Something unexpected happened a few years ago when drugmaker Ortho-McNeil introduced Ortho Evra, a contraceptive patch women can wear for a week at a time. To let women test how the adhesive feels on the skin, the company ran magazine ads with a chemical-free peel-off sample patch. A week later, to the drugmaker’s surprise, women who hadn’t realized the patch contained no medication began asking how they could get more magazines for refills. That’s the sort of thing that smacks health-care policy experts between the eyes. “Women thought it was safe to just slap it on from a magazine!” exclaims Sharon Cohen, associate director of the Pharmacy Access Partnership.
The more these women’s-health advocates thought about it, the more they felt the consumers were onto something: on-demand, hassle-free access to birth control. Why wait for a doctor’s appointment? Why not just get it when you need it? “There’s an intuitive sense that it should be that simple,” Cohen says.
Few people are saying we should dispense hormonal contraceptives like perfume samples, but there’s a growing wave of medical and political opinion that these methods are so safe, effective, and common that they should be a heck of a lot easier to get. Making the Pill and its modern descendants, the Patch and the NuvaRing, available directly from pharmacists is the goal of Cohen’s employer, an Oakland-based public health nonprofit that over the last six years has been quietly revolutionizing the way women obtain birth control. In 2001, Pharmacy Access Partnership convinced state legislators to back the nation’s first law to let pharmacists dispense emergency contraception — aka Plan B, or “the morning-after pill” — without a prescription. The next year, it launched the Health Step program, which lets women who got Depo-Provera injections from their doctor return to a pharmacist for follow-up shots. Now the group is paving the way for what would be the most sweeping change of all: taking the prescription out of the Pill.
It’s about time.
America has a serious problem: Nearly half of its pregnancies are unplanned, about three million a year, and 43 percent of them — roughly 1.3 million — end in abortion. You could build the world’s biggest calculator and still not be able to compute how much this extraordinary unplanned-pregnancy rate costs our society in medical and social support expenses, lowered educational and career attainment, and emotional distress. But as a tool to deal with the problem, hormonal birth control is unrivaled. It’s unobtrusive, reversible, affordable, simple to use, and 99-plus-percent effective if taken properly. Even factoring in misuse, the Pill has a 3 to 6 percent failure rate, better than condoms, diaphragms, sponges, or spermicides.
It’s also famously safe. As the nation’s leading birth-control method, the Pill has been used by 44.5 million women over four decades. When women are properly screened for preexisting conditions, most negative side effects are minor and temporary, while other side effects are actually beneficial. Pharmacy Access Partnership estimates that if even a quarter of the women “at risk” for unintended pregnancy, and who don’t currently use contraception, were to go on the Pill, half a million accidental pregnancies — and hundreds of thousands of abortions — could be avoided each year.
“I think contraception should be handed out on street corners,” says Judith DeSarno, president of the National Family Planning and Reproductive Health Association, a lobbying powerhouse that has embraced the concept of birth control on demand. “It helps women’s health. Financially, it helps the country to lower unplanned pregnancies. It would lower the abortion rate. I think it should be as easy as possible.”
Why then, after forty years of mainstream use, is birth control still such a pain to get?
It’s true that some pro-life factions still equate birth-control pills with abortion, and have lobbied to keep them less available. Some hospitals and insurance companies with religious affiliations have refused to prescribe or cover birth control, while Republican politicians are rallying to let pharmacists refuse to dispense certain drugs on personal moral grounds. But the bigger issue in the East Bay is one of convenience, and the primary culprit isn’t any pro-life group, but an entrenched medical establishment.
Generally, women seeking birth control have to visit a clinic or wait for a doctor’s appointment to get a prescription that is typically good for only a year’s supply. Renewing it usually requires a pelvic exam, in which the woman is screened for cancer and STDs. Even if the woman’s insurer covers both the doctor’s visit and the pills — and insurers sometimes don’t — most plans dole out the prescriptions one pack at a time: another month, another trip to the pharmacy, another copay. Perhaps most aggravating is that many plans cover only refills purchased just as the previous month’s supply runs out. Women who show up a few days early are told to come back later. If a woman arrives a few days late, that’s a bigger problem — she has probably delayed her next month of birth control, and that can wreak havoc with the effectiveness of hormonal methods.
