Published 23 December 2008, doi:10.1136/bmj.a3044
Cite this as: BMJ 2008;337:a3044

Head to Head

Should the contraceptive pill be available without prescription? Yes

¹ Ibis Reproductive Health, San Francisco, California, USA, ² Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco

Two areas in London are piloting over the counter oral contraceptives. Daniel Grossman argues that the policy should be widely adopted but Sarah Jarvis (doi:10.1136/bmj.a3056) believes it is the wrong approach to reducing unplanned pregnancy

Oral contraceptives are the most widely used hormonal method of contraception globally and the most commonly used reversible method in less developed countries other than China.¹ The pill is highly effective and with perfect use has a failure rate of 0.3% in the first year.² But in practice failure is much higher—closer to 8% or 9%.³ In most countries, women must have a doctor’s prescription to obtain oral contraceptives, although many developing countries do not enforce this and pills are effectively available over the counter.

Data from the United States suggest that, for at least some women, the prescription requirement represents a barrier to both initiation and continuation of hormonal contraceptives. A US national survey of women in 2004 reported that 41% of women not currently using contraception said they would start using the pill, patch, or vaginal ring if it were available directly in a pharmacy.⁴ Another study found that travel away from home and running out of pill packs were frequent reasons women missed pills,⁵ a common cause of contraceptive failure. Participants in a Scottish study of attitudes to contraception also commented that getting an appointment with a general practitioner can be hard.⁶

Safety

Is it safe for women to access oral contraceptives without a prescription? Over 50 years of experience have shown oral contraceptives to be very safe. In every age group, the risk of cardiovascular death among healthy non-smokers who take the pill is lower than the same risk for women carrying a pregnancy to term.⁷

However, the question remains whether women need to visit a clinician to determine whether oral contraception is appropriate for them. Ideally, doctors or nurses screen women for contraindications to the pill using evidence based criteria, such as those of the World Health Organization.⁸ But in practice this screening does not always take place.⁹

Research from Mexico, where the pill is widely available without a prescription, found that women obtaining the pill without visiting a clinician were no more likely to have contraindications to its use than women who saw a doctor.^{10 11} Two US studies found that women were able to identify if they had contraindications to oral contraceptives using a checklist,^{12 13} although older women were more likely to have unrecognised hypertension.¹³ These data are not surprising, given that, other than hypertension, all of the contraindications are based on history and require little clinical judgment.

Another concern about making oral contraceptives available without a prescription is women will not use them correctly. Again, few data suggest that clinician counselling is useful,¹⁴ and even when a clinic visit is required, compliance is not perfect.¹⁵ Oral contraceptives are available over the counter in Kuwait, and a study there found that compliance and continuation were no different between women who consulted a doctor and those who did not.¹⁶ A recent analysis of data from California found that women given 13 pill packs when they first started continued the method significantly longer and experienced fewer gaps in use than women given only one or three packs,¹⁷ suggesting that freer access improves continuation. Pharmacist provision of hormonal contraception was recently shown to be feasible and acceptable to women in Washington state. ¹⁸

Access to care

Would women miss out on other preventive services, such as cervical smear tests or screening for sexually transmitted infections, if they were not required to visit a clinician? Neither of these screening tests is medically required before prescribing oral contraceptives, and there has been a growing movement to unbundle these services in the US.¹⁹ The national survey mentioned above found that among women not currently using contraception, 88% had had a smear test in the previous 24 months.⁴ In fact, given the recent definitive evidence that oral contraceptive use reduces the risk of ovarian cancer,²⁰ it has been argued that the prescription requirement unnecessarily limits access to this effective chemoprophylactic agent.²¹

Although there are concerns in the US about the costs to women of obtaining oral contraceptives over the counter,²² in some states there is a precedent for maintaining government funding for over the counter emergency contraception for women on low incomes.²³

Making oral contraceptives available without a prescription would not eliminate the option of clinician consultation. Indeed, research in Mexico indicates that women move between provision sources, and more than half of women who obtain their pills from a pharmacy began use under a physician’s care.¹¹ Women who value a clinician’s input or have questions about their risk profile would still be able to consult with a physician or nurse—but they would not be required to. The prescription requirement is an out of date, paternalistic barrier to contraceptive use that is not evidence based. If governments are committed to addressing the challenge of unintended pregnancy—and the related problem of maternal mortality in the developing world, health systems must create mechanisms to allow freer access to hormonal contraception for all women at low or no cost.

