Should women have over-the-counter access to oral contraceptive pills?

Abstract

After more than a decade, the battle surrounding over-the-counter (OTC) access to emergency contraception (EC) in the USA has finally been won. Science trumped politics in the end, and women are now able to obtain OTC EC on the shelf, and not just in a pharmacy, but in other retail stores as well. Building on this victory, reproductive health advocates in the USA are now beginning to set their sights on the next advance in contraceptive access: OTC oral contraceptive pills (OCPs). OTC access to OCPs might sound revolutionary in the USA or Western Europe, but it is the reality for most women in the world. A recent analysis of prescription requirements for OCPs in 147 countries found that women can easily obtain pills in pharmacies without a prescription in most of these countries [1]. In only 31% of countries, a prescription is required to obtain OCPs. In 24% of countries, pills are formally available OTC, while some countries (8%) require a woman to undergo health screening by a pharmacy worker before pills are provided without a prescription. In 38% of countries, OCPs are technically in a class of drug that should require a prescription, but they are generally available informally in pharmacies without a prescription. A growing body of evidence from some of these other countries, as well as experimental research from the USA, indicate that OTC access to OCPs is both safe and effective. The main safety question is whether women can accurately identify contraindications to use without the assistance of a clinician. In two studies in the USA, women were able to accurately identify contraindications to combined OCPs using a simple checklist, although in one study, 7% of women had unrecognized hypertension that was not identified until they saw a clinician [2,3]. Women were much more accurate at identifying contraindications to progestinonly OCPs, a formulation that has fewer and rarer contraindications compared to combined OCPs [4]. OTC access to OCPs also may help women with method continuation by making it easier to get more supply. In a study from El Paso, Texas, women who obtained OCPs in Mexican pharmacies OTC were significantly less likely to discontinue their method over 9 months compared to women who obtained OCPs by prescription in clinics [5]. In another study from Kuwait, where OCPs are available without a prescription, OTC users had similar method continuation compared to women who used OCPs under the supervision of a physician [6]. Importantly, US women are interested in OTC access to OCPs. A recent nationally representative survey found that 37% of women at risk of unintended pregnancy said they would be likely to use an OTC OCP if one were available [7]. Interest was highest among current OCP users, of which 59% said they were likely to use an OTC pill. In addition, 28% of women using no method and 33% of those using a less effective method, such as condoms