Column: Despite benefits of over-the-counter birth control pills, there are also risks
Opill, the first daily, over-the-counter birth control pill, is now available. As with all OTCs, people can buy it without a prescription from a healthcare provider, but is this good or bad? It’s hard to make a definitive statement at this point because there are aspects of both.
First, the good. Opill is marketed as being convenient, safe, and effective. It’s certainly convenient: customers can purchase the pill online without consulting anyone. It’s largely safe: progestin-only pills like Opill have been prescribed for decades. And it’s effective: “perfect use” results in a 98% effectiveness rate.
Opill may also improve access for anyone living within contraceptive deserts, or areas where people lack sufficient access to facilities offering a range of contraceptive options. While it doesn’t single-handedly solve the problem of access, the pill does give people another option for contraception.
Next, Opill allows people to obtain the pill discreetly without the knowledge or approval of their partners. This can benefit victims of intimate partner violence who are prevented from accessing contraceptives.
There are, however, downsides. Increased access to birth control pills may discourage the use of barrier contraceptives such as condoms. Birth control pills don’t protect against sexually transmitted infections (STIs). Barrier methods do. If Opill’s availability discourages the use of barrier contraceptives, this may result in a higher prevalence of STIs.
Indeed, one study found that within a population at high risk for STIs, nearly half of women who consistently used condoms before going on oral contraceptives stopped doing so after going on the pills. That is concerning. The researchers also found that being advised to always use condoms in addition to oral contraceptives during clinic consultations significantly increased the odds of condom usage. This suggests that clinical consultations helped promote STI prevention whereas Opill eliminates the need for clinical consultations. From a public health perspective, this could be a problem.
Eliminating clinic visits can also be problematic in other ways. We lose benefits associated with shared decision-making, in which providers’ insights improve patients’ ability to make decisions. Clinical encounters are also an effective mechanism for catching situations where female patients may be the victims of abuse or trafficking. A supposed benefit of Opill is that it gives victims discrete access to contraceptives, but a better solution would be to detect abusive or exploitative situations and help victims escape those situations. Clinic visits can facilitate that process. Mail-ordered contraceptives cannot. In fact, they might impede it.
Opill is also a progestin-only pill, which works in two ways: by preventing sperm from getting to eggs and by preventing ovulation. Either way, fertilization—where sperm and egg meet and form an embryo—is prevented. This isn’t the whole story, though. Opill may also slow down the movement of the ovum through the fallopian tubes or affect endometrial function. This means two things.
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First, in rare cases where fertilization occurs, embryos may struggle to move from the fallopian tube to the uterus. This can cause an ectopic pregnancy, which is life-threatening and requires medical attention. So, when fertilization does occur, progestin-only pill users need to understand their increased risk for ectopic pregnancies. Second, if Opill changes the endometrium, embryos may struggle to implant (and therefore survive) within the uterus.
These effects are known as postfertilization effects and failure to mention them threatens informed consent. After all, they are relevant to people’s reproductive choices. One study, for example, found that 38% of respondents expressed an intention to not use or stop using any birth control method that had postfertilization effects. If, therefore, Opill potentially has postfertilization effects it would be alarming to find that these effects are not mentioned in its promotional materials.
Relatedly, when pills prevent implantation, do they actually “prevent pregnancy?” It depends. If pregnancy begins at implantation, then preventing implantation prevents pregnancy. If pregnancy begins at fertilization, then preventing implantation interferes with pregnancy. Unfortunately, people disagree over definitions of “pregnancy.” So postfertilization effects are “abortive” to some and “contraceptive” to others. This means the ethics of Opill intertwine with the ethics of abortion.
The takeaway is that OTC birth control pills, despite having benefits, could potentially do more harm than good and it is important to keep this in mind. From a public health standpoint, improving access to healthcare and improving the health of our communities are important goals. We cannot pursue these goals via morally objectionable or unnecessarily risky paths, however. And we must not become so enamored with the perceived good of an innovation that we overlook its risks.
− Nicholas Colgrove is an assistant professor in the department of Health Management, Economics and Policy at Augusta University.
This article originally appeared on Augusta Chronicle: Ethical issues to consider with over-the-counter birth control access
