Of the many barriers to contraceptive care — financial, geographic, linguistic, discriminatory — one issue that involves many of them is the doctor’s office. For those in need of transportation, child care, language services, Medicaid providers, or all of the above, it’s an often unseen struggle. However, three emerging distribution channels in various stages of development aim to simplify the process of obtaining and continuing oral contraception by eliminating the necessity of an in-person clinic visit.
More than 19 million women who are eligible for publicly funded contraception live in contraceptive deserts, according to Power to Decide, a nonprofit organization that advocates for reproductive autonomy. This means they don’t have reasonable access to the full range of birth control methods, with “reasonable access” defined as at least one health center or provider for every 1,000 women who qualify for publicly funded contraception.
Of these 19 million women, roughly 1.2 million live in counties without a clinic that offers the full range of contraceptive methods. But while health care clinics may not be accessible for people living in contraceptive deserts, pharmacies generally are — around 90% of Americans live within 5 miles of a community pharmacy.
Currently, 24 states allow pharmacists to prescribe hormonal birth control, and legislation is pending in 11 more states. This means people can potentially get forms of oral birth control that require a prescription from their pharmacy, eliminating the need for a separate visit to a health care provider. Implementation is slowly growing, as states, pharmacies, and insurance companies work out the logistics.
“Pharmacist prescribing is a solution for some women to access some forms of contraception,” said Tara Mancini, director of public policy at Power to Decide. While pharmacists are limited to offering oral contraception rather than a full range of methods (such as an IUD or an implant), Mancini said, it helps some women — including those without insurance who may not have a primary care provider and those who can’t afford the time or expense of traveling to a clinic that may be hours away.
For people who are barely making ends meet, avoiding the extra cost associated with a trip to the clinic may mean the difference between being able to access contraception and going without. Nearly one-third of oral contraceptive users say they have missed taking their birth control because they were not able to get their next supply in time, according to the 2020 Kaiser Family Foundation (KFF) Women’s Health Survey.
As states move toward the implementation of pharmacist-prescribed birth control, there are resources available to help them navigate complexities around pharmacist prescribing; Manatt Health, a health care consulting company with expertise in advocacy and legal initiatives, recently created a playbook for state leaders that explains laws related to pharmacist prescribing and outlines implementation strategies.
Proportion of oral contraceptive users who say they have missed taking their birth control because they were not able to get their next supply in time.
Mail Order via Telecontraception
In May 2020, about one in four women switched to telehealth appointments with their current providers to have birth control prescriptions refilled, according to a recent Guttmacher survey on early impacts of the pandemic on reproductive health. The growth in telehealth has given birth to its own subset of care delivery for those who do not have a provider relationship or whose provider doesn’t allow for telemedicine: telecontraception.
The Kaiser Family Foundation reports that telecontraception companies have seen client volume more than double during the pandemic. Telecontraception uses either synchronous, online visits with doctors, asynchronous sharing of information via apps, websites, and other online platforms, or a mix of both to determine whether a patient is a candidate for birth control. After reviewing patients’ information, the provider can order the birth control pill, patch, or ring to be mailed to them or sent to their local pharmacy. Cost may be covered through insurance or paid out of pocket; many telecontraception providers also charge an additional membership or consultation fee.
Amy Fan, co-founder of women’s online health platform and mail order birth control provider Twentyeight Health, has seen an increased demand for access to reproductive care online, and not just because of the pandemic. She believes mail order is key to improving access because women in underserved communities often have a harder time getting contraceptive care from clinics; this is especially true for people on Medicaid.
“One of three doctors in the United States does not accept new Medicaid patients,” Fan said. “That means for them to even find a doctor in the first place can be incredibly challenging.” Telecontraception makes it that much easier for people to access a clinician — and a birth control prescription.
Twentyeight Health is one of the few telecontraception providers that accepts Medicaid. Because of varying statewide requirements, many mail order birth control providers can’t or won’t accept Medicaid and other insurance. Nationally, Medicaid accounts for about 75% of all public family planning spending for services like birth control, and a disproportionate number of women covered by Medicaid are women of color.
Even with limited ability to serve Medicaid patients, telecontraception has bridged a gap in accessibility for many people. “About two-thirds of our users did not have access to prescription birth control prior to using Twentyeight,” Fan said. “So what that is telling us is that there is a really big advance in terms of access that telemedicine [or telecontraception] is providing.”
The Campaign for Over-the-Counter Birth Control
Organizations such as the American Medical Association, the American Academy of Pediatrics, and dozens of medical groups have come out in favor of over-the-counter (OTC) oral contraception, urging the FDA to finally grant approval to the two pharmaceutical companies seeking to bring two common formulations of the pill over the counter.
The American College of Obstetricians and Gynecologists (ACOG) also issued a committee opinion — a strong statement based on a review of published data — supporting unrestricted OTC access to oral contraception, pointing to ample research demonstrating its safety. Oral contraception is an over-the-counter product in more than 100 countries across the globe. The issue has also received strong bipartisan political support.
Number of countries across the world where oral contraception is available over the counter without a prescription
But the Food and Drug Administration (FDA), which is responsible for granting OTC status for birth control pills, is moving slowly on this issue — they’ve been involved in the pre-approval process for nearly five years, meaning the two companies seeking OTC status haven’t yet been able to file a formal application for approval. Without clearance from the FDA, neither company can move forward in the process.
There are many reasons why people are pushing so hard for birth control to be available without a prescription. National-state partnership In Our Own Voice: National Black Women’s Reproductive Justice Agenda recently conducted focus groups with Black women to gauge support for OTC birth control. According to Founder and President Marcela Howell, those surveyed felt strongly that being able to access birth control over the counter would remove many of the barriers to access they currently face. The women expressed an overall belief that OTC birth control was a step in the right direction in terms of giving women more autonomy, Howell said.
Related: Learn more about a coalition of organizations working together to advocate for OTC birth control.
Young people are also working on bringing birth control over the counter without age restrictions. Advocates for Youth, an organization that promotes effective adolescent reproductive and sexual health programs and policies, has formed a #FreeThePill Youth Council to uplift youth voices and perspectives around the challenges they face accessing contraception.
“Birth control is not controversial,” Mancini said. “It’s basic health care. Making it widely available so that people can decide for themselves if and when and under what circumstances to have a child is common sense.”