Unfettered Access to Reliable Contraception: Pharmacist Prescription Derails a Definitive Solution

More than 5 decades of physician-monitored use of oral hormonal contraceptives have demonstrated their safety and efficacy for most women. Oral contraceptives provide women with the ability to choose if and when they become pregnant, postpone pregnancy while they optimize health behaviors, and have less painful or more predictable menstrual cycles. Of note, they also enable women to have more control over their lives by timing pregnancy around education, careers, and other life situations. It is no surprise that almost every woman in the United States will use some form of contraceptive in her life. Nearly 90% of women will use a highly effective, reversible method of contraception, such as oral contraceptives, injected contraceptives, cervical rings, contraceptive implants, or intrauterine devices (1). Physicians know that no diagnosis is required to prescribe oral contraceptives. We do screen for easily recognizable risk factors, such as smoking. We also know that the risk for complications associated with oral contraceptives is lower than that of many over-the-counter medications, such as acetaminophen (2). We must ask ourselves whether we, as prescribers, actually prevent some women from receiving the contraceptive care that they want and need. The American Congress of Obstetricians and Gynecologists (ACOG) has asked this question, recognizing the safety of oral contraceptives and endorsing over-the-counter distribution. The ACOG also supports legislative efforts to allow women to purchase over-the-counter oral contraceptives without a prescription (3, 4). The ACOG firmly believes that we need to ensure that our efforts are effective, especially for women who have difficulty accessing contraceptives if a clinical encounter is required. Compromises are band-aids that only delay the implementation of solutions that provide unfettered access to these safe and life-altering medications. Cost has also historically been a barrier to patient access to contraceptive care. In the case of oral contraceptives, expense is not only associated with the monthly refill but also with the physician's visit for the prescription itself. Fortunately, under the Patient Protection and Affordable Care Act (ACA), contraceptive methods that are approved by the U.S. Food and Drug Administration are considered preventive care for women, so health insurers must cover at least 1 option from each of the 18 categories without a copay (5). Unfortunately, health insurers have been widely inconsistent in providing this coverage, with barriers and exemptions that lead to confusion and frustration among both women and their physicians. However, we continue to make slow progress in ensuring that every woman in the United States who needs and wants reliable contraception can easily obtain it. As physicians, we see the various situations that women in need of birth control live with each day. Even though the ACA has increased the number of persons with health insurance, 9% still lack insurance and many insured persons lack adequate contraceptive coverage (6). Some women with an imminent need for contraception have to wait weeks for an appointment. Other women need privacy that insurance coverage may not afford them, especially in cases that involve reproductive coercion or abuse. Making oral contraceptives available without a prescription would ensure that women have reproductive autonomy and privacy without the financial and time costs associated with a physician's visit. Hormonal birth control is most effective when it is used regularly. A direct line between the patient and her oral contraceptive would certainly facilitate adherence. Over-the-counter access to oral contraceptives should not eradicate the value of preventive care visits or reduce patients' interest in receiving this care. In fact, the ACA helps emphasize the value of preventive care by ensuring that screening for cancer and sexually transmitted infections, as well as other preventive services, are covered. Two states, Oregon and California, now allow pharmacists to prescribe and dispense oral hormonal birth control, which some see as a step toward improved access. However, a prescription is still required. For that reason, a pharmacist prescription simply exchanges one barrier for another; this is not over the counter. Requiring a pharmacist to provide the prescription reduces the accessibility of contraceptives to women, who would still need to arrange a consultation during pharmacy hours. In addition, any potential cost associated with a consultation would add to out-of-pocket expenses and could be prohibitive for many women. If we can agree that we trust women to control their reproductive futures, we must let them do so without qualifiers or gatekeepers. Prescriptions for birth control, whether from a physician or a pharmacist, are not necessary to ensure safety. Of note, thromboembolism, the most common serious risk associated with oral contraceptives, is not only exceedingly low but is also much lower than the risk for thromboembolism during pregnancy and the postpartum period (7). Consequently, helping women better prevent unwanted pregnancy will lower their overall thromboembolism risk. In studies, women have been shown to accurately self-screen their own contraindications for oral contraceptives, agreeing with their health providers' assessments nearly all of the time (8). Women can make these decisions. If oral hormonal birth control is known to be safe and women have demonstrated their ability to make the reproductive decisions that are appropriate to their own health backgrounds, what role will pharmacists serve? The approaches in California and Oregon have been described by some as a step in the right direction. However, a compromise too often ends a better conversation and derails a real solution. Women deserve more than a stopgap. Although we will continue to write prescriptions for women who prefer to access oral contraceptives without a copay, we must also support their ability to obtain birth control over the counter. If our shared goal is increasing access to safe, effective contraceptives, we need a comprehensive approach that truly embraces women's reproductive autonomy. Over-the-counter oral contraceptives are not a solution for every woman. However, they will help women receive the care they need if they are uninsured or underinsured or if the need to visit a health care provider prevents them from accessing contraception.