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Tuesday, December 18, 2012

Should oral contraceptives be available over-the-counter?

Last week, the Wall Street Journal published an opinion piece by Louisiana Governor and 2016 GOP hopeful Bobby Jindal, in which he argued that oral contraceptives should be made available without a prescription.  Jindal is pro-life and has governed accordingly, so his proposal is being seriously debated in the pro-life community.

Arguments in favor:
  • De-politicize contraception: Jindal notes that in the 2012 election, Democratic messaging was "that Republicans are somehow against birth control," which is "a disingenuous political argument."  Over-the-counter birth control would make that a non-issue in 2016 and beyond.
  • Protect free exercise of religion: The debate over contraception was never about being for or against birth control, but about who pays-- and specifically, whether Catholics who have religious objections to contraception can be forced to provide it.  If oral contraceptives cease to be prescription medication, the question of who pays will have a simple answer: the user, not an employer or an insurance company, will pay (just like people currently pay for condoms out of pocket).  Note, however, that this would not address other types of contraception covered by the HHS mandate, such as IUDs.
  • ACOG is in favor: The American College of Obstetricians and Gynecologists (ACOG) recently released an opinion in favor of over-the-counter oral contraceptives.  It does seem strange that morning-after pill-- which contains higher hormone levels, is less effective, and may (or may not) work after fertilization-- is already available over-the-counter, while regular pills are not.
  • Hurt Planned Parenthood's brand: Jindal doesn't mention this, but think about it: if birth control is available at any old CVS or Walgreen's without a prescription, it will be very difficult for Planned Parenthood to market itself as the source of contraception for women.  Combine that with the impending requirement that every Planned Parenthood affiliate do abortions, and the American people will quickly figure out what Planned Parenthood is really about.
Arguments against:
  • Women's health: One ACOG opinion does not a medical consensus make.  Oral contraceptives have serious risks, and we should not jump to a premature conclusion just because it's politically convenient.
  • Problems for teenagers: Jindal limited his argument to people 18 and over, but it could easily be expanded to minors.  Will parents be able to know if their daughters are on the pill?  Will they be on the lookout for potential complications?  Will OTC oral contraception encourage teen sexual activity?  Will OTC oral contraception discourage condom use, exposing teens to a greater risk of STDs?
  • Long-term pro-abortion strategy: Planned Parenthood has come out in favor of Jindal's proposal, which should make us pause.  Over the long term, abortion supporters would surely love for the abortion pill (RU-486/misoprostol/mifeprex) to be available without a prescription, which would be a disaster for babies and for women's health.  It's hard to make that happen without making more innocuous medications available OTC first.  (But note that some abortion advocates are publicly opposing the idea of OTC oral contraception, putting them at odds with Planned Parenthood.)
After all that, I'm still on the fence.  Convince me of your position in the comments section.

31 comments:

Kara Baylog said...

Yes yes yes yes yes in favor. Reasons 1,3 and 4 are just icing on the cake. Reason 2 is silly. The whole "who pay's" argument is inconsistent to the pro-life agenda (favoring life over other concerns, such as money) and there are plenty of things that individuals disagree with, even religiously, but have to pay into. I'm still smarting about the whole foreign wars thing. The argument that is made is that 1) this provided service is something we benefit from as a society (national security/ reduced abortions) and 2) no individual is compelled to act in a way that is contrary to they believe their beliefs dictate for them to do. (Quakers can get out of becoming drafted/ Catholics can opt to not take birth control themselves)

Against, Reason 1 is almost valid except for the fact that by its nature, any drug is likely to have side effects. This hasn't stopped OTC drugs. If BC is treated like any other drug, where those approved for OTC have undergone rigorous testing, and information is made available for people to buyers, then you've made a consistent, if not reasonably safe system that empowers personal choice in the matter. And The whole BC = more promiscuity is such a red herring, especially for teenagers. Teenagers don't really think ahead too much, have you noticed? If a teenager is trying to get BC for non-medical reasons, it is pretty likely because they have already made up their mind about sex, and besides, condoms are already available for a moment's notice should a teenager wish to have sex. Now, will there be isolated individuals who think "Oh, I can get pill BC, and that means I can have sex!" - I can't make any sweeping statements on the entire teenager population. But if this number is not significant, and even one teen already having sex is protected under OTC BC, it is worth it. saving lives > protecting someone's contrived moral opinions about sex.

