research on free birth control

Feminist Majority Foundation

Expanding Birth Control Access as the New Front in Reproductive Freedom

The Biden-Harris administration’s proposed rule to expand access to affordable contraception under the Affordable Care Act (ACA) is a timely and essential move, especially in the current political landscape where reproductive rights have been systematically eroded. This proposal would provide over-the-counter birth control without any cost sharing for women with private insurance, removing significant financial barriers to contraception for millions of women. This would include FDA-approved options such as Opill, the morning-after pill, and other methods like IUDs and condoms. Jennifer Klein, White House Gender Policy Council Director, emphasized that this move could have a transformative impact, ensuring more women can access contraception without cost-sharing. 

This initiative couldn’t be more urgent. In the wake of the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization —which overturned the nearly 50-year precedent set by Roe v. Wade —the landscape of reproductive healthcare has shifted dramatically. With abortion access now either severely restricted or outright banned in many states, the need for accessible birth control has become a frontline issue. Women who have lost access to safe and legal abortion options are left with limited reproductive choices, making contraception not just a health service but a critical tool of autonomy and control over one’s future. Department of Health and Human Services Secretary Xavier Becerra emphasizes this by saying, “Now more than ever, access to and coverage of birth control is critical as the Biden-Harris administration works to help ensure women everywhere can get the contraception they need when they need it”​

The proposed rule would not only strengthen access to prescribed contraceptives but also tackle the loopholes created by religious and moral exemptions that have allowed some employers and institutions to deny birth control coverage. These exemptions have been a contentious issue since 2018, when regulations allowed private health plans to exclude coverage for contraceptive services based on moral or religious objections​. Under this new rule, women and dependents enrolled in plans with such exemptions will be able to access contraception directly from willing providers without additional cost, ensuring that their employer’s religious beliefs don’t determine their reproductive choices​.

This policy comes at a time when contraception is more than just a personal health decision—it’s a matter of economic and social justice. Nearly 90% of women of reproductive age have used contraception at some point in their lives, and access to reliable birth control is closely tied to women’s ability to pursue higher education, maintain steady employment, and plan their families responsibly​. The ability to control if and when to have children is not just a matter of health; it’s a fundamental right that impacts every facet of a woman’s life. As Alexis McGill Johnson, president and CEO of Planned Parenthood, aptly put it, “Access to birth control is critical to reproductive freedom. It gives people the reins to decide their futures.”​

However, while this proposal is a positive step, it doesn’t go far enough. The fact that this expanded coverage applies only to those with private insurance leaves millions of women—especially those from low-income backgrounds—still vulnerable. Contraception should not be a luxury afforded only to those employed or enrolled in a university health plan. It should be available, free of charge, to every woman in America, regardless of income, employment status, or geography. Access to birth control shouldn’t depend on a person’s ability to navigate complex insurance systems or rely on an employer’s benevolence.

In addition, this rule still retains religious exemptions for employers, which means that women who work for religious institutions or employers who claim moral objections may still face hurdles. Although the proposal seeks to create independent pathways for these women to access contraception, the process could still impose unnecessary burdens, delaying access to timely contraceptive care ​. In a country that prides itself on freedom, we should be moving toward a system where reproductive health care is universal, not subject to the whims of individual employers or religious doctrine.

This proposal doesn’t address the needs of women without health insurance. While expanding access to no-cost birth control under the ACA is commendable, those without insurance remain sidelined. The U.S. should be aiming for universal access to contraception—comprehensive coverage that includes everyone, regardless of their insurance status. For a society to truly respect reproductive freedom, it must ensure that contraception is affordable and accessible to all, not just the privileged few.

The Supreme Court’s decision in Dobbs has created a reproductive health crisis in the United States. As state legislatures continue to attack abortion access, the federal government must counterbalance these efforts by protecting and expanding access to contraception. The Biden-Harris administration’s proposal is a necessary first step, but it’s only that—a first step. True reproductive justice will only be achieved when contraception is universally accessible, free from bureaucratic obstacles and moralistic exclusions. Women deserve nothing less.