Cite this as: BMJ 2008;337:a3044

---

Competing interests: None declared

References

1. Population Reference Bureau. Family planning worldwide: 2008 data sheet. www.prb.org/pdf08/fpds08.pdf.
2. Trussell J. Contraceptive failure in the United States. Contraception 2004;70:89-96.[CrossRef][Web of Science][Medline]
3. Kost K, Singh S, Vaughan B, Trussell J, Bankole A. Estimates of contraceptive failure from the 2002 national survey of family growth. Contraception 2008;77:10-21.[CrossRef][Web of Science][Medline]
4. Landau SC, Tapias MP, McGhee BT. Birth control within reach: a national survey on women’s attitudes toward and interest in pharmacy access to hormonal contraception. Contraception 2006;74:463-70.[CrossRef][Web of Science][Medline]
5. Smith JD, Oakley D. Why do women miss oral contraceptive pills? An analysis of women’s self-described reasons for missed pills. J Midwifery Womens Health 2005;50:380-5.[CrossRef][Web of Science][Medline]
6. Glasier A, Scorer J, Bigrigg A. Attitudes of women in Scotland to contraception: a qualitative study to explore the acceptability of long-acting methods. J Fam Plann Reprod Health Care 2008;34:213-7.[CrossRef][Web of Science][Medline]
7. Schwingl PJ, Ory HW, Visness CM. Estimates of the risk of cardiovascular death attributable to low-dose oral contraceptives in the United States. Am J Obstet Gynecol 1999;180:241-9.[CrossRef][Web of Science][Medline]
8. World Health Organization. Medical eligibility criteria for contraceptive use. 3rd ed. Geneva: WHO, 2004.
9. Tatum C, Garcia SG, Goldman L, Becker D. Valuable safeguard or unnecessary burden? Characterization of physician consultations for oral contraceptive use in Mexico City. Contraception 2005;71:208-13.[CrossRef][Web of Science][Medline]
10. Zavala AS, Perez-Gonzales M, Miller P, Welsh M, Wilkens LR, Potts M. Reproductive risks in a community-based distribution program of oral contraceptives, Matamoros, Mexico. Stud Fam Plann 1987;18:284-90.[CrossRef][Web of Science][Medline]
11. Yeatman SE, Potter JE, Grossman DA. Over-the-counter access, changing WHO guidelines, and contraindicated oral contraceptive use in Mexico. Stud Fam Plann 2006;37:197-204.[CrossRef][Web of Science][Medline]
12. Shotorbani S, Miller L, Blough DK, Gardner J. Agreement between women’s and providers’ assessment of hormonal contraceptive risk factors. Contraception 2006;73:501-6.[CrossRef][Web of Science][Medline]
13. Grossman D, Fernandez L, Hopkins K, Amastae J, Garcia SG, Potter JE. Accuracy of self-screening for contraindications to combined oral contraceptive use. Obstet Gynecol 2008;112(3):572-8.[CrossRef][Web of Science][Medline]
14. Moos MK, Bartholomew NE, Lohr KN. Counseling in the clinical setting to prevent unintended pregnancy: an evidence-based research agenda. Contraception 2003;67:115-32.[CrossRef][Web of Science][Medline]
15. Grossman D, Ellertson C, Abuabara K, Blanchard K. Barriers to contraceptive use present in product labeling and practice guidelines. Am J Public Health 2006;96:791-9.[Abstract/Free Full Text]
16. Shah MA, Shah NM, Al-Rahmani E, Behbehani J, Radovanovic Z. Over-the-counter use of oral contraceptives in Kuwait. Int J Gynaecol Obstet 2001;73:243-51.[CrossRef][Medline]
17. Foster DG, Parvataneni R, de Bocanegra HT, Lewis C, Bradsberry M, Darney P. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol 2006;108:1107-14.[CrossRef][Web of Science][Medline]
18. Gardner JS, Miller L, Downing DF, Le S, Blough D, Shotorbani S. Pharmacist prescribing of hormonal contraceptives: results of the direct access study. J Am Pharm Assoc 2008;48:212-21.[CrossRef][Web of Science]
19. Stewart FH, Harper CC, Ellertson CE, Grimes DA, Sawaya GF, Trussell J. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence. JAMA 2001;285:2232-9.[Abstract/Free Full Text]
20. Collaborative Group on Epidemiological Studies of Ovarian Cancer, Beral V, Doll R, Hermon C, Peto R, Reeves G. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23 257 women with ovarian cancer and 87 303 controls. Lancet 2008;371:303-14.[CrossRef][Web of Science][Medline]
21. The case for preventing ovarian cancer [editorial]. Lancet 2008;371:275.[CrossRef][Web of Science][Medline]
22. Gianfrancesco F, Manning B, Wang R. Effects of prescription to OTC switches on out-of-pocket health care costs and utilization. Drug Benefit Trends 2002;14:13-30, 44.
23. National Institute for Reproductive Health. Expanding Medicaid coverage for EC on the state level. www.nirhealth.org/sections/ourprograms/documents/ECMedicaidMemoFormatted.pdf.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Article

Should the contraceptive pill be available without prescription? No

Sarah Jarvis
BMJ 2008 337: a3056. [Extract] [Full Text]

Rapid Responses:

Read all Rapid Responses

Numerous health problems caused by taking oral contraceptives

Ellen C G Grant, et al.
bmj.com, 29 Dec 2008 [Full text]

Medicalization of Hormonal Contraception Keeps Women at Risk

Suzanne L. Newsome, et al.
bmj.com, 29 Jan 2009 [Full text]

Head to Head or Head to Toe

Seshu B Gosala
bmj.com, 30 Jan 2009 [Full text]

Online poll

Find out more on doc2doc >>