Reason 2 is easy. You already have to show ID to get the morning after pill, and even some other medications, even if they are OTC.

Reason 3 The abortion pill is not BC. It will never be categorized as BC. We are having discussions about the morning after pill being not BC but an abortifacent (even though studies indicate it is not http://ec.princeton.edu/questions/ecnotru.html). This is a slippery slope logical fallacy and there is no reason to think OTC BC would lead to it.

Kelsey said...

"The whole BC = more promiscuity is such a red herring, especially for teenagers. Teenagers don't really think ahead too much, have you noticed?"

I hear you, agree, and have actually made that exact point in previous articles. But I wanted this post to include ALL arguments for and against, including the ones that I personally think are lame.

That said, I *can* see sexually active teens moving from condoms to the pill. Because you know how horny teenage boys are. They don't want to wear condoms if they don't have to, and if the pill is just as easy to get as condoms, that puts some pressure on the girls to go that route.
Teens are more worried about pregnancy than they are about STDs; they probably wouldn’t use both...

Laura said...

According to the WHO, oral contraceptives are a class 1 carcinogen, just like cigarettes. If you put it behind the counter and a girl has to show ID - and be over 18 - then I say YES! I cannot go with an underage girl being able to get such a potentially harmful drug without her parents' consent.

Gordon Duffy said...

Tge abortion pill should also be available over the counter - especially with clinics being forced to close.

NorthStar156 said...

"If oral contraceptives cease to be prescription medication, the question of who pays will have a simple answer: the user, not an employer or an insurance company, will pay (just like people currently pay for condoms out of pocket)."

My understanding is that condoms are included among the contraceptive methods covered under the Obamacare/HHS mandate. Here is the relevant excerpt: "...[A] group health plan...must provide coverage for all of the following items and services, and may not impose any cost-sharing requirements (such as copayment, coinsurance, or deductible) with respect to those items and services:...With respect to women, ...preventive care...provided for in binding comprehensive health plan coverage guidelines supported by the Health Resources and Services Administration."

http://www.gpo.gov/fdsys/pkg/CFR-2011-title45-vol1/pdf/CFR-2011-title45-vol1-sec147-130.pdf

In turn, the Health Resources and Services Administration, under the heading "Health Resources and Services Administration Supported Women's Preventive Services: Required Health Plan Coverage Guidelines", lists "All Food and Drug Administration approved contraceptive methods,
sterilization procedures, and patient education and counseling for all
women with reproductive capacity.

http://www.hrsa.gov/womensguidelines/

In turn, the FDA lists male and female condoms among its "...approved...devices for birth control."

http://www.fda.gov/downloads/ForConsumers/ByAudience/ForWomen/FreePublications/UCM282014.pdf

Keep in mind that just because a prescription is not needed does not mean that one cannot be provided. I was prescribed Ranitidine, which is just another name for Zantac. As I recall, the reason my doctor prescribed it was so that it would be covered under insurance.

NorthStar156 said...

In my opinion, there is one and only one contraceptive method that the right-to-life movement should support: Nexplanon. All other methods have serious problems, such as high failure rates, possible post-fertilization effects, and/or limited applicability. Oral contraceptives have at least the first two problems. The evidence that I have seen, as I interpret it, shows that oral contraceptives have either no effect on abortion rates or a counterproductive impact.

NorthStar156 said...

Kara Baylog, why can women not just demand that their sexual partners pay for contraceptives?


