In places where abortion access is ending, contraception is more important than ever. Expanding contraception access reduces unwanted pregnancies, which in turn reduces the need for abortion services.
Over the past 30 years, abortion rates have dropped. And more options and better access to contraceptives — including increased coverage of contraception under the Affordable Care Act — have been credited as a driver of that decline.
Even in states with high marks for supporting reproductive rights, gaps in contraceptive use are unnervingly common.
But contraception still remains frustratingly inaccessible to many who wish to use it. According to Power to Decide, , a nonprofit dedicated to preventing unplanned pregnancy, 19 million women in the U.S. live in “contraception deserts,” where they “lack reasonable access in their county to a health center that offers the full range of contraceptive methods.” Even in states with high marks for supporting reproductive rights, gaps in contraceptive use are unnervingly common. In one recent study of 69,000 women in Oregon (an A- state for reproductive rights), more than half had an interruption in contraceptive prescriptions at some point within a six-month period.
“Cost and financial concerns — time off work, co-pays, transportation — still remain key barriers for people in getting the care they need,” according to Dr. Maria Rodriguez, a professor of obstetrics and gynecology at Oregon Health & Science University and the study’s lead author. “This is particularly true in states that have not expanded Medicaid, or for women with high deductible private plans.”
There are many opportunities to improve contraceptive care, and all states should seek to improve contraceptive use in the upcoming months and years. Here’s where to start.
1. Year-at-a-time supplies and accessible LARCs
Contraceptives need to be as continuous and uninterrupted as possible to provide the best coverage against unintended pregnancy. This requires affordability and convenience. Traditionally, oral contraceptives (birth control pills) and other short-term contraceptives (like the ring or patch) are dispensed one to three months at a time, with refills up to a year. Being able to obtain a year’s supply at once eliminates the need for repeated visits to the pharmacy and has been shown to reduce the need for pregnancy tests (which can be costly), pregnancies and health care costs. For these reasons, the Centers for Disease Control and Prevention recommends that women be prescribed a year’s supply of oral contraceptives and, more broadly, that “a woman should be able to obtain COCs [combined hormonal oral contraceptives] easily in the amount and at the time she needs them.”
Many states have laws promoting longer-term supply, allowing physicians to prescribe a year’s worth of birth control at a time or pharmacists to dispense a year’s supply at a time, and requiring insurance companies to cover medications dispensed in this way. Unfortunately, “very few insurance plans actually comply with the law,” Sophia Yen, a physician and CEO of Pandia Health, a birth control delivery company, told me.
Long-acting reversible contraception (LARCs) like intrauterine contraceptives (IUCs) or subdermal hormone implants can be in place from five to 12 years, eliminating any discontinuity in coverage. In Colorado, offering free LARCs to low-income young women had high uptake and was credited with leading to a marked drop in teen pregnancies and abortions. For their convenience, safety and real-world effectiveness, LARCs should be made cheap, widely available and part of any routine conversation about birth control.
2. Eliminate hurdles in the way of obtaining contraceptives
Online and telehealth prescribing offers convenient access to contraceptives like the pill, patch and ring. In a 2020 KFF survey, only 4% of women of reproductive age used online services to receive contraception, although this number is skyrocketing in the context of the Roe decision. “We’ve seen a three-fold increase of daily users to our site since the Supreme Court decision,” said Yen, a week after the decision was announced.
The vast majority of people still visit a brick-and-mortar facility to acquire their contraception. Allowing pharmacists to prescribe contraception directly to patients at the pharmacy (without requiring a physician or advanced practice provider visit for a prescription) improves access and efficiency. Data from Rodriguez’s study, mentioned above, suggests that pharmacist prescribing improves continuous coverage and the likelihood of remaining on contraception a year after initiation. These laws are in place only in 17 states, and how they are implemented remains a variable patchwork, blunting the potential impact of this approach.
Ultimately, the accessibility provided by over-the-counter contraception is the best option.
