by Maxine Lipner

Imagine having oral contraceptives as available as aspirin – a steady supply no further away than the open shelf of your neighborhood drugstore. Teenagers, busy working mothers, all women could buy the contraceptives without having to pay for a doctor’s visit or enduring a pelvic exam.

Ironically, making birth control pills available without prescription could lead to a rise in unwanted pregnancies

At first blush, over-the-counter (OTC) sales sounds like a progressive idea, and it’s gained some momentum of late. The Henry J. Kaiser Family Foundation held a major medical conference on the subject in July, and the Food and Drug Administration consideration for the move is stirring.

Those who favor non-prescription status say the birth control pill is being held hostage to the demand that a woman get a necessary – but unrelated – gynecological exam. It’s the equivalent, they say, of insisting that men be examined for testicular cancer before being allowed to purchase condoms.

But the issue is by no means as clearcut as it may first appear. Opponents note that setting women adrift in the market system might do more harm than good.

As Cynthia Pearson, program director of the National “Women’s Health Network, based in Washington, D.C., puts it, if the pill is available over the counter, “The well-educated, relatively well-off woman would be empowered, but women who are young, new users, or have a low income could actually be set back.”

For some low-income women, birth control is their ticket to health care, Pearson notes. “They can’t qualify for Medicaid because the rules are so stringent, but they can qualify for state family planning, federal family planning, and all sorts of different programs. Being a birth control user helps women get access to routine primary preventive screening tests.”

Luz Alvarez Martinez, director of the National Latina Health Organization, based in Oakland, California, concurs. Martinez, whose allegiance lies withpoor, non-Englishspeaking Latino women, is worried that making pills available over the counter would rob her constituency of the advice of healthcare professionals, on whom they rely to explain pill usage and contraindications.

“It’s difficult even for very educated people to get through reading all of the inserts,” Martinez points out. The tiny print, available only in English, and the complexity of instructions are significant barriers for many Latino women. Another difficulty would be selecting the optimal oral contraceptive from all the formulas and brands that are available. “Doctors themselves often have a hard time choosing the best [oral] contraceptive for each patient. How are women going to do this for themselves?” Martinez wonders.

Teenagers are another vulnerable group, who are often struggling to sort out the facts about sex and contraception. Teens just don’t have the same storehouse of knowledge that their older sisters have, Pearson points out. Just as with sex in general, first-time users of oral contraceptives pick up a lot of misinformation from each other.

Martinez worries that teens in particular may not understand the importance of following directions in taking the pill. “A young woman may have $23 to spend for the pills this month but not have the money when she needs the next cycle. So she might delay and just begin taking the pill again when she has the money,” Martinez notes. “Without having the education from healthcare providers on the importance of taking the pills in sequence, more young women may end up with unintended pregnancies.”

But Felicia Stewart, M.D., who is affiliated with the Sutter Medical Foundation in Sacramento, California, sees overthe-counter status for the pill as a benefit for teens. She projects a scenario in which young women would initially consult a health professional, who could assuage any concerns about the pill and teach them to use it correctly. They could then take advantage of easy OTC refill access. “The refill issue is a really big deal for teenagers – they have even less money and less flexibility than other women,” she says Taking time off to arrange transportation and show up at a clinic at the correct time, is an even bigger problem when you’re 17 years-old then when you’re 25.”

Another issue of particular concern for young women is sexually transmitted diseases (STDs). Birth control refill visits currently serve as a carrot of sorts to draw women back for important STD screening tests. Pearson believes that women are less likely to have the tests without such a lure and thus suffer lasting consequences.

“The proponents say women are smart. ‘We’ll tell them they need to come back for STD screening and they’ll just do the right thing,'” she says. “It’s a little naive to be that optimistic.” Pearson believes

Then there’s the issue of AIDS education. If a woman doesn’t need to consult a health professional before obtaining birth control, might she neglect to take necessary measures to protect herself from HIV? Martinez thinks so. “Studies have shown that the majority of Latino women do not feel that they are at risk for AIDS and HIV,” she notes. If they don’t go to a clinic for their oral contraceptive prescription they’ll also miss out on HIV education. That will make them very vulnerable, she fears.

Alexander Sanger, president ofPlanned Parenthood ofNew York City, counters that such counseling need not be linked to pill usage. “Women should be going to their doctor once a year anyway, to have a Pap smear, a breast exam, and HIV counseling,” he says.

Economic fallout

Selling the pill without prescription could have serious economic implications for those who can least afford it. Many such “women currently get prescription – but not over-thecounter – drugs free via Medicaid or Title X clinics.

Stewart believes poor women’s advocates are needlessly fearful on this issue. Just because some brands of a particular drug are sold over the counter doesn’t mean that other brands won’t still be available by prescription, as is the case for yeast infection medications.

Another source of contraceptives for low-income women, the not-for-profit clinics such as Planned Parenthood, might be threatened by non-prescription oral contraceptives. The clinics currently subsidize patient care with the revenues they make by reselling pills sold to them at a deeply discounted rate by pharmaceutical companies. Were pharmaceutical companies to decide that with over-the-counter availability such discounts were no longer an important measure for inspiring brand loyalty in women, the pill could become less accessible to the lowest income members of society, according to Pearson.

The loss of such revenue could mean some clinics would have to close their doors, according to Sanger. “Or what might happen is that the cost of the medical visit would have to go up to make up for the loss of pill revenue,” he adds. What about the pharmaceutical companies themselves? Are they in for a windfall? It’s hard to say how things will ultimately shake out, but Stewart does see them as reaping some benefits. Since the vast majority ofwomen in America take oral contraceptives at some time in their life, increasing their availability will probably end up increasing sales, Stewart observes.

The upcoming healthcare reform will no doubt have some impact on this issue. Theoretically, easy access to the healthcare system for all could guarantee that poor women wouldn’t lose their link to medical professionals. But for now, Martinez doesn’t see such potential changes as playing a role in the debate. “It’s going to be years before every woman is going to have easy access to health care, especially reproductive health care and that’s in question right now,” she notes.

Potential options

So what do we do now? Should feminists push for overthe-counter pill status despite the potential consequences or should they back the status quo? Perhaps the answer lies in expanding the current choices of prescription-only or overthe-counter status for drugs.

Alexander Sanger foresees the possibility of involving the neighborhood pharmacist in consumer education. “Right now they tell you which cold medication to take,” he says. “I think the druggist could perform the same function with birth control pills.”

Felica Stewart proposes some sort of testing of women’s knowledge before they’re allowed to buy oral contraceptives. A healthcare professional could evaluate a woman’s understanding of oral contraceptives before issuing her an ID card entitling her to purchase pills OTC for the next five years or so, says Stewart. Or, potential pill patrons could call a 1-800 nurse who could test their knowledge of pill usage and then fax them approval if they qualify.

Simplified pill labeling could also help. “We should evaluate the labeling based on what women learn from it – not what the lawyers for the drug companies or lawyers for the FDA think should be in it,” Stewart stresses. Television announcements, advertisements and programs to educate women about proper use of oral contraceptives are also a possibility.

Ingenious solutions like these could make that tempting image of oral contraceptives lining drugstore shelves viable for all women. In our zeal to make such a dream a reality, however, we have to be sure that we don’t dangle the pill just out of some women’s reach or inadvertently jeopardize our collective well-being.

Maxine Lipner is a New York-based health and medical writer whose work has appeared in New York Magazine and other publications.