Let the Pill Go Free

Last month, the 50th anniversary of the Food and Drug Administration’s approval of the birth control pill was marked by a lot of discussion about the ways in which the pill has failed to deliver on its promises. It did not solve women’s problems juggling work and family life — nor did it end gender discrimination or eliminate unintended pregnancies. Clearly, approving the use of the pill was only the beginning of the effort to meet women’s contraception needs.

The pill remains part of the solution, but its usefulness has been limited because it’s available only by prescription. As every woman who has run out of pills on a Sunday or forgotten to take them along on vacation knows, refills are not always easy to come by.
What’s more, the difficulties involved in obtaining a pill prescription, especially for women without access to a doctor, can cause gaps in contraceptive use. And the birth control methods that are available without prescription — condoms, spermicide and the sponge — have higher failure rates than the pill.

But there is something we could do to help the pill live up to its potential: let women purchase it over the counter. A half-century of evidence shows us that it’s safe to dispense the pill without a prescription.

The pill meets F.D.A. criteria for over-the-counter medications. Women don’t need a doctor to tell them whether they need the pill — they know when they are sexually active and want to avoid pregnancy. Pill instructions are easy to follow: Take one each day. There’s no chance of becoming addicted. Taking too many will make you nauseated, but won’t endanger your life, in contrast to some over-the-counter drugs, like analgesics. (There are even side benefits to taking the pill, like reduced risks of ovarian and uterine cancer.)

It’s true that the pill could be dangerous for women with certain conditions. Women who are 35 or older and smoke, and those with high blood pressure, are at greater risk of a heart attack or stroke if they take oral contraceptives that combine estrogen and progestin. But these are not complicated conditions to identify; women already have to tell their doctor about their health problems when they get a prescription, and research shows that women can screen themselves for contraindications almost as well as providers do.

Progestin-only pills, or minipills, might be an ideal option for an initial over-the-counter switch since they have fewer (and rarer) contraindications and potential complications. Along with the change, the pharmaceutical company, nonprofits and the government should collaborate on an educational campaign, including pamphlets packaged with the pills and public service announcements that would give women information about how to use the pill, deal with side effects, recognize serious complications and of course remind them to get regular checkups for preventative care like Pap smears.

The United States has one of the highest teenage pregnancy rates in the developed world, and better access to the pill is part of the solution to this problem. During the debate leading up to F.D.A. approval of the emergency contraception pill called Plan B for over-the-counter sale, some people expressed concern about expanding access to contraception for young women without doctors’ oversight, and they might say the same about the birth control pill. But there are no special health risks for younger women on the pill, and sexually active women, whatever their age, should have freer access to the full range of options to prevent pregnancy.

We also need to address the problem of pricing. Plan B became more expensive when it went over the counter. If that happened to the pill, it could be unaffordable for many women on Medicaid whose prescriptions are now covered. In some states Medicaid already covers over-the-counter contraception like condoms; Medicaid coverage in all states should be extended to all over-the-counter methods, including the pill.

Women don’t need a doctor to tell them if they need cold medicine or condoms, and they shouldn’t need a doctor’s permission to take the pill. Over-the-counter sales would expand access to safe, effective contraception, and help women take control over their sexual and reproductive lives.

Source: Kelly Blanchard, New York Times, 21 June 2010