All of this is what Belle Taylor-McGhee, Pharmacy Access Partnership’s executive director, calls a series of barriers for those at the greatest risk of unintended pregnancy: young teenagers, low-income women, the uninsured, and those who can’t see a doctor during typical office hours. Last year, the nonprofit commissioned a national survey of 811 women to gauge their interest in getting birth-control pills direct from a pharmacist. The feedback was overwhelming: Two-thirds of the respondents, regardless of age, race, religion, or educational background, said yes, so long as pharmacists provided medical screening first. More strikingly, 40 percent indicated that they were not using any form of birth control, but would use a hormonal method if they could get it without seeing a doctor. This alone could have a profound effect on the unplanned-pregnancy rate.
Switching a drug from prescription-only to over-the-counter status is hardly a new concept. Scores of onetime prescription drugs have moved onto retail shelves after being proven safe without a doctor’s okay — hydrocortisone cream for skin rashes, Benadryl for allergies, Sudafed for congestion, and Zantac for acid reflux, to name a few.
In many ways, Taylor-McGhee says, the drugstore is the ideal place to reach out to women the health-care system overlooks. “There’s one on every corner, there’s one in your community, they have convenient hours, they’re open on weekends and holidays,” she says. You also don’t need an appointment or insurance, and can remain relatively anonymous. Many people feel more at ease approaching a pharmacist for advice than a physician. Nobody is going to come at you with a speculum.
“I have no doubt that over-the-counter availability would mean better use of more effective contraception, particularly for teenagers,” says Dr. Philip Darney, chief of obstetric gynecology at San Francisco General Hospital. “They are the ones most likely not to have regular contact with the health-care system, to be frightened of the pelvic exam, to run out of birth-control pills.”
Taking the Pill out of doctors’ hands is a big idea that raises a host of big questions: Is it safe? Who will pay? Will pharmacists want to get involved? There are plenty of details to nail down before this proposal gets to the legislative stage, but making “pharmacy access” work is no mystery. In fact, if you live in the East Bay, there may be a successful model just around the corner.
Around one East Bay corner, in Oakland’s Fruitvale district, is Farmacia Remedios, a small drugstore less than a year old that specializes in selling Mexican products to a mostly Catholic, Spanish-speaking community. Pharmacist Gregory Tertes is boyish and eager to serve his growing clientele; if latecomers straggle in after he has closed the counter, he’ll still pop back there to offer advice in his recently acquired Spanish.
Tertes participates in Pharmacy Access Partnership’s emergency contraception program, which has been running since 2002, and now operates in about fifty East Bay pharmacies. He can’t dispense the Pill, Patch, or Ring without a prescription — only Plan B, the morning-after pill — but the program shows how drugstores could be used to dole out conventional birth control. It trains pharmacists on the use of emergency contraception, and then allows them to dispense Plan B to drop-in clients without a doctor’s input. Tertes is certain he is reaching women who don’t interact with the traditional health-care system. “There are definitely people who come to me who would not go to a doctor for it,” he says.
Plan B contains a high dose of the same hormones contained in the Pill, but is meant to be taken only in an “emergency,” not on a continuing basis. It’s recommended for women who have been raped, have experienced condom failure, or have otherwise had unprotected sex.
In most cases, according to recent research, Plan B prevents pregnancy by halting ovulation — no egg, no embryo. But if a woman has already ovulated, the hormone speeds the movement of the ovum down the fallopian tube, allowing less time for fertilization to occur. As defined by modern medicine, pregnancy begins only when a five-day-old embryo, a microscopic cluster of cells called a blastocyst, successfully implants in the uterine lining, and if all else fails Plan B works to prevent this from happening. The drug cannot terminate a pregnancy — if the egg has successfully implanted by the time the patient takes the Plan B tablets, she is already pregnant and the pills do nothing. Emergency contraception has to be taken within five days of unprotected sex, although it works best in the first three. Time is of the essence, and in lobbying the California legislature the Pharmacy Access Partnership hammered home this simple fact: A trip to the pharmacy is much faster than a wait for a doctor’s appointment.
The legislature agreed, and in 2001 made California the second state, after Washington, in which emergency contraception is available direct from a pharmacist. Five other states — Alaska, Hawaii, Maine, New Hampshire, and New Mexico — have followed, and nine more have introduced similar legislation. (Washington enacted the policy with an administrative change, not a law.) On the federal level, however, the US Food and Drug Administration recently bogged down over whether emergency contraception should get over-the-counter status in every state, even though its advisory committees have already voted 23-to-4 in favor of deregulation. It is now considering a proposal that would make Plan B the first ever “dual-label” drug, which would be sold over-the-counter to one group (women sixteen and older), and by prescription to anyone else.
