Monday, December 17, 2012

The Pill Over the Counter?

The ability of women to access the contraceptive pill is mediated through the health care profession: in particular, the pill is a prescription drug. Almost two decades ago in August 1993, a doctor named David Grimes wrote in the American Journal of Public Health (footnotes omitted): "On public health grounds, oral contraceptives could be made available in vending machines and cigarettes by prescription only. ... Our society's approach to these two agents, both widely used by young women, is paradoxical. Cigarettes, which are readily available even to children, kill over a thousand persons each day. In contrast, oral contraceptives prevent unwanted pregnancy and improve women's health. Nevertheless, the medical profession poses numerous obstacles to this method of contraception, including a physical examination, a prescription, often a pharmacist, and an impenetrable package insert. ... [T]hese medical requirements neither serve nor protect women; they are merely impediments."

Some important voices in the health care profession seem to be coming around to this point of view. The Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists has now published its opinion concerning "Over-the-Counter Access to Oral Contraceptives." The committee begins:

"Unintended pregnancy remains a major public health problem in the United States. Over the past 20 years, the overall rate of unintended pregnancy has not changed and remains unacceptably high, accounting for approximately 50% of all pregnancies. The economic burden of unintended pregnancy has been recently estimated to cost taxpayers $11.1 billion dollars each year. According to the Institute of Medicine, women with unintended pregnancy are more likely to smoke or drink alcohol during pregnancy, have depression, experience domestic violence, and are less likely to obtain prenatal care or breastfeed. Short interpregnancy intervals have been associated with adverse neonatal outcomes, including low birth weight and prematurity, which increase the chances of children’s health and developmental problems.

Many factors contribute to the high rate of unintended pregnancy. Access and cost issues are common reasons why women either do not use contraception or have gaps in use. Although oral contraceptives (OCs) are the most widely used reversible method of family planning in the United States, OC use is subject to problems with adherence and continuation, often due to logistics or practical issues. A potential way to improve contraceptive access and use, and possibly decrease the unintended pregnancy rate, is to allow over-the-counter access to OCs."
Of course, it's easy to toss out some potential reasons why offering birth control pills over-the-counter might pose some unwanted tradeoffs. Would women be appropriately aware of possible side effects? Would women use oral contraceptives regularly and thus effectively if they were available over the counter? If women could get the pill over-the-counter, might they then have fewer doctor visits that could focus on preventive health care? How would an over-the-counter pill interact with insurance reimbursement? Would pharmacists be involved in some way? 

Just about every drug, including many over-the-counter drugs, can cause unwanted side effects for some people, or be be misused or ineffectively used. The appropriate dividing line here is not to require perfect safety, but to make a judgement that the drug is safe enough that people can self-medicate. That 1993 essay in the American Journal of Public Health argued that two decades ago: "More is known today about the safety of oral contraceptives than has been known about any other drug in the history of medicine. Thirty years of intense epidemiologic study have confirmed
that oral contraceptives are very safe." On the other side, the factors that limit women from having access to effective contraception pose real and immediate risks to their own health, and often to the health of their children.

When the Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists speaks up, it is essentially a group of doctors who specialize in this area, saying that with all the health risks taken into account, the available evidence suggests that over-the-counter access to the pill makes sense.

Many of the non-health-related arguments about making the pill available over-the counter are easily dismissed. For example, the concern that women with access to reliable contraception may not show up for preventive care is just old-style paternalism with a concerned face. Should we also require that condoms be sold via prescription, so that young men will be pressured to go to doctor's offices for their regular check-ups? Yes, figuring out how an over-the-counter pill would interact with insurance and with pharmacists is worth consideration. But surely, those factors should not be the central ones in thinking about whether a drug should require a prescription.

The contraceptive pill has been a society-shaking innovation. In the "millenium issue" of the Economist magazine back at the very end of 1999, the contraceptive pill was described this way: "But there is, perhaps, one invention that historians a thousand years in the future will look back on and say, “That defined the 20th century.” It is also one that a time-traveller from 1000 would find breathtaking—particularly if she were a woman. That invention is the contraceptive pill."

Among academic economists, probably the best-known work on the pill is a paper by Claudia Goldin and Lawrence F. Katz, "The Power of the Pill: Oral Contraceptives and Women’s Career and Marriage Decisions," published in 2002 in the Journal of Political Economy. The academic paper is available here; a write-up of the material for a broader readership in the Second Quarter 2001 issue of the Milken Institute Review is available here.  Goldin and Katz describe their work this way: "The fraction of U.S. college graduate women entering professional programs increased substantially just after 1970, and the age at first marriage among all U.S. college graduate women began to soar
around the same year. We explore the relationship between these two changes and the diffusion of the birth control pill (“the pill”) among young, unmarried college graduate women." While Goldin and Katz are careful to point out that many other factors were in play around this time, they make a compelling case that the availability of the pill played an important role, too. As they put it: "The Pill thus enabled a larger group of women to invest in expensive, long-duration training without paying a high social price."

 But while the pill has fundamentally altered the lives of women who have ready access to health care appointments and doctors who write prescriptions, there are also many women for whom the  requirement to see a doctor regularly and to get a series of prescriptions presents real logistical a nd personal barriers. It's time to stop using the contraceptive pill as a sort of carrot-and-stick to encourage regular doctor visits by women. It should be available over the counter.
Acknowledgement: I ran across the 1993 article in the American Journal of Public Health in a March 2012  Bloomberg column by Virginia Postrel called, "Fight Birth-Control Battle Over the Counter."