It can be hard to get birth control, particularly for women in rural settings. A new wave of companies makes it easier. But are they the best solution to the problem?
More than 19 million women in the US live in contraceptive deserts — areas where there’s no reasonable access to a health center that provides a full range of contraceptive options. With the advent of online services like Nurx, Hers, and Pill Club, many can order their contraceptives online. In particular, the services make it simple to acquire birth control pills, the second most common contraceptive method behind female sterilization.
Sexual and reproductive health advocates have praised this development. “Patients can struggle to access the care that they need, and anything innovative that can help them safely access contraception is going to be good for patients,” section chief of Yale Medicine Family Planning Dr. Nancy Stanwood said in an interview with Healthline.
The pandemic has increased demand for remote care. Nurx raised $22 million in a recent round of investment as birth control prescribed through the services shot up 50% in the early months of the coronavirus outbreak.
A 2016 study found that 29% of women faced barriers in obtaining birth control. Can online prescription services help them overcome these barriers? Investors are banking on it.
Barriers to Birth Control
For many people seeking contraceptives, a trip to the doctor’s office is a significant hurdle, explains Susan Vandergriff, executive director of A Step Ahead, a reproductive health nonprofit based in Chattanooga, TN. “We see all sorts of access problems, especially in our rural areas.”
Long wait times, inability to take time off work, and prohibitive distances to the nearest clinic can keep people from making appointments. And in rural settings, “confidentiality is an issue,” says Vandergriff. “Women don’t want to go get services from their mom’s best friend who they go to church with.”
One way to increase access is to remove the need for a doctor’s appointment altogether, in-person or otherwise.
The American Center for Obstetricians and Gynecologists “supports over-the-counter access to hormonal contraception without age restrictions”.
While every medical intervention carries risk, complications from birth control are relatively rare with simple self-screening methods, according to ACOG.
In 13 states, pharmacists can prescribe self-administered hormonal contraceptives, including birth control pills. But 11 states protect a pharmacist’s right to refuse to dispense contraceptives on religious or personal grounds. In Tennessee, for example, pharmacists can prescribe birth control pills, but have the right to refuse, as well — potentially forcing a person seeking care to go home empty-handed.
Online Prescription Services: The Middle Ground?
Between over-the-counter birth control and an in-person doctor’s visit, “the middle ground” is remote prescription, said Dr. Brandi Ring in an American Medical Association presentation.
A 2019 survey found that nearly half of telemedicine patients in America live in the South. Companies delivering remote prescriptions for birth control have found a ready market in the region. According to Nurx, the company was overwhelmed by demand when it launched in states like Texas, where half the counties are contraceptive deserts.
Online prescription services are not able to operate in all 50 states. West Virginia, for example, “prohibits providers from issuing prescriptions without establishing an ongoing physician-patient relationship”. In most states, however, companies like Nurx are able to operate without violating local laws.
However, the rapid growth of online prescription services has raised concerns about safety. A 2019 New York Times investigation of Nurx found that at least one patient was rushed to the ER due to Deep Vein Thrombosis (DVT), a condition that arose from birth control acquired through the service. The prescribing doctor at Nurx had authorized the medication even though the patient had two conditions that predisposed her to DVT if she used the prescription.
In a statement, Nurx responded, “Our rates of DVT from birth control among our patient community of over 200,000 people is 0.023%, which is significantly lower than the national average, which ranges between 0.1–0.3%.”
Many experts agree that it’s generally safe to prescribe birth control virtually. According to Carmela Zuniga, project manager at Ibis Reproductive Health, “research overwhelmingly shows birth control pills are safe and effective and women can self-screen for contraindications to oral contraceptives using a medical checklist. Research has also shown that online platforms prescribing birth control adequately screen for contraindications.”
The Business Model: The Price for Access?
At Nurx, the patient pays an annual consultation fee of $15 (not covered by insurance) to be screened by and receive a prescription from a medical professional, plus $0 – $30 for the medication, depending on insurance status and co-pay. The company submits an insurance claim on behalf of the patient for the medication itself and fills the prescription via partner pharmacies.
