Prescription Birth Control Access Among U.S. Women at Risk of Unintended Pregnancy

Introduction

Preventing an unwanted or mistimed pregnancy is important for the health and well-being of the 43 million women at risk of an unintended pregnancy in the United States. ¹ Half of all pregnancies in the United States are unintended, and the proportion increased between 2001 and 2008 (from 48% to 51%). ² Women who use contraceptives correctly and consistently comprise only 5% of all unintended pregnancies; the vast majority of unintended pregnancies are attributed to contraceptive nonuse and inconsistent use. ³

Oral contraceptives, used by 10.6 million women, are the most widely used contraceptive method in the United States. ¹ Other prescription-based hormonal contraceptives, including the contraceptive patch and ring, are also commonly used. ¹ These methods are 91% effective with typical use and 99% effective with perfect use. ⁴ However, limited research indicates that the prescription requirement for these methods may be a barrier to uptake and consistent use for some women. ^{5 –7}

Studies have shown that not having time for medical visits and the cost of a doctor's visit can make it difficult for women to obtain a prescription or refill for contraception. ^5,6 Other research has found that running out of pills and not being easily able to resupply is a common reason for inconsistent pill use. ⁷ However, little is known about the extent of these difficulties and who is most affected by them. We aimed to contribute to the literature by exploring the prevalence of and factors related to difficulties in obtaining prescriptions for hormonal contraceptive methods among adult women in the United States.

Materials and Methods

We conducted a nationally representative survey of adult U.S. women who were at risk of unintended pregnancy to explore their experiences accessing prescription-based hormonal contraception (i.e., pill, patch, and ring). These data were collected as part of a larger survey that included questions about women's support for over-the-counter access to oral contraception in the United States. ⁸ Women living in the United States, aged 18–44, who spoke English or Spanish, and who were considered at risk for unintended pregnancy (i.e., they had had heterosexual intercourse in the past 12 months, were not pregnant or trying to get pregnant, had not delivered a baby in the past 2 months, and were not protected by male or female sterilization ⁶ ) were eligible to participate. The survey was conducted in English or Spanish and administered by GfK using their KnowledgePanel, a nationally representative, probability-based, nonvolunteer, online household panel. ⁹ The methodology of the panel and administration of this survey have been previously described. ⁸ The study was approved by the Allendale Investigational Review Board, and the survey was fielded in November to December 2011.

GfK provided a data file with weighting variables that incorporated design-based weights. These weights accounted for panel recruitment and were benchmarked against the most recent Current Population Survey's demographic and geographic distributions for noninstitutionalized women aged 18–44 ¹⁰ and Pew Hispanic Center Survey's Spanish language distributions. ¹¹

The survey included questions about participants' background characteristics, contraceptive use, and experiences obtaining and filling a prescription for hormonal contraception. Participants were asked if they had ever tried to get a prescription for a hormonal birth control method, such as birth control pills, the patch, or the ring. If they said yes, they were asked about their ease of access to these methods. Our outcome of interest was difficulty obtaining or refilling a prescription for hormonal contraception (1 = yes, 0 = no). Women were considered to have had difficulty if they answered “somewhat difficult” or “very difficult” (opposed to “somewhat easy” or “very easy”) to the question, “In general, how easy or difficult was it for you to get a prescription for a birth control method (birth control pills, the patch, or the ring)?” and/or if they answered yes (opposed to no) to the question, “Did you ever run out of your birth control method (birth control pills, the patch, or the ring) and have problems getting more supplies when you needed them?” and/or if they answered yes to any specific difficulties obtaining or refilling a prescription for hormonal birth control that was provided in a list of response options or if they wrote in other difficulties not listed.