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Biden administration proposes a rule to make over-the-counter birth control free

Chandelis Duster

In this photo illustration, a package of Opill is displayed on March 22. Justin Sullivan/Getty Images hide caption

The Biden administration is proposing a rule that would expand access to contraceptive products, including making over-the-counter birth control and condoms free for the first time for women of reproductive age who have private health insurance.

Under the proposal by the U.S. Department of Health and Human Services (HHS), Labor Department, and Treasury Department, which was announced by the administration on Monday, health insurance companies would be required to cover all recommended over-the-counter contraception products, such as condoms, spermicide and emergency contraception, without a prescription and at no cost, according to senior administration officials.

It would also require private health insurance providers to notify recipients about the covered over-the-counter products.

The proposed rule comes as the Biden administration seeks to expand access to contraceptives and as other reproductive health, including access to abortion, has become a central issue in the 2024 presidential election campaign . Republican-led states have restricted access to abortion since the Supreme Court overturned Roe v. Wade in 2022. About half of states now ban or severely restrict abortion, which has coincided with steep declines in prescriptions for birth control and emergency contraception in those states.

Birth control prescriptions are down in states with abortion bans

HHS Secretary Xavier Becerra said when health care insurers impose burdensome administrative or cost sharing requirements for services, “access to contraceptives become even more difficult.”

“We have heard from women who need a specific brand of birth control but the cost of their prescription isn’t covered by their health insurance. We have made clear that in all 50 states the Affordable Care Act guarantees coverage of women’s preventive services without cost sharing, including all birth control methods approved by the Food and Drug Administration,” Becerra told reporters. “This proposed rule will build on the progress we have already made under the Affordable Care Act to help ensure that more women can access the contraceptive services they need without out-of-pocket costs.”

The products would be able to be accessed the same way prescription medicines are accessed, such as at the pharmacy counter, according to senior administration officials. Getting the products through reimbursement would also be an option, depending on the health insurance plan, officials said.

Birth control became available to those with insurance without a copay because of the Affordable Care Act, but that required a prescription.

In July 2023, a daily oral birth control pill, Opill, became the first over-the-counter birth control pill to be approved by the Food and Drug Administration. It became available for purchase online in March and can be purchased for $19.99.

The Biden administration in January announced several actions aimed at strengthening access to abortion and contraceptives, including the Office of Personnel Management issuing guidance to insurers that will expand access to contraception for federal workers, families and retirees.

There will be a comment period on the proposed rule and if approved, it could go into effect in 2025, according to senior administration officials.

However, if former President Donald Trump wins the election, he could reverse the rule.

NPR’s Sydney Lupkin and Bill Chappell contributed to this report.

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Health insurance needs to fully cover over-the-counter birth control like condoms, White House says

WASHINGTON (AP) — Millions of people with private health insurance would be able to pick up over-the-counter methods like condoms, the “morning after” pill and birth control pills for free under a new rule the White House proposed on Monday.

Right now, health insurers must cover the cost of prescribed contraception, including prescription birth control or even condoms that doctors have issued a prescription for. But the new rule would expand that coverage, allowing millions of people on private health insurance to pick up free condoms, birth control pills, or “morning after” pills from local storefronts without a prescription.

The proposal comes days before Election Day, as Vice President Kamala Harris affixes her presidential campaign to a promise of expanding women’s health care access in the wake of the U.S. Supreme Court’s decision to undo nationwide abortion rights two years ago. Harris has sought to craft a distinct contrast from her Republican challenger, Donald Trump, who appointed some of the judges who issued that ruling.

READ MORE: Abortion passes inflation as top election concern for women under 30, survey finds

“The proposed rule we announce today would expand access to birth control at no additional cost for millions of consumers,” Health and Human Services Secretary Xavier Becerra said in a statement. “Bottom line: women should have control over their personal health care decisions. And issuers and providers have an obligation to comply with the law.”

The emergency contraceptives that people on private insurance would be able to access without costs include levonorgestrel, a pill that needs to be taken immediately after sex to prevent pregnancy and is more commonly known by the brand name “Plan B.”

Without a doctor’s prescription, women may pay as much as $50 for a pack of the pills. And women who delay buying the medication in order to get a doctor’s prescription could jeopardize the pill’s effectiveness, since it is most likely to prevent a pregnancy within 72 hours after sex.