While Plan B is available through pharmacy-access programs in 49 of California’s 58 counties, it isn’t strictly “over-the-counter” — you won’t find it next to the Tylenol. The pharmacist must first give the woman a safety screening questionnaire and counseling — she pays about $40 for everything. “I go over it with them; I warn them about the side effects,” says Tertes of Farmacia Remedios. “If they’re coming in frequently, I strongly recommend other types of birth control.”
But that’s about all he can do — if a woman is interested in the Pill, he must refer her to a clinic such as Planned Parenthood. It’s not just his Plan B clients who are interested, Tertes says. Almost daily he turns away women who walk up to his counter seeking birth-control pills — which are available in Mexico and a handful of other countries without a prescription.
Tertes isn’t the only frustrated pill-counter out there. Pharmacy Access Partnership recently completed another national survey showing that 85 percent of pharmacists are interested in providing prescription-free hormonal birth control. It’s disconcerting, after all, to dole out Plan B packets to women who are clearly at risk for unintended pregnancy yet be unable to do more than point toward the condom aisle or give them a clinic’s phone number.
Granted, there is a crucial difference between Plan B and the Pill. A woman may take Plan B once or twice in her lifetime, but might use daily contraceptives for months, years, even decades. They’re not always one-size-fits-all drugs, and because women stay on them longer, there’s a greater risk of long-term side effects. Is a health history questionnaire enough to safely dispense daily contraception? Don’t you need a pelvic exam?
The surprising answer is no. True, in private doctors’ offices, getting a prescription for the Pill has traditionally been coupled with an annual pelvic exam, breast exam, and Pap smear. These tests serve a valuable purpose in detecting infections and early signs of cancer. But in 2001 a San Francisco-led research team published an eye-opening reassessment in the Journal of the American Medical Association arguing that pelvic exams were not useful in detecting any conditions that would bar women from using hormonal birth control. The main risk factors with this category of drugs are decidedly nonpelvic conditions such as a history of blood-clotting problems, heart disease, stroke, hypertension, known breast malignancies, or being a smoker. These are the sorts of things more readily caught with a blood-pressure test and a thorough medical history. Mandating pelvic exams, the study concluded, “may reduce access to highly effective contraceptive methods, and may therefore increase women’s overall health risks. These unnecessary requirements … unwittingly reinforce the widely held but incorrect perception that hormonal contraception methods are dangerous.”
The FDA, World Health Organization, and Planned Parenthood, among other public health agencies, no longer advocate a pelvic exam as a prerequisite, yet many private medical practices still use the promise of a new birth-control prescription as a hook to get women to take the exams. “Young women should be screened for sexually transmitted infections and should have a Pap smear,” Darney says, “but holding their contraception hostage isn’t the way to do it.”
Nor is it necessary, if you extrapolate the results of last year’s Pharmacy Access Partnership survey: 93 percent of the women using nonhormonal birth-control methods and 88 percent of those not using birth control reported that they’d voluntarily gone in for a Pap within the last 24 months. While the survey wasn’t definitive, it strongly suggested that women already understand the benefits of the test.
With the Pap hurdle out of the way, at least in theory, Washington state launched a pilot program two years ago to gauge consumer response and see how pharmacists would handle the increased workload of assigning birth control. It operated much like California’s emergency contraception program: Specially trained pharmacists took women’s blood pressures and medical histories, and screened out those at risk. The women initially got three months’ worth of pills, and had to return for a follow-up screening and blood-pressure check to get the rest of the year’s supply. After paying $25 each for those two visits, the women got an unlimited number of free follow-ups; for the drugs, they could either pay out of pocket or bill their insurance companies.
Dr. Jaqueline Gardner, the University of Washington pharmacy professor who led the experiment, gives it a big thumbs-up, although the final results won’t be published until later this year. The rate of adverse side effects mirrored what doctors see during ordinary clinical practice, and some of the drugstores said they’d be interested in offering similar services in the future. “The big research question at hand was: ‘Could you put this into pharmacy practice and safely prescribe?’ and we believe the answer is yes,” Gardner says. “Our experience has been that every time pharmacists are brought into public health situations in which they could increase access to services that are not getting done … they’ve shown themselves to be not only happy to do it, but people are very satisfied with what they provide.”
