly points out, the risk of VTEs increases even