Ultimately, the accessibility provided by over-the-counter contraception is the best option. “It is important that people realize the oral contraceptive pill has a safety profile similar to that of over-the-counter medicines, like Tylenol,” said Dr. Rodriguez. Since 2012, the American College of Obstetricians and Gynecologists (ACOG) has recommended that hormonal contraception, including pills, patches, vaginal rings and depot injections be made available over the counter. Earlier this month, the American Medical Association adopted a policy to encourage the Food and Drug Administration to approve over-the-counter access to oral contraceptives. Enabling people to walk into pharmacies and pull contraceptives off the shelves without a prescription at all would be a major breakthrough in contraceptive access.
Contraceptive care has traditionally been left to OB-GYNs and primary care physicians. However, we are in an all-hands-on-deck situation. Any contact with the health system is an opportunity to close gaps in contraception for those who do not wish to be pregnant. A broad range of health care providers care for patients with conditions that are made more complex, severe, or even life-threatening by pregnancy, including diabetes, pulmonary hypertension, cardiovascular disease and stroke. Some specialists routinely prescribe medications that are teratogenic, meaning they carry a risk of causing birth defects, like those that treat seizures. Because reproductive health is so intimately connected with health and well-being, more providers should include in their routine practice counseling patients about contraceptives, prescribing medications, placing subdermal contraceptive devices, and contributing to education and referrals for intrauterine devices and sterilization (vasectomy, tubal ligation or removal) procedures. Unfortunately, the barriers to patients receiving contraception include health care professionals’ own knowledge deficits and fears about prescribing, such as risks and side effects. “It is critical that all health care providers recognize that the risks of pregnancy always outweigh the risks of contraception,” says Dr. Rodriguez. “For (hetero)sexually active, reproductive age people, 85% will become pregnant within a year if they are not using contraception. For highly effective methods, like the IUD, there are next to no contraindications for use.” Our universal role in education as a core component of overall health is key as well. “In coming years, having more non-OB-GYNs place long-acting implants [like Nexplanon] would be helpful,” Dr. Jane van Dis, an OB-GYN physician in New York (and my frequent collaborator) said. “But more importantly, we need comprehensive sex education. Contraception can be moot unless people know they need to take it and understand their options.” Too few states acknowledge, on a policy level, that there are actually two parties to a pregnancy. Just as the ACA mandates any FDA-approved form of female birth control should be covered with no co-pay or deductible, all states should ensure that payers cover male contraception, including condoms and vasectomy. Too few states acknowledge, on a policy level, that there are actually two parties to a pregnancy. Innovation to increase accessibility and timeliness of sterilization is also needed; for example, there is no medically justified reason for the standard 30-day waiting period between vasectomy counseling and the procedure, something that is imposed by Medicaid programs and less often by commercial insurers. Intended to ensure certainty and avoid in-the-moment coercion, requiring a delay and multiple visits may fail to respect individuals’ decision-making, create a greater burden of time and inconvenience, and, because they are applied mostly to low-income patients, exacerbate inequities in contraception. “It’s yet another way that people with fewer means have their reproductive autonomy more limited,” said Dr. Ashley Winter, a urologist practicing in Oregon. Increased access to and ease of continuous, uninterrupted contraception is vital and urgent for states that wish to uphold reproductive justice and health for all its people. In theory, even (one might say especially) states that severely restrict or outlaw abortion access should make contraception, the most effective route of preventing unwanted pregnancies, as simple, cheap, and accessible as possible and ensure a state’s population is well-informed about reproductive health and family planning. Blocking abortion while utterly failing to support access to contraception is cruelly imposing pregnancy, and its dangers and costs, on people and their communities. In a post-Roe world, contraception access is not something we can afford to get so wrong.
Dr. Esther Choo
Esther Choo, M.D. M.P.H., is an emergency medicine physician, health policy researcher and founding member of Equity Quotient, a company that advises organizations on building cultures of equity. She has provided commentary on the pandemic and other health care topics through appearances on MSNBC, CNN, the BBC and Yahoo! Finance and editorials published in The Lancet, the British Medical Journal, The Washington Post, NBC Think and USA Today. 
3. Improve all health care professionals’ engagement in education, counseling, prescribing and referrals
4. Don’t forget male contraception
