How over-the-counter birth control pills could improve reproductive health

Being able to buy birth control pills off the shelf took a big step forward on May 10. Two advisory committees to the U.S. Food and Drug Administration voted unanimously to make a birth control pill available without a prescription.

The pill, called Opill and known by the generic name norgestrel, is a progestin-only pill. That’s in contrast to combined oral contraceptive pills, which contain progestin—or another form of progesterone — along with a form of estrogen (SN: 4/13/23). Progesterone and estrogen are two of the hormones that regulate the menstrual cycle.

Opill gained FDA approval for prescription use in the United States in 1973, under a different brand name. The advisory committees that recently met were tasked with considering a switch from prescription to over-the-counter status, which involves reviewing data that the drug can be used safely and effectively without the oversight of a physician.

The FDA committees — one with expertise on non-prescription drugs, the other with obstetric and gynecological drugs — endorsed the switch, and they are not alone. Medical organizations including the American College of Obstetricians and Gynecologists, the American Medical Association and the American Academy of Family Physicians are also in favor of an over-the-counter birth control pill. The FDA is expected to announce a decision on the recommendation this summer.

If Opill gets the over-the-counter nod, it would become the most effective birth control method on store shelves, surpassing existing options like condoms and sponges. It would also remove barriers that can make getting this birth control option challenging for many people.

The possibility that a birth control pill could become more easily available comes as the United States faces a maternal mortality crisis, abortion bans and possible restrictions on an FDA-approved abortion medication (SN: 3/16/23; SN: 6/24/22; SN: 5/18/23). Science News talked with two sexual and reproductive health equity researchers about the impact of over-the-counter access to the pill on reproductive health and autonomy. The interviews were edited for length and clarity.

SN: What barriers do adults and adolescents face in terms of access to different birth control methods?

Rachel Logan, University of California, San Francisco: I think it’s the same barriers for both groups, although I think adolescents face more. It is transportation to health care appointments. [There are] barriers within care, such as some providers requiring a pelvic examination or a full gynecological exam before providing or prescribing contraceptive methods. [It is] a lack of insurance coverage. Unfortunately in this country, because we don’t have federally mandated, comprehensive sex ed, some people just may not know about all of the contraceptive methods that exist.

There continues to be the stigma associated with needing contraception and who uses contraception that is very patriarchal and really demeaning to people, like it says something about you if you have to use these methods, as opposed to [contraception being] an essential tool in your reproductive health journey. Another area that I don’t think is talked enough about is contraceptive coercion — that could be from a parent, a partner or a health care provider — where your options to use the method of your choice are limited for whatever reason.

SN: What could it mean for adults and adolescents to have over-the-counter access to hormonal birth control, especially considering the maternal mortality crisis and abortion bans?

Anu Manchikanti Gómez of the University of California, Berkeley: Providing people the opportunity to be unpregnant is always important, but more important than ever because of these additional crises. Abortion bans have many effects, obviously, on people’s ability to access abortion. But [bans are also] having a chilling effect on health care providers in some states. Maybe they are leaving those states where abortion is banned, or not coming [to those states] in the first place. Those are generally the same providers who might be doing contraceptive counseling or providing pap smears or prenatal care, [so] there can be less access to this care. Birth control can’t solve those issues, but there may be ways that more access is going to be particularly helpful when access is being lost in other ways.

Logan: It feels like we’re in a very critical moment where reproductive autonomy is definitely under threat. So this could mean extending options to people who otherwise may not have an option or a way to obtain a method of birth control that works for them. Being able to walk into a store and pick something off of the shelf that you can use and is very safe and effective is life changing.

SN: What do we know about the historical impact of prescription birth control?

Gómez: The availability of hormonal birth control has been transformative for, historically, cis gender women’s participation in the world, in the workforce, in their ability to engage in education. Being able to control your fertility is such an important part about being able to control your destiny. There are many things that can affect our ability to live the lives that we want, but if you are a person who can become pregnant, [it’s] really important to have the option of deciding if, when and how you want to become pregnant or remain pregnant.

SN: When choosing a birth control method, what does it mean to take a person-centered contraceptive care approach?

Gómez: A person-centered approach, if we’re talking about contraceptive access, means … actually support[ing] the person in making the decision that’s best for them versus what someone else thinks they should be doing. There’s a long history of birth control abuse and coercion in the United States, from forced sterilization to aggressive promotion of certain methods toward Black communities and people who are poor. Even though there are different levels of effectiveness of different types of methods, that doesn’t make one more medically appropriate.

For some people, they don’t like something that they can’t stop using without going to see a health care provider [such as an implant or other long-acting reversible contraception]. You may feel that you’re losing bodily autonomy through using a method that you can’t stop using on your own. That’s a very real concern for some people, and it’s definitely grounded in some of the historical abuses and racism and ongoing experiences of low-quality care that some people, too many people, experience.

Logan: [A person-centered approach] is being OK with people saying, “no,  I don’t want to use that method,” and saying, “that’s fine,” as opposed to [providers] feeling like it’s their job to convince people to get on a method or to use a particular method. [It’s] showing people that you care about them using what feels right and best for them. We’re aligning people’s preferences with methods that are available.

SN: Does the possible over-the-counter availability of hormonal birth control assist with this approach?

Logan: Yes. It gives people the power that they need without these constraints that are really only hurdles. This is in no way to replace routine preventative care. It is to reduce barriers to methods that we know are safe and effective that people can use independently. I think the health care system is already very strained. Is it a good thing that we’re moving some services that we know to be safe and effective outside of the health care system? I would say yes.

Gómez: [Easier access] can make a huge difference for people. Being able to start using [a birth control pill] without seeing a provider, that removes many layers of barriers. All of those can reduce people’s ability to use it at all or to use it continuously. Not everyone wants to use the pill, [but for those who do] having over-the-counter access is really going to help people.