Do you have evidence that indiscriminate government promotion of contraceptives leads to fewer abortions? Have any states clearly achieved that result using a contraceptive mandate?

NorthStar156 said...

"Because you know how horny teenage boys are."

I would be interested in hearing a detailed description of the research method you used to derive that conclusion.

Kara Baylog said...

To your first question, follow my logic here for a moment if you will: The goal is to get society as a whole to reduce abortions as much as possible via reduced unwanted pregnancies - (not ruling out legal avenues as well, just looking at this one strategy, which address the vast majority of abortions).
If (1) contraceptives do in fact reduce the number of unwanted pregnancies, and thereby abortions, then we want them for be proliferated as much as possible.
If (2) we want to proliferate contraceptives as much as possible, we must make them easy to access from both a logistical and financial aspect.
Therefore, reducing or eliminating cost of BC and making it easy to get (via OTC for example) will help in that goal.
Asking the sexual partner to pay for contraceptives is a great idea, from an individualistic level. Actually, I demand it from my boyfriend. However, we aren't talking about an individual, we are talking about society. Not all women do or can request it from their partner(s). It is a taboo thing. When I set those rules for my boyfriend, I half expected some negative feedback (he's great and supportive, but not every guy is). So for some women, between social pressures and financial pressures, telling them to simply request their partners pay for it is not feasible, and they will forgo BC. Statistically though, we can see this will not stop them from having sex.

To your second question:
http://healthland.time.com/2012/10/05/study-free-birth-control-significantly-cuts-abortion-rates/

Kara Baylog said...

Do you have any literature on that (Nexplanon vs other BC? I'd like to read it.

Kara Baylog said...

I agree, and STDs are a whole other issue. I don't think free contraceptives are a panacea to all society's ills, but I do think they address the most important one: the abject destruction of innocent life.
There are better ways and worse ways to implement free BC though. If it is just made a free for all, sure, you might see that pressure on girls arise (although at least in my high school experience, teenage girls are no less horny than teenage boys). Ideally, you'd get any change in policy with a strong educational arm that pressures both girls and boys to take BC responsibility, and just as easy access to condoms, and yes, probably parental consent until the age of majority.

Kara Baylog said...

To your first question: because if we make the argument that contraceptives reduce abortions by reducing unwanted pregnancies, then we want to implement a policy that facilitates the use of BC as much as possible. Certainly, it is a good idea to demand your partner(s) contribute to avoiding pregnancy, in whatever way you see fit, (BC, FAM, Abstinence), but it is also very hard to get the guy to agree to that. I've found a good guy who is supportive and takes a role in that, but not everyone does. I am half surprised I didn't get negative feedback from my boyfriend when I first set out these rules. Between the social pressures that might make a woman less likely to request that her husband/boyfriend/partner pay into preventing pregnancy, and the financial pressures of maybe that woman not being able to afford it, what you would have is less women on BC.
So to sum up, individually, great idea to demand your partner share in the cost. Societally speaking? You will not reach your goal of reduced abortions.
Again, this is assuming that if available, BC = reduced unwanted pregnancies = reduced abortions.

Your second question addresses that "IF". Here is a reply to that: http://healthland.time.com/2012/10/05/study-free-birth-control-significantly-cuts-abortion-rates/

P.S. If you do not hit the reply button to respond to this, I will not see it and we can consider this conversation closed. Furthermore, I will assume it is because you never came up with anything compelling enough to contradict my points.

NorthStar156 said...

"If you do not hit the reply button to respond to this, I will not see it..."

Why not? Is there some technical reason?

NorthStar156 said...

I realize that most people use the quote feature, but I struggle to follow the tree when it gets complicated. The reply feature also makes it difficult to see when new comments have posted. Moreover, while the reply makes it easier to see the comment being replied to, it does not focus in on the specific words within the comment that are relevant. For all of those reasons, I tend to post a new comment and quote the exact words to which I wish to reply. To find the latest reply, click on "Discussion" and then "Newest." Until they improve the reply feature, I do not think it is worth using.

