It is estimated that approximately half (45%) of pregnancies are unplanned and of those, about 27% of women wished the pregnancy had occurred at a later time and 18% were unwanted (Guttmacher Institute, 2019). The American College of Obstetricians and Gynecologists (ACOG), the American Medical Association, and others have endorsed removing the United States Food and Drug Administration restriction on hormonal contraception methods (oral contraceptive pills, vaginally inserted rings, the patch, and depot medroxyprogesterone acetate [DMPA] injections) requiring a prescription and allowing over-the-counter (OTC) access (ACOG, 2019).

Several studies have demonstrated safety of providing OTC access to hormonal contraceptive methods and that doing so can increase continuation rates when the requirement of needing a prescription is removed (ACOG, 2019). Often women who try to use hormonal contraception encounter barriers, including lack of insurance and difficulty in getting an appointment or accessing a clinic (ACOG). Of women who try hormonal contraception, about a third will stop by the end of the first year due to side effects or difficulty maintaining regular administration. Others cite inability to continue due to time or cost in accessing a provider visit to get a new prescription (ACOG). There is no requirement for screening for sexually transmitted infections or cervical cancer or for breast and pelvic examinations before starting hormonal contraception methods and the lack of obtaining these should not be used to deny women access to their chosen contraception method (ACOG).

Concerns about widening access include a possible cost increase for women with insurance that had been paying for the prescription and risk of venous thromboembolism (VTE). A potential insurance solution could be to have a cost-offset paid by insurers to improve overall access (ACOG, 2019). For VTE or other potential comorbidity factors, there are self-screening tools that women can use to select the most appropriate hormonal contraception. Studies and real-world application have demonstrated safety in using this method (ACOG). There are many OTC medications that can be unsafe for certain individuals (such as acetaminophen with liver failure or ibuprofen with renal failure) that are deemed safe for patients to have unrestricted access to and allow them to monitor if it is safe for their use. It is important to remember that VTE risk with pregnancy is far higher than the risk with combined oral contraceptive use (ACOG). For DMPA to be accessed OTC, women would need to self-inject but this concern is unwarranted when looking at women who self-inject medications for diabetes, infertility, and anticoagulation. Studies have demonstrated that allowing for self-injection of DMPA actually may increase continuous use (ACOG).

Unintended rates of pregnancy are highest among women with low income (less than 200% of the poverty level) with the highest rates among women with incomes 100% less than the federal poverty level, women of color, and younger women (18-24) (Guttmacher Institute, 2019). This may correlate with women who have difficulty accessing healthcare and health insurance. Adolescents may have the added fear of disclosing to parents that they are sexually active and so will avoid accessing hormonal contraception for fear that parents will find out (ACOG, 2019). Denying OTC access to hormonal contraception does not mean that a patient will access a provider or get routine screening to allow them a prescription, rather it may mean that they do not have access to hormonal contraception as an option. By removing the barrier requirement of an in-person provider visit to get a prescription, which is often necessary annually, access to contraception can be improved allowing more women the ability to safely prevent an unintended or unwanted pregnancy. Using a model where a pharmacist dispenses contraception may be a reasonable intermediate step to widening access on the path to removing restrictions for full OTC status (ACOG). For additional information about making hormonal contraception more accessible as an OTC medication, visit http://freethepill.org.

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