Pharmacy Access Partnership hopes to organize a similar pilot program for California as early as next year. But despite Washington’s success, there’s no guarantee of smooth sailing. Not all pharmacists embrace the idea of pharmacy access for the Pill, even though they may have collaborated with the nonprofit on other initiatives.
Jim Cohen has owned the Medicine Chest in Hayward for twenty years, and for the last several has been dispensing emergency contraception and refill Depo-Provera shots. His shop is about as different from Farmacia Remedios as two drugstores can be — instead of banda tunes blaring from ceiling speakers, ’50s hits pump from a jukebox. Instead of tightly packed shelves of perfumes and Mexican candies, the Medicine Chest has a classic soda fountain with vintage red-vinyl booths. Cohen sinks back in his office chair, puts up his cowboy-boot-clad feet, and closes his eyes while he mulls the question of pharmacy access to hormonal birth control. “I have some fears about that,” he finally concludes.
Like Tertes, Cohen believes repeat users of Plan B should be encouraged to try routine birth-control methods, but he has reservations about taking responsibility for starting a hormonal method then and there. He isn’t reassured by the recently adjusted FDA guidelines regarding pelvic exams and Pap smears — he’d still rather that women had them. And, he wonders, shouldn’t he also be administering a pregnancy test? “If I were in a clinic setting where I had access to all that stuff that would be another issue, but just in a retail pharmacy like this I don’t think it’s appropriate,” he says. “It would be really complicated, I think, to work out the protocols of how things are going to work. It’s not as simple as someone coming in for emergency contraception.”
Cohen is correct in noting that, while there is only one Plan B, there are dozens of brands of birth-control pills on the market. Although most are equally effective, work the same way, and are based on similar chemicals, there are differences. They come in varying dosage levels and may have different side effects. Some contain progestin (synthetic progesterone), while others use combinations of the female sex hormones estrogen and progesterone. Some pills give the woman consistent doses for 21 days, followed by 7 days of placebo pills; others alter the daily dosage each week for three weeks, then revert to placebos for the fourth week. Cohen wonders whether pharmacists will be able to select the right type for each patient.
Darney and other supporters of greater access to the Pill are convinced pharmacists can be trained to do it right. So long as the pharmacist is taught how to select among the broader categories of pills, Darney says, choosing between brands differs little from selecting between bottles of ibuprofen: It’s mainly packaging, and the consequences of picking the wrong brand are not severe. “If you were unhappy with your choice, the unhappiness won’t be due to some horrible consequence,” he says. “It will be due to the bothersome things about taking birth-control pills — irregular bleeding, sometimes nausea.”
Indeed, modern birth-control pills — which employ doses ten times smaller than those first approved by the FDA — have a superior medical track record. “Very frankly, hormonal contraception is safer than aspirin,” says Judith DeSarno of the National Family Planning and Reproductive Health Association. However, oral contraceptives have been linked to a few serious conditions, most notably increased risk of blood clots. For this reason, the Pill isn’t recommended for women with a personal or family history of blood clots — or hypertension, since the hormones also can elevate blood pressure.
There’s conflicting evidence on breast cancer risk. The National Cancer Institute cites three studies: A 1996 epidemiological study involving more than 153,000 women found that current or recent users of oral contraceptives had a slightly higher risk of developing a tumor, while a later study of 4,411 women reported a “significantly” elevated risk for women aged 20 to 34. A third study, involving 9,257 women, found no significant increase in risk for women 35 to 64. In the comprehensive 1996 analysis, the researchers found that a woman’s breast cancer risk returned to normal within ten years of quitting the Pill. There’s also some evidence linking oral contraceptives to the development of glandular cervical cancer and a very rare form of liver tumor.
For people who oppose birth control for ethical or religious reasons, these potential risks are another reason to avoid it. Tim Wohlers directs client services for the Pregnancy Care Clinic, a faith-based counseling program based in Antioch and Concord. The group is pro-life and promotes abstinence; for pregnant women, it offers help with parenting and information about adoption, abortion, and parenting options. Clinic staffers will provide information about birth control, but won’t prescribe it, and they are careful to spell out its risks — something Wohlers thinks many birth-control advocates don’t do thoroughly enough. “If the risk there is even very, very small, a one-in-a-million chance you’re going to get breast cancer, we need to inform people of that and have really good information on failure rates,” he says, adding that people should also be made aware of the risks to those with a family history of blood clots, stroke, or heart problems.