NorthStar156 said...

"Do you have any literature on that (Nexplanon vs other BC?"

Yes. One study was detailed in the following link.

It found that while 40.5 percent of all women at risk of unintended pregnancy used long-acting forms of contraception, only 1.1 percent of women obtaining abortions had relied upon long-acting forms of contraception in the month they became pregnant.

On the other hand, the study found that 21.7 percent of sexually active women relying upon condoms or withdrawal generated 34.9 percent of the abortions.

http://www.guttmacher.org/pubs/journals/3429402.html

In addition, failure rates for contraceptive methods are very instructive. For example, according to Guttmacher, male condoms have a one-year, typical-use failure rate of eighteen percent. They also assert that a typical woman is sexually active but trying to avoid pregnancy for about thirty years of her life. Therefore, extrapolating that eighteen percent figure across thirty years yields a failure rate of over 99.7 percent. (Mathematically, the 99.7 percent figure can be derived by subtracting the annual typical-use failure rate (.18) from 1, raising the result to the power of thirty, and then subtracting the result from 1.)

That same method produces a lifetime failure rate of less than 1.5 percent for Implanon. (Implanon was the predecessor version of Nexplanon. Nexplanon has features that make it even more effective.)

The lifetime failure rate for oral contraceptives is about 94 percent.

So, clearly, Nexplanon is dramatically more effective than the most commonly-used methods of contraception.

While some of my links are now dead, I have seen other studies that confirm the effectiveness of long-acting methods of contraception. For example, one study found that while twenty-five percent of teenagers in Georgia and North Carolina who chose a contraceptive method other than Norplant (an implant)
experienced an unintended pregnancy, none of the Norplant users became pregnant. Another study found that while seven percent of women and girls 18 years of age and younger who were using oral contaceptives became pregnant, the number who became pregnant
while using Norplant and Depo-Provera was too low to precisely estimate(zero to two percent). In addition, a
colorado state demographer determined that the Colorado Medicaid program's approval of the use of Norplant implants was a large factor in a 25 percent drop in overall repeat fertility rates in that state.

Also see the following video.

https://news.wustl.edu/news/Pages/23899.aspx

IUDs have two big problems. First, they are discouraged, if not prohibited, for women who have not yet given birth to at least one child. According to Mirena's web site, "Mirena...is recommended for women who have had at least one child." For Paragard, I found this quotation: "There is a higher risk of expulsion for women who have never given birth. IUDs also, from what I have seen, have a high likelihood of having a post-fertilization mechanism.

http://www.mirena-us.com/just-the-facts/index.jsp#jump_b3

http://en.wikipedia.org/wiki/Paragard

NorthStar156 said...

"Your second question addresses that 'IF'."


The problem with that study is that the researchers emphasized to the women the effectiveness of long-acting methods of contraception. The success might reflect that emphasis, not the provision of free contraception.

NorthStar156 said...

"Your second question addresses that 'IF'."

The problem with that study is that the researchers emphasized to the
women the effectiveness of long-acting methods of contraception. The
success might reflect that emphasis, not the provision of free
contraception.

NorthStar156 said...

"...it is also very hard to get the guy to agree to that."

I have a hard time believing that.


I think it is also important to look at the effect that policies have on men. Studies have shown that both unwed child-bearing and abortion are lower when states aggressively enforce their child-support laws. That suggests that, when the costs of intended pregnancies are high for men, they are less likely to start them.

NorthStar156 said...

"...it is also very hard to get the guy to agree to that."

I have a hard time believing that assertion.

I think it is also important to look at the effect that policies have on men. Studies have shown that both unwed child-bearing and abortion are lower when states aggressively enforce their child-support laws. That suggests that, when the costs of intended pregnancies are high for men, they are less likely to start them.

NorthStar156 said...

I have a long response waiting in moderation.

NorthStar156 said...

