Roosevelt Institute | Cornell University

The Case for an Over-the-Counter Oral Contraceptive

By Alicia DuranPublished January 6, 2021

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The oral contraceptive pill is safe and effective at preventing pregnancy; however, the prescription requirement makes it difficult for women to access the pill. An over-the-counter oral contraceptive would relieve challenges associated with the prescription requirement and improve family planning for women.

The oral contraceptive pill is one of the best-studied, safest, and most popular methods of birth control worldwide. Despite this, women continue to face barriers to access the pill. In a survey of women who had difficulty obtaining hormonal contraception, 14 percent reported cost, including difficulty paying for an appointment, as the biggest barrier. The next most common barriers were challenges making an appointment or getting to a clinic (13 percent). Evidently, the prescription requirement has led to difficulty obtaining contraception for certain women. In fact, among women who have ever tried to obtain a prescription for contraception, 29 percent reported experiencing problems. The Patient Protection and Affordable Care Act made great advances in reproductive health policy by mandating the complete coverage of contraception; however, women continue to face barriers to contraception—especially the pill. In order to provide safe and effective family planning to all women, an over-the-counter (OTC) oral contraceptive should be made available in the United States. 

Compared to male condoms, oral contraceptives are highly effective. Seven percent of women will become pregnant in the first year of using the pill, while 13 percent will become pregnant using male condoms. Despite its effectiveness, nearly half  (45%) of the 6.1 million pregnancies in the United States in 2011 were unintended. Of these unintended pregnancies, only 5 percent were attributed to women who used contraceptives correctly and consistently; the majority of unintended pregnancies are a result of contraceptive misuse or nonuse. For the 43 million women at risk of an unintended pregnancy, it is important to afford them effective contraception to help prevent unwanted or mistimed pregnancies. An easily available OTC oral contraceptive would help reduce the number of unintended pregnancies by eliminating the need for an appointment and its associated costs. It can make it easier for women to start using the pill and keep using it longer and more consistently.

The safety of oral contraceptives has been made certain through decades of research. The directions for taking oral contraceptives are simple, making misuse or abuse unlikely; in fact, no one can overdose on the pill. For those who oral contraceptives pose risks, a study showed that women were able to use a simple checklist to discern whether it was safe for them to take the pill. Likewise, studies have shown that women and healthcare providers are interested in an OTC oral contraceptive. In a study of 2,026 sexually active adult women, 39 percent reported they were likely to use an OTC pill. The American College of Obstetricians and Gynecologists, a leading organization for women’s health physicians, concluded that an oral contraceptive should be made available OTC. Finally, studies have shown that an OTC oral contraceptive does help women stay on the pill longer. In a study of women who obtained the pill OTC in Mexico and women who obtained the pill by prescription in El Paso, Texas, discontinuation was higher for women from El Paso (25.1 percent). 

Although about a third of all women face barriers to prescription contraception, women of color and women of low socioeconomic status experience lower accessibility. Forty-eight percent of Hispanic women reported difficulties obtaining or refilling a prescription for contraception, compared to 29 percent of all women. Thirty-seven percent of women whose incomes were less than 200% of the federal poverty level and 55 percent of uninsured women reported experiencing difficulties also. Consequently, rates of unintended pregnancy are highest among these women. Access barriers among these women are likely compounded, making it more difficult to obtain a prescription for contraception. For example, people of color and low-income individuals are more likely to be uninsured. As a result, these women are more likely to experience difficulty making, keeping, and paying for a doctor’s appointment. Thus, the availability of an OTC oral contraceptive can help women of color and low-income women afford effective contraception. 

Although an OTC oral contraceptive would help alleviate barriers associated with clinic visits, there are trade-offs to moving the pill OTC. Under the Affordable Care Act, private insurance providers are required to cover FDA approved contraceptives without cost sharing. This includes OTC methods used by women if they are prescribed. Thus, an OTC pill could be covered by insurance only if a healthcare provider prescribes it. Though it would be ideal for insurance providers to cover OTC contraceptives without a prescription, the availability of an OTC oral contraceptive would still alleviate challenges for some women. 

Oral contraceptives are available without a prescription in over 100 countries; the United States, the leader in pharmaceutical innovations, has yet to make the pill available OTC. As discussed, there are high rewards to gain from an OTC oral contraceptive with little risk in return. With so much potential from an OTC oral contraceptive, why hasn’t the pill moved over-the-counter?