Wohlers worries that making the Pill more easily available will multiply the dangers. “What about the thirteen-year-old girl who is going to be picking up the box, bringing it home, throwing the box and any information that was written in medical jargon on a little strip away?” he asks. “Who is going to inform her about the risk and potential side effects and life issues that are going to come out of a decision like that?”
Some pro-life advocates go so far as to insist birth control is downright dangerous, and misleadingly lump it with RU-486, the drug used to induce medical abortions. RU-486, which also has a strong safety record, isn’t birth control, but a rigorously controlled prescription drug used to abort a fetus during the first seven weeks of pregnancy. It may be obtained only through a series of clinical appointments.
Representatives of two pro-life doctors’ groups did not respond to interview requests, but Pharmacists for Life International did. The group recently made headlines by defending a pharmacist’s right to refuse to dispense the Pill or Plan B to patients with prescriptions. Executive director Bo Kuhar doesn’t mince words on the subject of oral contraceptives. “They are flat-out dangerous and only fill the coffers of Big Pharma while millions of women suffer the side effects and dangers,” the pharmacist writes in an e-mail. “Warnings found in the professional insert for these products clearly [show] they are physically quite harmful to women. Studies also show women using steroids as found in [oral contraceptives] and other products have many more psychological and physical problems, as well as broken relationships and marriages, than women who do not use them.”
Kuhar declined to cite the studies he was referring to, and eventually stopped replying to e-mails altogether. And while you’d be hard pressed to find a credible study linking the Pill to psychological problems or broken marriages, it’s not hard to locate medical literature linking oral contraceptives to a long list of health benefits. Taking the Pill decreases a woman’s risk of endometrial and ovarian cancer, ovarian cysts, ectopic pregnancies, and pelvic inflammatory disease. Birth-control pills also are often prescribed to combat acne or govern irregular menstrual cycles, and can reduce common premenstrual symptoms such as cramping. In addition, pro-choice advocates are quick to stress that any form of hormonal birth control is far less risky than carrying a pregnancy to term, which kills about one in ten thousand pregnant women in the United States. “Even without considering pregnancy, birth-control pills have a positive effect on health,” SF General’s Darney says.
Would hormonal contraceptives maintain the same safety record if dispensed without a doctor’s supervision? Dr. Glenda Newell, associate director of primary care for Planned Parenthood Golden Gate, supports exploring pharmacy access for low-risk patients who’ve been rigorously screened, but says there’s only so much a pharmacist can tell from a questionnaire. Women eager to get the drugs often lie about their medical histories; others are unclear about the date of their last period, which makes it hard for the provider to know whether the patient might be pregnant. “In providing access for people, you don’t want to make it so easy that something falls through the cracks,” Newell says. She also wonders who will be liable and ready to offer care in case of an adverse reaction. “Is the pharmacist going to handle that phone call?” she asks. If the pharmacist must refer someone to a doctor, the physician says, “then we the providers are put in the position of having to give advice to a patient we’ve never seen, nor do we have a chart on.”
The directors of Pharmacy Access Partnership say they don’t intend to create conflict between pharmacists and doctors. “The concept is not to replace any other current clinical or routine gynecological care,” Taylor-McGhee says. “It’s an added point of access for women that fits their lifestyle.”
One thing that concerns both proponents and skeptics of pharmacy access is that the Pill doesn’t protect against sexually transmitted diseases, as condoms do. “Access is great, but are pharmacists going to be offering condoms at the same time they’re offering birth control?” Newell asks. “Because [if not], the patient walks away thinking ‘I’ve gotten this taken care of’ when they’ve only got the birth-control piece taken care of.” Nearly everyone interviewed had pretty much the same solution to this conundrum: Encourage women to use both.
But money could be the real X factor in all this: How will deregulating birth control affect price and insurance coverage? Officials from the Pharmaceutical Researchers and Manufacturers of America (representing prescription drugmakers), Consumer Healthcare Products Association (which lobbies for nonprescription drugmakers), and America’s Health Insurance Plans (an insurance lobby) declined comment — the proposal was just too new and too speculative, they said.
