Birth Control Without Rx: Will Women Get the Care They Need?

A new law went into effect in California on April 1 that enables women to receive a birth control prescription from a pharmacist. A similar law has been in effect in Oregon since the beginning of the year, but there is a significant difference between the two states’ laws. According to an article by The Pew Charitable Trusts, “The California law is more expansive than Oregon’s. It allows pharmacists to prescribe a vaginal ring and hormonal birth control shots in addition to pills and patches that release hormones through the skin.” The authors also state that access would be improved given that “93 percent of Americans live within five miles of a pharmacy.” While I applaud the increased access that will most likely decrease the unintended pregnancy rate, which hovers around 50%, I also have some concerns.

My biggest concern with the California law is that new and follow-up patient visits regarding birth control methods are a great opportunity for health care providers to screen for relationship abuse, converse about issues around sex and pleasure, and screen for sexually transmitted infections. If patients are seeing a pharmacist instead, these elements of care either won’t be done because pharmacists do not have the capability, or they won’t be done well.

I am also concerned that one visit to the pharmacist is not enough to reinforce teaching of how to use patients’ chosen birth control method and what to do if they mess up. For pills, patches, and rings, I see my patients back in 6 weeks for follow-up, and at that time I check on side effects and review with them when to refill and what to do if pills are missed or a patch or ring is not placed on time. I also discuss how to get refills and why prescriptions are only good for a year, as that is time to follow-up.

For Depo-Provera shots, will the pharmacists only start administration if patients are in their first 5 days of menses, or will they do quick starts and see them in 2 weeks for a pregnancy test? For their follow-up Depo-Provera, will they only give patients their shots between weeks 11–13 after the first shot, or will they be able to utilize the off-label schedule of up to 17 weeks later?

Another concern is that some women, despite the Affordable Care Act, still don’t have insurance for primary care and should also receive primary-care screenings. Given how busy pharmacists are, judging from how long it takes my patients to get a prescription filled after I send it (1–2 hours, depending on the pharmacy), I am not sure how pharmacists are going to make time for the cursory screenings they are supposed to do.

Based on my web research, the pill is available without a prescription in most parts of the world. This is where I think advocates and pharmaceutical companies have their sights set. In California, this was the path to Plan B (the morning-after pill) becoming an over-the-counter (OTC) medication. The problem with OTC medications is that you cannot pay for them with your insurance, and some of them are expensive, which still limits access. When Plan B was still on patent, it was about $50 over the counter. Now, if a woman plans ahead and buys emergency contraception from Amazon, she can find it for as low as $25.

I think we could best decrease the unintended pregnancy rate through improved access if the pill, the patch, the ring, and emergency contraceptives were OTC and insurance covered their cost.