By Rachel Crumpler
After the Supreme Court overturned Roe v. Wade this summer, accessing abortion across the nation became more challenging as dozens of state legislatures restricted the procedure — some enacting restrictions after as little as six weeks, when many women don’t yet realize they’re pregnant.
In other states, abortion remains legal beyond the timeframes set in these new laws. North Carolina, which still allows the procedure up to 20 weeks, has seen a surge in demand particularly from out-of-state patients, contributing to longer wait times.
“People often would think in the past that they could try their best to try to prevent pregnancy and if it didn’t happen, at least they had abortion as an option if they weren’t ready to become parents or go through the adoption process,” said Bianca Allison, an assistant professor in the Department of Pediatrics at UNC School of Medicine who works with adolescents and young adults around their sexual and reproductive health care needs. “But I think now that is a much more challenging option.”
The changing landscape surrounding abortion access over the past six months has made contraception more top of mind for many women.
Even though access to contraception remains a challenge for some, there’s some good news on the way. While many people prefer a long-lasting form of contraception that still requires a doctor’s visit, changes to North Carolina law will make it easier for women to go to a local pharmacy to pick up some types of birth control that formerly were only available by prescription.
Prevention a priority for young women
Allison said more patients have talked with her about pregnancy prevention at appointments following the Supreme Court decision in late June. Especially among the younger people she serves, Allison has seen increased demand for long-lasting birth control options such as IUDs and implants.
April Miller, an assistant professor of obstetrics and gynecology at Wake Forest University School of Medicine, said she’s also seen more patients seeking long-term fixes for pregnancy prevention.
Since the Dobbs decision that overturned Roe, Miller said she’s had an increased number of young women in their early 20s express a desire for tubal ligation, a procedure that permanently prevents pregnancy.
“I think it’s because they are afraid that other things will be overturned and they won’t be able to get contraception in the future,” Miller said, who encourages anyone younger than 30 years old to consider other effective and reversible contraception methods such as IUDs and implants.
Although abortion is no longer protected by the Supreme Court, access to contraception still is. It’s a right to privacy first recognized in Griswold v. Connecticut in 1965.
Physicians say contraception access has improved in recent years due to emerging avenues to obtain it such as telehealth appointments and pharmacists. There remain barriers to access, such as inadequate knowledge, costs and lack of transportation, that pose problems.
“There are many more options available for those seeking contraception than there were in the past,” Miller said. “But I do think we still have a ways to go as far as getting people access.”
Data on contraception usage from a national Kaiser Family Foundation report examining reproductive-age females’ experiences with contraception found that:
- 90 percent have used contraception at some point in their reproductive years and 76 percent have used more than one contraceptive method.
- 85 percent of people use contraception to prevent pregnancy, though people may have other reasons for usage such as managing a medical condition or preventing a sexually transmitted disease.
- One in six sexually active females said they are not trying to get pregnant and are not using contraception for various reasons such as concerns about side effects, religious reasons and lack of desire to use a method.
- 77 percent of females using contraception had their most recent birth control care visit at a doctor’s office, 11 percent went to a clinic such as Planned Parenthood, a community health clinic, or a walk-in clinic, 8 percent got their birth control care at a pharmacy or drugstore, and just 3 percent had their most recent visit through an online birth control website or app.
- Among those using contraception in the past 12 months, 70 percent of females with private insurance reported that their insurance covered the full cost of their contraceptive method. 25 percent said they paid at least part of the cost out-of-pocket.
- One quarter of females said they are not using their preferred method of contraception for reasons such as concerns about side effects, unaffordability or their provider recommending a different method.
Preventing unwanted pregnancies
Nearly half of U.S. pregnancies are unintended, according to America’s Health Rankings. The percentage of unintended pregnancies is higher among Black women, women with incomes below 200 percent of the federal poverty level, women without a high school education and unmarried women living with a partner.
In North Carolina, data released in 2021 by nationwide pregnancy prevention advocacy group Power to Decide show over 600,000 women with low income in North Carolina live in contraceptive deserts. A contraceptive desert is a county or area that lacks reasonable access to a health center offering the full range of contraceptive methods.
Access to contraception is key to preventing unwanted pregnancies. About 95 percent of unintended pregnancies occur in women who do not use contraception or use it inconsistently or incorrectly, according to America’s Health Rankings.
There are over a dozen methods of short- and long-acting contraception that range in ease of access, cost, permanence and efficacy. With the array of options available, Miller said it’s reasonable to expect that someone can find a method that fits their needs, and physicians can counsel patients through the options.
Nearly all women use contraception in their lifetimes. The National Center for Health Statistics’ latest data on contraception usage found that, in 2017-2019, 65.3 percent of women ages 15 to 49 in the United States were currently using a method of birth control. Many more women have used some form of contraceptive at some point during their childbearing years.
Before choosing a contraceptive method, Miller said it’s helpful for patients to research the options as well as know their health history and their future fertility plans.
Allison added that individuals should consider several factors to determine what is the best option for them.
“Different birth control pills have different side effect profiles — both good and bad,” Allison said.
“Some can improve acne, improve mood, make periods lighter or nonexistent. Some might make periods heavier,” she said. “Efficacy has a huge range. Even visibility — if you are using a birth control pill or a patch, then others could see that, versus an IUD or an implant that are essentially invisible.”
Allison said she encourages patients to explore different aspects of all the different options. She said it helps them make better decisions “of what makes the most sense for them based on what’s most important to them.”
An online resource
An evidence-based website recommended by Miller and Allison that goes through each contraception option in detail is Bedsider, an online birth control support network operated by Power to Decide. The site details information on each option such as quick facts, costs, and side effects and benefits associated with it.