Family-planning lobbyists, who’ve spent countless hours pondering this question, acknowledge the complexities that loom. “It’s a double-edged sword if it goes over-the-counter,” DeSarno says. “Here we are fighting very hard to get insurance coverage for contraception, and if it goes over-the-counter, insurance companies don’t cover over-the-counter drugs — Medicaid doesn’t pay for it either, so that would be a huge hit.” Women, she worries, might then have to pay full price out of pocket, particularly if tight-fisted insurers see it as an opportunity to write off birth control as a “lifestyle” drug. As for low-income women whose contraception is paid for by state-funded family-planning programs, the legislators would have to decide whether to keep covering the cost, says Norma Arceo, a spokeswoman for the California Department of Health Services.
Rivalry between brand-name manufacturers, who would have to compete in the consumer market, might drive prices down. Then again, the costs of engaging in an advertising war could just as easily raise prices. George Pennebaker, president of the California Pharmacists Association, who supports pharmacy access for birth-control pills, points out that the switch would likely happen brand by brand as the drugmakers petition the FDA with proof that their pills are safe enough for nonprescription use. “Manufacturers are going to be sitting in a boardroom office trying to decide if they want to make it an over-the-counter drug — they’re going to have some long and interesting conversations and study an awful lot of statistics,” he says. “And they’re going to be sales statistics, not medical statistics. The decision is: ‘Is it going to sell better as an over-the-counter product?'”
It most likely will. Even now, oral contraceptives are an exceedingly lucrative market. Consumers use them for years at a time and, unlike most medicines, they are aimed at healthy people. That’s one heck of a target audience. In fact, if birth control didn’t generate such a tremendous load of cash, it’s possible the Pill would have never been more than a glint in Margaret Sanger’s eye.
In the bad old days, the home remedies women used to prevent pregnancy were so thoroughly bizarre, vile, and dangerous that it’s hard to believe our species survived at all. Except, of course, that the remedies rarely worked.
Out of desperation, ladies consumed everything from mercury to gunpowder to dried beaver testicles brewed in alcohol to pennyroyal, which is highly toxic except in small amounts. They tried spermicides made out of nearly any sticky thing imaginable (honey, rosin, olive oil, elephant dung), and cervical caps fashioned out of just about anything else (paper, fruit rinds, beeswax, rubber, sponge). Back then, emergency contraception meant nasty postcoital douches of vinegar, liquid chloride, or Lysol; some of these attempts caused severe infections. Women who were more concerned with heavenly payback stuck to the church-sanctioned method of abstinence, or, if married, the rhythm method.
The ineffectiveness of most of the early methods was partly obscured by the fact that, prior to the Industrial Revolution, women became fertile much later — around age seventeen or eighteen — and teenagers could experiment somewhat without risking parenthood. Nowadays, partly due to better nutrition, most girls get their first period between twelve and thirteen, meaning that the unwed teen mom is a relatively recent cultural phenomenon. So is our understanding of how pregnancy works. It wasn’t until 1827 that scientists discovered that mammals have eggs, or until 1843 that they understood the route to fertilization. It was around that time the first modern contraceptive methods were introduced: the diaphragm in 1842 and the rubber condom in 1869.
Along with this greater understanding of reproductive biology came a government crackdown fueled by fears that birth control would lead to promiscuity and lewdness. Congress passed the anti-obscenity Comstock Law in 1873, making it illegal to distribute contraceptive devices through the mail, which was how most people got them. State laws made it a crime punishable by fines or jail time to distribute information on the subject, or even for married couples to use birth control at home.
America’s first birth-control activists were led by Margaret Sanger, a nurse appalled by bungled back-alley abortions she’d seen, and by the death of her own mother after eighteen pregnancies. She opened the first birth-control clinic in 1916 and was promptly arrested. Activists like Sanger adopted highly confrontational tactics: They would boldly flout the Comstock Law to provoke high-profile arrests and force matters into the courts. Their fight, which took nearly fifty years to win, kicked into high gear in 1961 when Planned Parenthood leaders Estelle Griswold and Charles Lee Buxton bucked state law to open a clinic in Connecticut, home at the time to some of the nation’s strictest anti-birth-control laws. Forty years ago this month, the US Supreme Court quashed the Comstock Law in the case of Griswold v. Connecticut, a ruling that gave birth to the notion of a constitutional right to privacy. This key concept underlies not only the Roe v. Wade ruling that legalized abortion, but many other privacy rights that are now considered fundamental to American life.