Data analyses were conducted using the survey function within Stata 12.0 (Stata; StataCorp, College Station, TX) to account for complex sampling design. Statistical tests assumed significance at p < 0.05. Univariable and multivariable logistic regression analyses were performed to estimate the odds of difficulty obtaining or refilling a prescription for hormonal contraception by demographic and reproductive background characteristics. All variables were used as binary or categorical predictors, with one category selected as the reference group based on a large sample size and/or meaningful comparison. Missing data were excluded from these analyses. All independent variables shown in Table 1 were included in an initial multivariable regression model. Sequentially, extraneous variables with a p > 0.20 were removed. All variables shown in Table 3 were included in the final model. We used the 2011 Department of Health and Human Services poverty guidelines ¹² to convert respondents' income level and the number of people in their household into a dichotomous variable indicating poverty status (≤200% federal poverty level or >200% federal poverty level). The specific problems related to obtaining or refilling a prescription that women reported, which they selected from a list of response options or wrote in for other reasons not listed, were coded thematically into the following categories: challenges related to obtaining an appointment or getting to a clinic; cost barriers or lack of insurance coverage; not having a regular doctor or clinic; difficulty accessing a pharmacy; the clinician requiring a clinic visit, exam, or Pap smear before providing refills; and other reasons.

Results

Discussion

One-third of American women who had ever tried to obtain hormonal contraception reported difficulties with prescription or refill access. While the Patient Protection and Affordable Care Act (ACA) will resolve some of these issues through expanding the pool of women with insurance and contraceptive coverage with no copayment, ¹³ these data indicate that additional barriers still need to be addressed. First, while uninsured women were more likely to report problems obtaining a prescription or refill (55%), 32% of women with public insurance and 24% with private insurance also reported difficulties. Issues independent of insurance status included challenges obtaining an appointment and taking time off from work or school to go to the clinic and inconvenient clinic hours, among others. Another common barrier to hormonal contraceptive access was not wanting a pelvic exam to get a method. Pelvic exams are not required or medically necessary before providing hormonal contraception. ¹⁴ Despite this, a recent national survey showed that almost one-third of clinicians always require pelvic examinations before provision of oral contraceptives ¹⁵ and most obstetrician–gynecologists believe they are of some importance for assessing hormonal contraception eligibility. ¹⁶ While providers have responsibilities to provide recommended health screenings, hormonal contraception should not be contingent on these activities. Education of both providers and patients is needed to ensure hormonal contraception provision is evidence based so as to prevent unnecessary barriers to hormonal methods.

Additionally, the finding related to increased difficulties among Spanish speakers highlights the need to ensure access to language and culturally appropriate services and that non-English speakers receive accurate information about new coverage possibilities under the ACA. However, undocumented and recent immigrants are not eligible for many of the benefits under the ACA ¹⁷ and will continue to face barriers accessing contraception. Efforts to address this coverage gap are needed. The decreased barriers reported among women with a high school degree or some college compared with those with a college degree are surprising and should be explored further in future research. The finding may reflect easier access to healthcare services for those that were still in school at the time of the survey.

An additional means of alleviating barriers to these methods is to make oral contraceptives available over the counter. Removal of the prescription requirement for the pill has been shown to be safe, ^{18 –20} effective, ²¹ and acceptable to women. ⁸ As a result, the American College of Obstetricians and Gynecologists issued a Committee Opinion in 2012 supporting over-the-counter access to the pill. ²² If priced affordably and covered by insurance without a prescription requirement, over-the-counter availability for oral contraception could expand access for both uninsured and insured women who face obstacles related to the prescription requirement.

This study has several limitations. The data were collected in 2011 before the contraceptive coverage guarantee under the ACA began to take effect and may not reflect the current experience of American women. However, the study provides a useful baseline assessment of barriers to prescription hormonal contraception to which future studies post-ACA implementation may be compared. In addition, the measures of barriers to access do not specify timing and we cannot be certain if the participant experienced the barrier recently or in the past. Another potential limitation is the risk of nonparticipation bias as only 56% of women initially contacted completed the screening questions. However, panel members were not informed of the survey topic until they completed screening, and this completion rate is similar to surveys on other topics using this panel. ^{23 –26} Finally, the survey excluded adolescents; given that this population may face particular barriers accessing contraception, future research should focus on women under age 18.

Conclusions

Barriers to hormonal contraceptive methods are common among U.S. women. Expanded insurance coverage from the ACA may alleviate some of these problems, but additional efforts are needed, including education of women and providers on hormonal contraception guidelines, and ensuring health resources and services are also tailored to non-English-speaking women. Finally, the removal of the prescription requirement for oral contraceptives may also reduce access barriers and facilitate consistent contraceptive use.