WATCH: Over-the-counter birth control pill approved for sale in U.S.

If implemented, the new rule would also require insurers to fully bear the cost of the once-a-day Opill, a new over-the-counter birth control pill that the U.S. Food and Drug Administration approved last year. A one-month supply of the pills costs $20.

Federal mandates for private health insurance to cover contraceptive care were first introduced with the Affordable Care Act, which required plans to pick up the cost of FDA-approved birth control that had been prescribed by a doctor as a preventative service.

The proposed rule would not impact those on Medicaid, the insurance program for the poorest Americans. States are largely left to design their own rules around Medicaid coverage for contraception, and few cover over-the-counter methods like Plan B or condoms.

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Ahead of election, White House proposes free over-the-counter birth control

Good morning! We’re just over two weeks until Election Day. But it’s still October, a month where back in 1980 a Ronald Reagan campaign operative coined the term “October surprise.” Got tips? Send ‘em on over to your guest host at [email protected] .

Today’s edition: Two federal agencies are collaborating to advance efforts to develop new products that help people quit smoking. How a new parental consent law in Idaho is affecting care for young people. But first …

Could birth control be free without a prescription?

In July 2023, the Food and Drug Administration approved the first over-the-counter birth control pill in the United States. But there was a catch: The medication was not free for most people.

The White House is now proposing to broaden access to free birth control covered by private health insurance plans — a bid that surfaces one of Democrats’ most potent issues just over two weeks before Election Day, my colleague Carolyn Y. Johnson and I report. The administration is unveiling a proposed rule today that would mandate private health plans cover over-the-counter birth control — including daily pills, emergency contraceptives and condoms — without a prescription and at no cost.

Democrats are focusing on reproductive health ahead of the election after abortion rights measures have had a winning streak at the ballot box.

Vice President Kamala Harris has made reproductive rights a centerpiece of her campaign for the White House, and Democrats are banking on the issue to help the party not only defeat former president Donald Trump but also maintain control of the Senate and recapture the House. This November marks the first presidential election since the Supreme Court overturned the constitutional right to an abortion in June 2022, fueling a seismic shift in the nation’s reproductive health landscape.

Reproductive health advocates have said making contraception easily available is more important than ever in a post- Roe world where most abortions are banned in more than a dozen states. Prominent Democrats and reproductive rights advocates have urged the Biden administration to make over-the-counter birth control free.

The details

The Affordable Care Act mandates that insurance companies cover contraception at no cost. But plans are not required to cover items available over the counter unless the patient has a prescription.

The rule seeks to change that, with Biden administration officials projecting that roughly 52 million women of reproductive age who are covered by private health plans would be able to get free birth control over the counter.

One key question: How would such a proposal work in practice?

Health plans could choose different ways to administer the plan, officials said, while adding that more details could come in a final rule. Some consumers may be able to get free birth control by picking it up in a store aisle and bringing it to the pharmacy counter. Officials didn’t rule out the possibility of consumers buying products and then seeking reimbursement from their health plans.

The White House would also seek to expand the choice of birth control — currently, insurers are required to cover only one drug within each category of contraception. Under the proposal, insurers would have to cover all approved drugs, unless they have a therapeutic equivalent that is covered. The end result would be more brands of birth control pills and a wider selection of IUDs available for free.

But will the administration actually finalize the rule? It will be a tough lift because the plan must undergo a 60-day comment period, and it often takes months to years for federal agencies to respond to comments and release a final plan. But a key administration official insists finalizing the rule in the coming months is possible.

“We will work quickly to conclude it before the end of this administration,” Jennifer Klein, the director of the White House Gender Policy Council, said in an interview. “The urgency is clear.”

Read our full story here.

Agency alert

FDA, NIH push for innovation in smoking cessation therapies

On tap today: The Food and Drug Administration and the National Institutes of Health are teaming up for a joint public meeting to discuss potential new tools to help adults and youths stop smoking.

In an op-ed last week , senior officials from both agencies emphasized the “urgent need” for innovation in smoking cessation treatments, calling it a “high-priority area” for the federal government. Notably, they suggested that reductions in smoking should be considered a meaningful endpoint in clinical trials for new products, a departure from their traditional emphasis on complete abstinence.