All the while, Sanger had dreamed of a pill women could take to prevent pregnancy. Discreet and female-controlled — no one but the woman need know she was using it — it would let women choose when to bear children, and thus allow them to play a greater role in the workforce and society. By the 1940s, Sanger’s dream was entering the realm of possibility. Scientists understood enough about the link between hormones and female fertility to know estrogen and progesterone could inhibit ovulation. But natural progesterone was fabulously expensive — up to $1,100 an ounce — and it could not yet be made in a lab. A major breakthrough came when chemist Russell Marker discovered that it could be derived from a wild yam native to Mexico, which local women traditionally ate to prevent pregnancy — one old-time remedy actually had worked!
But while a birth-control pill was now scientifically feasible, religious authorities found the idea morally repugnant. The Catholic Church, in particular, opposed any form of contraception except the rhythm method, in which married couples have sex only during the “safe” parts of the menstrual cycle, when women are unlikely to conceive. Feminists, hoping to sway the debate from morality to science, sought out doctors to legitimize their cause. They found a champion in John Rock, a Catholic doctor who argued that the pill was natural because it mimics chemicals already present in women’s bodies; by suppressing ovulation, he said, the drug merely extended a woman’s number of “safe” days.
Fearing boycotts, many drug companies still wouldn’t touch the Pill. Finally, in 1957, drug company G.D. Searle approached the FDA with a drug it called Enovid, asking that it be approved as a therapy for “menstrual disorders,” since the Pill also regulates the menstrual cycle. The agency approved Enovid, but required a label warning that the drug would prevent ovulation.
American women weren’t dumb. Within two years, a half million had gone to their doctors complaining of “menstrual disorders” and asking for Enovid. Pharmaceutical companies weren’t dumb either: They smelled profits. The average American woman wants only two children, which means she needs some form of contraception for the better part of three decades. That’s called built-in customer loyalty. By 1960 Searle had come around to marketing Enovid as a contraceptive, and the Pill had finally arrived. Rival companies quickly followed. Today 98 percent of American women have used some form of birth control, and 82 percent have tried the Pill.
This makes some people very unhappy. Some of the religious groups that originally condemned hormonal birth control still do. And some pro-lifers view it as causing abortions, although this view is not universal in right-to-life circles. To understand their objections, it helps to understand that, much like emergency contraception, the Pill prevents pregnancy in three ways, each providing a backup for the others. It suppresses ovulation; it thickens the woman’s cervical mucus, making it more difficult for sperm to reach the egg; finally, should sperm manage to fertilize the egg, the Pill prevents the resulting blastocyst from implanting in the uterus. Failure to implant is also a natural phenomenon — it happens in about one in five cases.
Although science views pregnancy as beginning at implantation, many religious faiths teach that life starts when sperm meets egg. In this light, some abortion-rights opponents view the third mechanism as “chemical abortion.” It’s a serious concern for them; there are even Web sites that attempt to tally how many potential lives have been aborted via birth control pills. Consequently, some pro-lifers think increased access to hormonal birth control means increased access to abortion. “Since they are all abortifacient in one mechanism of action, no doubt the rates of all abortion will go up,” e-mails Kuhar of Pharmacists for Life International, who claims that the rate of chemical abortions from oral contraceptives and other hormonal birth-control products is four to five times that of surgical abortion. “It stands to reason,” he writes, “those staggering rates can only go up when the products are unsupervised.” It’s impossible to check Kuhar’s math, but you see his reasoning.
A more moderate pro-life critique of expanding access to the Pill is that by making it easier to get, you make it — and therefore extramarital sex — more socially acceptable. “If something is there and easily accessible, people are going to try it more,” says Wohlers of the Pregnancy Care Clinic. A Presbyterian pastor as well as a clinic staffer, he says he often counsels young girls who were smooth-talked into sex before they were ready, or others who made relationship choices thinking they couldn’t get pregnant — and then did, or ended up with an STD or a broken heart. “I see so many people that thought that the consequences were going to be all taken away and they made choices they might not have made otherwise and are really hurting because of it,” he says.
Pharmacy access also eliminates what Wohlers views as a de facto “cooling-off” period. “The whole waiting period of having to make an appointment to see a doctor, I think that sometimes that can be really helpful,” he says. “You have to talk with a doctor and make sure you have a really good understanding that these aren’t foolproof, and what the failure rates are, and how to properly understand the method of what you’re using.”
