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Making Contraception More Available

MHE PublicationMHE June 2022
Volume 32
Issue 6

Demand for birth control obtained through telehealth or without a prescription continues to grow, and some states have loosened up their rules. Meanwhile, groups and organizations involved in contraception are bracing themselves for the effects of the U.S. Supreme Court decision today overturned Roe v. Wade and the constitutional right to abortion.

Editor's note: Updated on June 24

Access to abortion will be curtailed in many states after today's U.S. Supreme Court decision overturning Roe v. Wade. At the same time, other states and organizations are making it easier to obtain contraception and medication abortion drugs.

With increased availability of contraception, “there are certainly (fewer) unwanted pregnancies and abortions,” said Krishna Upadhya, M.D., M.P.H., FAAP, vice president of quality care and health equity at Planned Parenthood Federation of America.

Before the court decision today, the number of abortions in the U.S. had been steadily decreasing for about 30 year. But a recent report from the Guttmacher Institute showed an 8% increase from 2017 to 2020 (862,320 in 2017 to 930,160 in 2020). Thirteen states have "trigger laws" that will ban abortion after the Supreme Court ruling today.

While access to abortion is being curtailed, some states, organization and businesses are taking steps that are increasing access to contraception. Allowing people to obtain hormonal birth control without a prescription is one way some states have improved access to contraception. In February 2022, North Carolina became the most recent state to enact such a law, which allows people to purchase contraceptive pills and patches at drugstores after consulting with a pharmacist but without a prescription from a doctor. According to the Guttmacher Institute, it’s one of 17 states and the District of Columbia that allow pharmacists to provide birth control, a group that includes right-leaning states such as Arkansas (its regulations are still being developed) and Idaho.

However, a majority of states still require a prescription — that can be a barrier to access for some people, notes Upadhya. They may lack transportation to get to a healthcare provider or have a busy schedule with work and child care issues. Even if birth control is dispensed at a drugstore without the need for a prescription, it may be difficult to travel to a brick-and-mortar store pharmacy, Upadhya says.

Carrie N. Baker

Carrie N. Baker

Cost is also an issue, notes Carrie N. Baker, Ph.D., J.D., professor of American studies and professor of the study of women and gender at Smith College. Birth control may not be covered by insurance if it is acquired without a prescription. And some women with insurance still face copays or provider charges, she points out. The Affordable Care Act requires coverage for 18 methods of contraception without cost sharing, but health insurers can use formularies, prior authorization requirements and other restrictions that wind up limiting contraceptive choices, according to the Guttmacher Institute.

COVID-19 demand

Women can face other challenges as well when it comes to obtaining contraception. Approximately 19 million women live in contraception deserts, where they “lack reasonable access to healthcare,” says Varsha Rao, MBA, CEO of Nurx, a virtual care startup in San Francisco that focuses on women’s health. Most contraception deserts also have few pharmacies, including rural areas or urban ones that underserve, Rao says.

Varsha Rao

Varsha Rao

Nurx was founded in 2015 to help address that shortage by offering a women-focused healthcare platform. Along with providing contraception to residents of almost 40 states, it offers services such as tests for sexually transmitted infections, pre-exposure prophylaxis for HIV, and some migraine and dermatological treatments.

Chelsea Clinton, daughter of former President Bill Clinton and vice chair of the Clinton Foundation, is a board member. In February, Nurx merged with Thirty Madison, a specialty healthcare company that has brands that offer care for migraines, hair loss and other conditions.

Nurx provides asynchronous care, meaning the patient provides information about their needs and then a provider reviews it and asks questions if needed before writing a prescription. The birth control is delivered to the patient’s door. Most patients pay with their own money, but the company also accepts insurance.

As the COVID-19 pandemic swept through the country, Nurx saw demand for contraception jump 50%, Rao says, and requests for emergency contraception jumped 300% as the pandemic made it more difficult for patients to see providers. Emergency contraception, which prevents pregnancy, can involve the insertion of a copper intrauterine device, which prevents sperm from fertilizing an egg, or oral medications such ulipristal and progestin that inhibit ovulation. Nurx sells the oral medications. Nurx serves approximately 400,000 consumers each month, and approximately 40% of its patients are in the South.

Planned Parenthood has moved toward providing services remotely. The organization has an app through which residents of 40 states and the District of Columbia can request birth control or emergency contraception. Once they pay, the contraception is mailed to them. Planned Parenthood accepts Medicaid from residents of Michigan, Minnesota and Wisconsin. The organization also has a telehealth option that accepts some health insurance plans.

The effect of abortion restrictions

The abortion case the court decided today is called Dobbs v. Jackson Women’s Health Organization. At issue was a Mississippi law that bans almost all abortions after 15 weeks of pregnancy. The majority opinion was written by Justice Samuel Alito and joined by four other justices in overturning Roe V. Wade. Chief Justice John Roberts voted to uphold the Mississippi law but didn't sign on to Alito's opinion overturning Roe v. Wade.

According to a Guttmacher tally before today's court decision, nine states have enacted 33 abortion restrictions this year. Among the most restrictive is the law in Texas that bans most abortions as soon as any cardiac activity can be detected, which is at approximately six weeks of pregnancy.

Rao says requests for emergency contraception from Texas have nearly doubled since the “heartbeat law” went into effect.

Anti-abortion activists are increasingly focusing on medication abortions, which now account for almost 55% of the abortions in the United States; in Europe they account for 90% of abortions, notes Baker.

In medication abortion, a drug called mifepristone is taken first. It blocks the production of progesterone so the pregnancy can’t continue. Misoprostol is then taken 24 to 48 hours later, causing cramping and bleeding that empties the woman’s uterus.

Results of a small study reported in the Aug. 24, 2021, issue of JAMA Network Open showed that medication abortion drugs delivered by telehealth was safe and effective. Ushma Upadhyay, Ph.D., M.P.H., an associate professor of obstetrics, gynecology and reproductive science at the University of California, San Francisco, and her colleagues reported that 105 of the 110 participants having a medication abortion had a complete abortion without intervention.

Nineteen states require providers to distribute the medication in person, Baker says. Women may try to get around those rules by going to other states for telehealth abortions, having medication sent to friends in other states or using a mail-forwarding service, she says.

Allowing access to abortions via telehealth reduces travel time and costs for women who don’t live near a clinic and would have to travel elsewhere for care, says Kaori Sueyoshi, M.P.A., M.P.P., director of innovation at Planned Parenthood. Telehealth also means women don’t have to take time off work or find child care, as they would with an in-person abortion, she says: “It fits the needs of people who are most underserved,” Sueyoshi says.

Anti-abortion activists and lawmakers say medication abortion drugs obtained via telehealth subvert state laws, and some states prohibit them. Texas, for example, has added fines and possible jail time for anyone who prescribes the pills by way of telehealth or through the mail.

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