Most other online prescription services follow the same revenue model, charging an annual consultation fee that is not covered by insurance plus the monthly cost of the pills (typically in that $0 to $30 range) plus shipping or processing.
In comparison, the cost of birth control prescribed by a doctor or pharmacist in-person can vary wildly. Under the Affordable Care Act, most birth control pills and visits to prescribe them are free with insurance. A 2020 Supreme Court ruling could roll back this access on certain plans, however. And for uninsured women, the cost of a one-month supply of birth control can range from $20-$50, not including the medical visit to acquire the prescription.
In other areas of medicine, money has been shown to influence the drugs doctors prescribe. The fact that online services can generate revenue from the sale of drugs and pay the medical professionals who prescribe them is a potential conflict of interest.
The Past and Future of Birth Control
Due in no small part to “more and better” contraceptive use, teen birth rates have dropped dramatically in the past few decades. But some states are lagging behind, especially ones with high rural populations and fewer full-service sexual and reproductive health clinics. Between 1992 and 2010, mostly rural West Virginia’s teen pregnancy rate dropped 25% — a significant drop, but still well behind California’s 62%.
While advocates wait for undisputed, national over-the-counter birth control access, prescribing apps are filling a need for a discreet, affordable, and efficient way for people to access contraceptives.
Pharmacist-Provided Self-Screening Questionnaire
Pharmacist-provided self-screening questionnaires are used by the pharmacist to safely prescribe hormonal birth control for women. Below we offer links to two state versions of the self-screening questionnaire:
Tennessee Pharmacist-Provided Hormonal Contraceptives Self-Screening Questionnaire
Problem Addressed: Access to Healthcare
Written by Ciara McLaren
Published on Sep 9, 2020
Updated Sep 14, 2020
Sources
Susan Vandergriff, Zoom interview with Ciara McLaren, Aug 25, 2020
Carmela Zuniga, email interview with Ciara McLaren, Aug 31, 2020
Power to Decide, “Contraceptive Deserts”, https://powertodecide.org/what-we-do/information/resource-library/understanding-contraceptive-deserts, accessed Aug 28, 2020
Free the Pill, “Who prescribes the pill online?”, https://freethepill.org/online-pill-prescribing-resources/, accessed Aug 28, 2020
Jonathan Shieber, “Nurx has $22.5 million in new money, a path to profitability and new treatments for migraines on the way”, Tech Crunch, Aug 11, 2020, https://techcrunch.com/2020/08/11/nurx-has-22-5-million-in-new-money-a-path-to-profitability-and-new-treatments-for-migraines-on-the-way/, accessed Aug 28, 2020
Ariane Datil, “Telehealth company sees 50% increase in birth control requests during pandemic”, WUSA9, May 19, 2020, https://www.wusa9.com/article/entertainment/television/programs/q-and-a/telehealth-company-sees-50-increase-in-birth-control-requests-during-coronavirus-pandemic/65-8b22609e-2cb0-43a0-aea7-412e4a6e65b9, accessed Aug 28, 2020
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American Well, “Telehealth Index: 2019 Consumer Survey”, https://static.americanwell.com/app/uploads/2019/07/American-Well-Telehealth-Index-2019-Consumer-Survey-eBook2.pdf, accessed Aug 28, 2020
US Census, “Rural America”, https://gis-portal.data.census.gov/arcgis/apps/MapSeries/index.html?appid=7a41374f6b03456e9d138cb014711e01, accessed Aug 28, 2020
Sarah Buhr, “Birth control app Nurx now delivers to the ‘contraceptive deserts’ of Texas,” Jun 5, 2017, https://techcrunch.com/2017/06/05/birth-control-app-nurx-now-delivers-to-the-contraceptive-deserts-of-texas/, accessed Aug 28, 2020
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Charles Ornstein, Mike Tigas and Ryann Grochowski Jones, “Now There’s Proof: Docs Who Get Company Cash Tend to Prescribe More Brand-Name Meds”, ProPublica, Mar 17, 2016, https://www.propublica.org/article/doctors-who-take-company-cash-tend-to-prescribe-more-brand-name-drugs, accessed Aug 28, 2020
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