If you have a preference for using this feature, I can use it to respond to you. However, in general, I think you are off base in suggesting that it must be used. If Kelsey wanted to mandate its use, she could have asked us to use it exclusively to respond to posts.

NorthStar156 said...

The response does not seem to be coming back, so I will try to recreate what I wrote.

A study by the Alan Guttmacher Institute found that while 40.5 percent of all women at risk of unintended pregnancy used long-acting forms of contraception, only 1.1 percent of women obtaining abortions had relied upon long-acting forms of contraception in the month they became pregnant. Conversely, the study found that the 21.7 percent of sexually active women relying upon these two methods of contraception generate 34.9 percent of the abortions.

http://www.guttmacher.org/pubs/journals/3429402.html

Studies on failure rates of different methods show that Nexplanon is most effective and has few competitors. For example, the commonly-used male condom has a one-year, typical use failure rate of eighteen percent. According to Guttmacher, the typical woman in the United States is sexually active but trying to avoid pregnancy for thirty years of her life. Therefore, that one-year failure rate must be extrapolated across thirty years of use to get the true, lifetime failure rate. Mathematically, that can be done by subtracting the annual typical-use failure rate (18%) from 1,
raising the result to the power of thirty, and then subtracting the
result from 1.

That same procedure yields a failure rate for Implanon of less than 1.5 percent. Nexplanon is the successor to Implanon and has features that make it even more effective.

Oral contraceptives, using the above procedure, have a failure rate of 94 percent.

Clearly, then, Nexplanon is dramatically less likely to fail than the most commonly used methods of contraception.

http://www.guttmacher.org/pubs/fb_contr_use.html

My links have broken, but other studies confirm the performance of long-acting forms of contraception. For example, one study found that while twenty-five percent of teenagers in Georgia and North Carolina who chose a contraceptive method other than Norplant (an implant) experienced an unintended pregnancy, none of the Norplant users became pregnant. Another study found that while seven percent of women and girls 18 years of age and younger who were using oral contaceptives became pregnant, the number who became pregnant while using Norplant and Depo-Provera was too low to precisely estimate (zero to two percent). In addition, a colorado state demographer determined that the Colorado Medicaid program's approval of the use of Norplant implants was a large factor in a 25 percent drop in overall repeat fertility rates in that state.

Also, see the following video.

https://news.wustl.edu/news/Pages/23899.aspx

Also, note that some Western European countries have achieved low rates of abortion and tend to use more long-acting methods.

Other long-acting methods tend to be nearly as effective as Nexplanon, but all of them have serious drawback. Sterilization is, of course, usually permanent. IUDs seem to only be recommended for women who have already given birth to at least one child ("Mirena...is recommended for women who have had at least one child"). They also have a mechanism of action that is likely to be sometimes post-fertilization. As a result, the right-to-life movement will not get behind IUDs any time soon. Injectables cause bone density loss and are significantly less effective than Nexplanon.

http://www.mirena-us.com/just-the-facts/index.jsp#jump_b1

NorthStar156 said...

The response does not seem to be coming back, so I will try to recreate what
I wrote.

A study by the Alan Guttmacher Institute found that while 40.5 percent of
all women at risk of unintended pregnancy used long-acting forms of
contraception, only 1.1 percent of women obtaining abortions had relied upon
long-acting forms of contraception in the month they became pregnant.
Conversely, the study found that the 21.7 percent of sexually active women
relying upon condoms or withdrawal generated 34.9 percent of the abortions.

http://www.guttmacher.org/pubs...

Studies on failure rates of different methods show that Nexplanon is most
effective and has few competitors. For example, the commonly-used male condom
has a one-year, typical use failure rate of eighteen percent. According to
Guttmacher, the typical woman in the United States is sexually active but
trying to avoid pregnancy for thirty years of her life. Therefore, that
one-year failure rate must be extrapolated across thirty years of use to get
the true, lifetime failure rate. Mathematically, that can be done by
subtracting the annual typical-use failure rate (18%) from 1,

raising the result to the power of thirty, and then subtracting the

result from 1.