Bedsider also includes a capability to compare methods side by side in a chart to help inform people’s choices.
An emerging site
In addition to the doctor’s office, health clinics and health departments, there is an additional emerging site where some forms of contraception can be obtained in North Carolina.
Under a new law, House Bill 96, which went into effect Feb. 1, pharmacists in the state are allowed to provide hormonal contraceptives to people 18 years and older as well as those younger with parent or legal guardian consent. North Carolina joined over a dozen other states that have also granted pharmacists this authority.
This means people in North Carolina no longer need a prescription from a physician to get hormonal birth control pills and patches.
“Women need better access to birth control and we do see pharmacists as being part of the solution,” Penny Shelton, executive director of the North Carolina Association of Pharmacists, said.
Jill Sergison, co-founder of Points True North, a consulting firm that is helping lead the roll-out of the pharmacy-prescribed contraception initiative with the UNC Eshelman School of Pharmacy, said pharmacies hold a lot of promise to reach people in rural areas and contraception deserts who likely live in closer proximity to pharmacists than a physician, she said.
“I think people from all communities will benefit from this level of access,” she said. “Plus, if you can get your birth control pill while you’re getting milk, that’s so nice.”
The ability to get hormonal contraceptives at pharmacies is not yet widespread, though. While the bill gave pharmacists this ability, Shelton said it didn’t “flip a switch” where pharmacists could immediately provide this service.
Now, about nine months after the law took effect, it’s really only starting to get off the ground.
“With any new authority, there’s a slow gradual up slope to how it’s going to be provided,” Shelton said, adding that she feels North Carolina is in the first phase of implementation involving spreading awareness and working out logistics. “We’re kind of down here at the beginning of that slope.”
The standing order with the protocols needed to provide this service at pharmacies was signed by state health director Elizabeth Cuervo Tilson on March 14. As part of providing this service, pharmacists must complete hormonal contraception training first.
Cheryl Viracola, director of practice advancement at the North Carolina Association of Pharmacists, said of the approximately 6,000 active pharmacists in the state either working full time or part time in a community setting, about 27 percent are in the training pipeline. Over 1,600 pharmacists have registered for the three-hour training and about 800 of those have already completed it.
Completing training is not a big lift for pharmacists, Viracola said, and she anticipates people will continue to complete it.
The state’s pace of implementation does not reflect disinterest in providing contraception, Shelton emphasized. But she said there remain logistical pieces that have to be worked through to provide it and make it a sustainable service, especially when reimbursement is not built in.
Reimbursement is a change Shelton said she is going to push for in the upcoming legislative session.
Taking on this new responsibility while pharmacies are increasingly taxed from cold and flu season and COVID vaccinations is also challenging, she added.
In other states, the rollout of providing contraception at pharmacies has occurred at a similar rate, Shelton said.
“A year from now, we should really see uptake in the actual pharmacies where it’s becoming more common — not commonplace yet — but it’s becoming more common that you could go to a pharmacy and have the service provided,” Shelton said.
Until then — and also to help build that momentum — Viracola advised that anyone interested in getting contraception at a pharmacy should call to see if it provides hormonal contraceptive services before going. If the pharmacy does not yet provide contraception, it’s reasonable to ask about the anticipated timeline. Consumers expressing interest in the service may potentially propel pharmacies to speed implementation along since they know patients are waiting.
Barriers to access
But barriers remain. Transportation and language access issues can limit access for certain individuals.
One of the most common concerns patients bring up is cost, Miller said.
Allison said that for anyone with insurance, the cost is almost always zero. Since the passage of the Affordable Care Act in 2010, federal law requires health insurance companies to cover the full range of “female-controlled” contraceptive methods, including counseling and related services, without out-of-pocket costs. This includes most private health plans.
Some people can also take advantage of the NC Medicaid Family Planning Program or “BE SMART.” The program provides family planning, reproductive health and contraceptive services to eligible men and women, whose income is at or below 195 percent of the federal poverty level, with no age restrictions. FDA-approved and Medicaid-covered birth control methods, procedures, pharmaceutical supplies and devices are free and there are no copays for services received through the program.
Without insurance or if paying out of pocket, the costs for contraception vary by type of birth control but can range from $200 to $500 per year or about $15-50 per month for someone using a daily, weekly or monthly method such as birth control pills, patches or rings. An implant or IUD is more expensive at about $1,000 but lasts for many years.
Many Federally Qualified Health Centers and health departments provide contraception services on a sliding scale based on a person’s income level, so these locations can be good resources for low-cost contraception.
Another major barrier is inadequate knowledge or inaccurate information, Allison said.
She said she believes this stems from a lack of standardized comprehensive sexual health education. Allison would like to see more young people receive information where they feel empowered with the knowledge to make decisions about their reproductive health and pregnancy prevention.
Miller said she’s happy to help patients understand their contraceptive options, but she’s limited to only helping the patient in front of her.
“No matter how many patients I’ve seen, there’s always more patients out there who don’t know about contraception and what their options are, so I think definitely increasing patient community education helps a lot.”
Push for more over-the-counter contraceptive options
The American College of Obstetricians and Gynecologists has long supported over-the-counter access to hormonal contraception. This would make contraception much easier to obtain and the group says several studies have demonstrated that women are capable of using self-screening tools to determine their eligibility for hormonal contraceptive use.
The Food and Drug Administration is currently reviewing an application submitted by Perrigo’s HRA Pharma in July for its birth control pill, Opill, to be made available over the counter. If approved, people in need of birth control could walk into a pharmacy and buy it without a prescription, making it the first-ever birth control pill that people could buy over the counter in the United States.