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Removing Barriers to Contraceptive Access

Katy B. Kozhimannil, PHD, MPA, is an associate professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health and Director of Research at the University of Minnesota Rural Health Research Center. Her research applies health policy and health services research to the field of women's health, with a focus on maternal and child health. Dr Kozhimannil conducts research to inform the development, implementation, and evaluation of health policy that impacts reproductive-age women and their families. Twitter @katybkoz. E-mail
Starting tthis week, women in California can get birth control pills at the pharmacy counter, without a physician prescription. In Oregon, women over 18 have been doing so since January. This policy strategy—adopting legislation that allows for pharmacist-prescribed contraception access for some hormonal methods (generally, pills and patches)—removes some barriers to access, but falls short of what evidence suggests makes the most financial and clinical sense: making effective contraception as readily accessible as possible to all sexually active women who wish to avoid pregnancy. 
For example, the American College of Obstetricians and Gynecologists supports over-the-counter (OTC) access to oral contraceptive pills, along with many other countries, with positive effects on outcomes. In the United States, we have some unique barriers and constraints, as well as some unique opportunities to improve contraceptive access in order to reduce our costly and stubbornly high rate of unintended pregnancy.
The experiences in Oregon and California provide hope for overcoming political gridlock around contraceptive access; both legislative efforts were bipartisan, and Oregon’s bill was led by Republican legislator (and physician) Knute Buehler.  However, women’s health advocates as well as some Democrats are concerned that these bipartisan agreements don’t go far enough to improve women’s access to contraception, highlighting both the politics at play as well as the evidence supporting easier access than currently-enacted legislation allows. 

While the current efforts underway in Oregon and California have the potential to reduce rates of unintended pregnancy and abortion, they may also reduce healthcare costs through efficiency gains. That is, allowing women pharmacy access to birth control means that physician time and resources are freed up to focus on the myriad other unmet primary care needs

Barriers to Accessing Contraceptives Not Covered by the New Laws

Yet, the laws don’t reduce access barriers for all forms of contraception. Some of the most effective birth control methods are long-acting reversible contraceptives (LARC), including intrauterine devices (IUDs) and birth control implants, which cannot reasonably be made available OTC but do have other modifiable access barriers. The use of LARC holds great promise for both individual and population-level efforts to reduce unintended pregnancy. 
Indeed, a recent article highlights the “IUD revolution,” and notes the considerable success of efforts to increase LARC access via massive efforts to increase IUD use in Colorado, Delaware, Texas and beyond. Reporter Sarah Kliff described 3 key barriers to access:
  1. LARCs are expensive and can cost $500 or more
  2. There are lots of widespread misconceptions about IUDs and implants
  3. It’s often difficult to find a clinic with the skilled personnel and supplies to provide LARCs. 

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