Free the Pill! 

It's highly effective and "safer than aspirin." Selling it over the counter could prevent hundreds of thousands of abortions annually. So why on earth can't women get their birth control without a prescription?

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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.

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