The truly mind-blowing thing is that activists on both side of this debate profess the same goal: reducing the abortion rate. Couldn’t improved access to reliable birth control be a bridge between moderate factions on both sides? After all, more than four out of five American woman have used the Pill, which means countless pro-life women and their partners also have used it. Pharmacy Access Partnership’s Taylor-McGhee throws down the gauntlet: “If you say that you really are opposed to abortion and you want to stop abortion, then you ought to be doing everything you possibly can to prevent unintended pregnancy,” she says. “So why are we standing in the way of women having access to something that’s going to prevent an unintended pregnancy and possibly an abortion?”
But the divide may already be too vast. Asked whether the two sides might be able to join hands on the matter of birth control, Wohlers doesn’t hesitate. “Never,” he replies wistfully.
If anything, there’s reason to believe the poles are growing farther apart. Particularly alarming to the pro-choice camp is a subtle campaign by abortion-rights opponents to change the legal definition of when life begins. Last year’s Unborn Victims of Violence Act, which grew out of the Laci Peterson murder, mandates that two crimes have been committed if the victim is pregnant and loses the baby. Although federal policy has long held that pregnancy begins at implantation, this recent law defines pregnancy as a fertilized egg. It’s a seemingly trivial and unenforceable detail, and yet it lays the groundwork for the argument that unimplanted embryos have human rights, and that birth control is a crime against them. “You can’t even really touch that one in court, because how would you be able to prove a woman was carrying a fertilized egg?” DeSarno asks. “But it’s very clever of them to change the definition in this way, because at some point it’s going to [put] the easy access to contraception that Americans take for granted at risk.”
For birth-control advocates, such ominous moves have created a sense of urgency, a need to rapidly make hormonal contraceptives a more accessible, and therefore accepted, part of American life. The pharmacy is a logical place to do it. Far less controversial than schools, available at odder hours than clinics, more approachable than doctors’ offices, they offer health-care technicians who are usually happy to do more than count and pour. As it stands, retail pharmacists perform an increasing number of clinical services that were once the sole province of doctors: for example, flu shots and other immunizations, diabetes management, blood-pressure testing and, recently, emergency contraception. There’s every reason to believe that most of the concerns raised by doctors and pharmacists could be addressed with a well-designed protocol — making sure women return for check-ups, as the Washington pilot study did; and making sure they leave the store armed with information about using condoms and the need for an annual Pap smear. It may not be simple, but it’s far from impossible.
The science, the demand, and the Washington test model are in place — all that’s needed now is the political will, and that’s on the rise in California. There’s a burgeoning sense among women’s-health advocates that the fight for the Pill didn’t end in the ’60s with the demise of the Comstock Law; that the policies keeping such a tight line on birth control are driven less by medical necessity than by a centuries-old subliminal fear that if sex doesn’t lead to permanent consequences — like kids — women will keep on having it. And liking it. And that they’ll spend less of their time bearing and raising children, and more doing whatever else it is they’d like to do.
Because even in the 21st century, the sexual double standard is in full effect. You can point to the prevalence of contraceptives and say women are now as libertine as they want to be, but making oral contraceptives legal and available for a price isn’t the end of the road. Not by far. There are still enough barriers that three-million-plus women accidentally end up pregnant every year, and that should be impossible to ignore. The burden falls not just upon those three million women, but our health-care system, social service programs, employers, and state and federal budgets — upon all of us, in other words. “The bottom line is, do we want women to have control over making these private medical decisions so they can fully participate in society?” Taylor-McGhee asks. “Until we get to the point where birth control is deregulated and women don’t have to go through these hoops and hurdles, we’re still going to be running into issues like, will her provider say no? Will her pharmacy stock it? Can she get it where she needs it and when she needs it? Will she be able to afford it?”
Unless our policymakers remove more of the restrictions governing birth control, there are going to be times when the answer to these questions is no. And the unfairness is apparent as soon as you ponder what would happen if the people being denied birth control were men. Because deep down, a lot of us have a sneaking suspicion that if men could get pregnant, the handling of birth control would be wildly different. If men could get pregnant, birth control would be a right, not a product. It would be federally funded, most likely, if not handed out on the street like Easter candy. If men could get pregnant, we wouldn’t be having this discussion at all.