Oregon’s New Birth Control Law: Social Justice Or Dangerous Practice?

By Samantha Davis

On January 1 of this year, Oregon became the first state in the U.S. where people over the age of 18 can receive up to one year’s supply of oral and patch contraceptives at a pharmacy without a prescription. House Bill 2879 was a bipartisan effort — championed by Republican Representative Knute Buehler and Democrat House Majority Leader Val Hoyle. Buehler, a surgeon, put health care at the core of his state representative platform, stating: ‘‘I believe that health care reform should be grounded in what works best for patients.’’ The bill also received support from Planned Parenthood Advocates of Oregon and was signed by Governor Kate Brown in June, who said that the bill “has a simple premise that I whole-heartedly believe in: increase access and decrease barriers.”

Pharmacists also generally support the new measures. Marcus Watt, executive director of the Oregon Board of Pharmacy, said, “I see this law only as a positive for everyone. Patients are given a more convenient way to access their medication at a lesser expense, while pharmacists are able to better utilize their knowledge and expertise.”

But are there greater downsides to this legislation than such quotes would make it seem?

The New Legislation

The new law in Oregon requires patients requesting contraception over the counter to fill out a health questionnaire covering medical history and smoking habits, in addition to having their blood pressure checked. If the attending pharmacist detects no issues, women will be dispensed their contraception. In order to offer this treatment, pharmacists in Oregon are required to attend a five-hour training course before being able to dispense contraception without a physician’s prescription. The course is intended to fill gaps in pharmacists’ knowledge on contraceptive therapeutics and prescribing. Pharmacists are allowed to refuse prescribing a patient over-the-counter contraception on religious grounds, but, if they do so, are required to refer the customer elsewhere.

While Oregon is the only state to have enacted such legislation, it is likely to become more common throughout the U.S. California is poised to implement a similar law in March, and Washington and Colorado have followed suit by introducing similar bills.

This is a bold move at a time when many politicians are seeking to restrict women’s access to contraception by defunding Planned Parenthood and blocking a provision in the Affordable Care Act that mandates private health plans completely cover the cost of contraceptives. Indeed, nearly 60 lawsuits have been filed challenging the ACA requirement to provide free birth control, and the House of Representatives has already voted 37 times to repeal the ACA. Increased political pressures to restrict people’s access to contraception in the U.S. are creating an increased perception of women being held hostage for their birth control, contingent on a physician’s approval. A 2013 survey found that over 60% of women were in favor of over-the-counter birth control access.

At a time of such uncertainty, many people are heralding the victory for women’s sexual health in Oregon. Dr. Mark DeFrancesco, president of The American Congress of Obstetricians and Gynecologists, said, “My basic tenet is there should be nobody between the patient and the pill.” In a statement to the New York Times, Oregon state Representative Knute Buehler, a main force behind the bill, stated, “I feel strongly this is what’s best for women’s health in the 21st century.”

Looking At the Value Adds — And The Risks

Providing over-the-counter access to the Oral Contraceptive Pill (OCP) could help improve access to the medication, which is a crucial need — both for non-pregnant and pregnant people, as well as their babies. Increased contraceptive access has been shown to reduce the incidence of unintended pregnancy and abortion. This is a particularly notable fact, considering that in the past 20 years, the rate of unintended pregnancy has not changed significantly in the U.S.; it currently accounts for approximately 50% of all pregnancies across the country.

These unplanned pregnancies carry with them serious consequences. People with unintended pregnancies are more likely to smoke or drink alcohol during their pregnancy and are less likely to obtain prenatal care. In women who’ve already started having children, shorter intervals between pregnancies are associated with low fetal birth weight and prematurity. This in turn increases the chances of the child having health and developmental problems later on in life. Thus, an improvement in contraception access could mean a vast improvement in prenatal care and fetal health. Over-the-counter access to oral contraception has been successfully implemented nationally in other countries such as Jamaica, Kuwait, Mexico, and Thailand.

