The most effective birth control isn’t OTC

Women in California who don’t want to wait to get birth control prescriptions from their doctors can now purchase their pills, patches, rings and shots directly from pharmacists.

The new program, which began earlier this month, has been widely hailed as a victory for women’s reproductive rights by doctors’ organizations and healthcare advocates. Yet the fanfare misses an important point: Women visiting their pharmacists won’t have access to the most reliable forms of birth control on the market because those methods, such as implantable rods or intrauterine devices (IUDs), will still require a trip to a doctor’s office.

Although the pill is still the top choice for nearly 26% of women using birth control, nine of 100 women who take it over a year will have an unintended pregnancy, according to the U.S. Federal Drug Administration. (The transdermal patch and vaginal ring, which account for nearly 3% of all forms of contraception, have similar failure rates. Of the nearly 5% of women who prefer injections, six out of 100 women will accidentally get pregnant within a year.) Nearly half of the 3 million unintended pregnancies that occur in the U.S. each year are due to contraceptive failure, according to an analysis of government data by the reproductive health organization Guttmacher Institute.

In one study published in the New England Journal of Medicine, more than 330 women out of nearly 7,500 participants — or over 4% — got pregnant while using the pill, patch or ring within one year. (It

rose to 9% by the third year.) By comparison, the rate was less than 1% for women who chose implantable rods or IUDs.

The reliability of implants and IUDs has prompted the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics to call for greater access to them, especially for teens. Currently, about 1 in 10 women choose the IUD as their form of birth control, and a little more than 1% have embraced the implant.

“We’re interested in increasing access ... but pharmacy-provided contraception is still a significant improvement for women who rely on pills,” says Kelli Stidham Hall, assistant professor in the department of behavioral sciences & health education at Emory University in Atlanta.

There’s another reason fewer women are asking for these more effective forms of birth control: They can costs hundreds of dollars even with insurance coverage. In a study of nearly 2,000 women ages 18 to 22 that was recently published in the journal Contraception, Hall found that cost was a top reason young college women didn’t choose implants or the IUD.

Yet when price wasn’t a barrier, more than three-quarters of women opted for these more reliable forms of birth control, according to a 2015 study published in the Journal of Women’s Health of more than 9,000 women who were given their choice of birth control for free. They were also more likely to still be using them a year later compared to hormonal birth control — 87% versus 57%, respectively.

“IUDs and implants are superior at preventing pregnancy across all age groups,” says Dr. Andrea Hoopes, an assistant professor in adolescent medicine at Children’s Hospital Colorado in Aurora who studies teens’ attitudes about contraception. “So it’s paramount that we become creative in offering all forms of birth control though many outlets.”

It’s unclear what those are; the IUD and implant must be inserted by a healthcare provider, which isn’t practical at your local CVS.

In the meantime, pharmacists in California are still trying to figure out how to implement the new program. Of the state’s roughly 7,000 pharmacies, only about 300 independent outlets have started offering pills, patches, rings and shots directly to consumers.

“It’s going slow, but that’s not a bad thing. There were some logistics the pharmacists needed to iron out,” says Kathleen Besinque, associate professor at the USC School of Pharmacy and past president of the California Pharmacists Assn.

For example, pharmacists have to offer blood pressure screenings on the spot. That’s because women with high blood pressure must be prescribed birth control containing low doses of estrogen; a high dosage can worsen hypertension. They also have to decide how to advertise and how to bill for their services. While insurance will cover the medication, it doesn’t cover the visit, so pharmacists are working out whether they will charge patients an additional consultation fee of $30 to $45 that patients would submit directly to their providers.

The new program also signifies a continued expansion of pharmacists’ roles from medication dispenser to counselor.

“Some pharmacists are worried about having enough time to really sit down with patients and go over all their options when they have other people waiting,” says Sally Rafie, a pharmacist specialist at UC San Diego Health who studies healthcare providers’ opinions. She advises women to think of a pharmacist as one of many players who work together. “Maybe a woman just moved here but needs a three-month supply of pills until she sees her primary care provider,” she says. “It’s all about choice.”