That same procedure yields a failure rate for Implanon of less than 1.5
percent. Nexplanon is the successor to Implanon and has features that make it
even more effective.

Oral contraceptives, using the above procedure, have a failure rate of 94
percent.

Clearly, then, Nexplanon is dramatically less likely to fail than the most
commonly used methods of contraception.

http://www.guttmacher.org/pubs...

My links have broken, but other studies confirm the performance of
long-acting forms of contraception. For example, one study found that while
twenty-five percent of teenagers in Georgia and North Carolina who chose a
contraceptive method other than Norplant (an implant) experienced an unintended
pregnancy, none of the Norplant users became pregnant. Another study found that
while seven percent of women and girls 18 years of age and younger who were
using oral contaceptives became pregnant, the number who became pregnant while
using Norplant and Depo-Provera was too low to precisely estimate (zero to two
percent). In addition, a colorado state demographer determined that the
Colorado Medicaid program's approval of the use of Norplant implants was a
large factor in a 25 percent drop in overall repeat fertility rates in that
state.

Also, see the following video.

https://news.wustl.edu/news/Pa...

Also, note that some Western European countries have achieved low rates of
abortion and tend to use more long-acting methods.

Other long-acting methods tend to be nearly as effective as Nexplanon, but
all of them have serious drawback. Sterilization is, of course, usually
permanent. IUDs seem to only be recommended for women who have already given birth to at least one child ("Mirena...is recommended for women who have
had at least one child"). They also have a mechanism of action that is likely to be sometimes post-fertilization. As a result, the right-to-life movement will not get behind IUDs any time soon. Injectables cause bone density loss and are significantly less effective than Nexplanon.

http://www.mirena-us.com/just-...

NorthStar156 said...

Yesterday when I was trying to clean up this post, it disappeared. It happened again tonight, but I found the post again. However, I am not going to edit it any more, so I apologize if it has problems.

NorthStar156 said...

I just posted below. Search for the following text: "Nexplanon is dramatically less likely to fail than the most commonly used methods of contraception."

Kara Baylog said...

That might be true, (I have not seen such evidence at all, I'm just acknowledging that it may exist) but it isn't relevant. We aren't talking about the role the gvt should play in ensuring male parents are responsible in their duties, we are talking about a woman's individual options in a sexual relationship: a) no BC, b) get BC on your own or c) get male partner to contribute or pay completely for BC. Too often, guys will buy condoms, but they refuse to go further than that. I know this come anecdotal evidence with female friends. It doesn't mean it is the majority of men (it may or may not be) but if even one guy refuses to take part responsibility, it is too much. Considering that I am interested in getting maximum BC coverage for the purpose of reducing unwanted pregnancies/ abortions, making BC free or cheap to women would be that safety net to take care of those women whose men are irresponsible and whose own financial situations preclude self-coverage.

I am less interested in enacting laws simply to help men have greater self-control over themselves. Outside of the pregnancy question, what a man does with his time is his own affair.

Kara Baylog said...

Because I am not going to re-read the entire comment wall just to find your one intended reply. Additionally, your intended reply will lack the context of the response I gave previously. I don't remember my posts verbatim, and I don't visit here regularly, as you might have noticed.

Kara Baylog said...

Oh I agree that any long term free BC program would need to include a comprehensive educational aspect. Why not enact in real life what the study did? Free contraception along with the emphasis on the effectiveness of long acting methods?

NorthStar156 said...

Testing......

Ingrid Heimark said...

I support OC being available without prescription, the more available, hopefully the fewer unwanted pregnancies and the fewer abortions

Chandler Klebs said...

I thought oral contraceptives were already available without a prescription. I tend to be against the use of contraception similar to the way I am against guns, cigarettes, alcohol, football, and skydiving. Anything that has potential risks is something that probably should be avoided. My question is though, why is there so much focus on the hormonal forms of birth control?