However, increased availability of the oral contraceptive pill (OCP) could also mean a decreased use of essential preventative care services, including STI and cancer screening, as well as annual wellness visits to primary care providers who can use their time with patients to screen for more common conditions such as heart disease and diabetes. According to the CDC, the OCP is the most widely used reversible method of contraception in the U.S. But, as with every medication, it isn’t without adverse effects, and there are certain safety concerns every woman should be aware of before starting the pill. This primarily concerns the increased risk of blood clots, heart attack, and stroke. The rate of venous thromboembolism for people on the contraceptive pill is extremely low (roughly 3–10/10,000); however, this risk is compounded by women who have high blood pressure, smoke, or have a family history of blood clots or stroke. Obesity can also compound these risks.

The reasoning behind the OCP requiring a prescription is to ensure a physician is monitoring these risks, such as by continuously measuring blood pressure, and hopefully taking preventative action. This kind of monitoring is especially important concerning high blood pressure as it often has no symptoms. One study measured the blood pressure of 1,200 women aged 18–49 and found approximately 6% had undiagnosed high blood pressure. Another U.S.-based study found women who obtained OCPs without a prescription were more likely to have relative contraindications such as: high blood pressure, active smoker, obese, or otherwise at risk for complications. In this case, a physician can discuss suitable alternatives in order to ensure a woman finds the contraceptive method that suits her and her health best.

In an over-the-counter OCP model, doctors aren’t involved with this kind of monitoring — which is why not everyone in the medical community is fully in support of laws like Oregon’s. Dr. Poppy Daniels, an OBGYN who specializes in treating blood clotting disorders, is one such dissenter. Many of her patients suffer from undiagnosed clotting disorders that are only discovered after beginning hormonal contraception: “My concern is that you’re basically taking women who have no counseling, no family history, no risk assessment, and they’re just getting [hormonal contraception] with no guidance,” Daniels says. “We’re losing the doctor-patient relationship . . . I’m medically responsible for the patients I see, and they deserve to know the potential risks and benefits of each medication.”

Further, not requiring a doctor’s prescription could mean fewer women attending preventative health services such as STI and cancer screenings, as well as annual wellness visits with Primary Care Physicians. The American College of Obstetricians and Gynaecologists recommends an annual health assessment for every woman. This visit should ideally include a discussion of the woman’s current reproductive health plan, which provides an opportunity for the clinician to ask the patient what (if any) birth control she currently uses, screen for potential adverse effects of her chosen method, and advise her of appropriate alternatives. This visit can also be an opportunity to discuss if the woman would like to become pregnant in the coming year and receive advice about beginning folic acid and iron supplementation to ensure optimal health during the prenatal period.

While STI and cervical cancer screenings are not necessary in order to receive birth control, these annual visits can be further utilized to ensure optimal gynecological health. The CDC recommends that women aged 21–65 get a Pap smear to screen for cervical cancer every three years. If women get an HPV test and a Pap smear at the same time and have normal results, they can be tested every five years. Cervical cancer is the most preventable gynecologic cancer, and routine screening can save lives.

A Shift In Responsibility

The American College of Obstetricians and Gynecologists have officially recommended over-the-counter access to oral contraceptives since 2012; however, they also recommend that women should self-screen for most contraindications to oral contraceptives using checklists. Yet, conducting a literature review revealed that there are currently no universally accepted checklists available. Given that legislation making the OCP available over the counter shifts responsibility onto the patient for monitoring their health and possible contraindications, such a gap is notable.

As a young woman who is not planning on having a family anytime soon, I love the idea of being able to receive a year’s supply of contraception without having to make a doctor’s appointment. It’s more convenient and saves on co-pays to see my doctor when I’m feeling healthy. I also like the idea of being covered if I go on vacation and forget my pill. However, as a doctor I’ve seen young women who’ve had strokes with no other risk factors other than the contraceptive pill. Although this is a rare side effect, it does give me pause about increasing access to the medication without oversight. Additionally, as a physician, I want to ensure that my patients are aware of all their contraceptive options so they can choose the one that suits them best. Being able to access contraception without a prescription may close this dialogue.

Dr. Jill Rabin, co-chief in the division of ambulatory care, Womens Health Programs at Northwell Health in New Hyde Park, New York also supports the new legislation, but affirms that increased access should not replace visiting your doctor. “This does not obviate the need to come to your doctor . . . You need to establish a relationship with a gynecologist you trust.”

Only time will tell the long-term effects of this new legislation. I, for one, remain cautious but hopeful.

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Lead image credit: Wikimedia Commons

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