The authors also called for more research on e-cigarettes, including long-term health outcomes and whether the devices could eventually be marketed as therapeutic tools, rather than just tobacco products.

In other news from the agencies …

Lykos Therapeutics sees a “path forward” for its MDMA-assisted treatment for post-traumatic stress disorder after federal regulators declined to approve it over the summer.

In a statement Friday, the company announced that its new interim CEO, Michael Mullette , and chief medical officer, David Hough , had a “productive meeting” with the FDA about next steps for the first-of-its-kind treatment. Next steps include an additional Phase 3 trial, and a potential independent third-party review of prior clinical trial data.

Key context: In August, the FDA rejected Lykos’s current application , citing “significant limitations” in its data that the agency said prevented it from determining whether the treatment was safe and effective. The federal regulator called for another large study — a request the company has pushed back on, arguing that the existing data is adequate to prove the drug’s efficacy.

Idaho’s new parental consent law for health care draws sharp criticism

The Post’s Karin Brulliard is out this morning with a deep dive into Idaho’s new law requiring parental consent for nearly all health care that a minor receives.

Supporters of the law, which allows for emergency treatment, say it’s a reasonable step to prevent adolescents from discussing issues such as birth control and gender identity with doctors, counselors and other adults unless their parents are informed first.

But critics argue it ignores the reality that not all parents are present or trustworthy and removes essential confidentiality protections by granting parents access to minors’ health records. Three months after the law’s implementation, they say it’s limiting adolescents’ access to counseling, complicating evidence collection in sexual assault cases and forcing schools to seek parental permission to treat scrapes with ice packs and Band-Aids.

• “It has been a terrible bill with terrible outcomes,” said state Rep. Marco Erickson (R), a youth organization director who voted for the measure despite misgivings. “I have seen youth not want to participate in therapy for fear their abuser would gain access to what they are talking about.”

The bigger picture: The law is part of a broader parental rights movement. It was supported by the Alliance Defending Freedom , a conservative Christian group that has notched several U.S. Supreme Court victories and points to gender-affirming school counseling as an example of youth health care gone awry. The group says seven states, including Idaho, now “fully” protect parental rights in health-care decisions.

Industry Rx

FLOTUS, top health officials hit Las Vegas for HLTH 2024

On our radar: Thousands of health-care providers, industry leaders and advocates are converging on Las Vegas this week for HLTH 2024 , a major conference featuring top government officials and even a few celebrities.

The event, which kicked off Sunday at the Venetian Expo Center , runs through Wednesday. Here’s what we’re keeping an eye on:

On tap today: FDA Commissioner Robert Califf will discuss health-care innovation, regulation and patient safety. Later, Chelsea Clinton and White House Gender Policy Council Director Jennifer Klein will talk about reproductive rights and the challenges surrounding abortion access.

On Tuesday: Rep. Morgan Luttrell (R-Tex.), Sen. Kyrsten Sinema (I-Ariz.), and Shereef Elnahal , undersecretary for health at the Department of Veterans Affairs , will explore the future of psychedelic medicines and their potential for mental health therapy.

On Wednesday: first lady Jill Biden will spotlight the White House’s efforts to advance women’s health research. Her remarks will be followed by a discussion on the topic featuring Renee Wegrzyn , director of the Advanced Research Projects Agency for Health , and Carolyn Mazure , chair of the White House Initiative on Women’s Health Research, among others.

In other health news

• On the move: CVS Health has named David Joyner its president and CEO, replacing Karen Lynch . Joyner, who previously served as executive vice president of CVS Health and president of CVS Caremark , also joined the company’s board of directors.
• The first shipments of intravenous fluids from Baxter International’s overseas facilities arrived in the United States over the weekend, the federal health department announced , adding that hospitals now have 50 percent more product available than they did immediately after Hurricane Helene.
• Humana Inc. sued the Centers for Medicare and Medicaid Services, seeking a federal court’s reversal of the agency’s decision to cut the rating of one of its most popular Medicare Advantage plans, John Tozzi reports for Bloomberg News .

Health reads

Harris goes after Trump on abortion rights during Georgia rally (By Brianna Tucker, Maegan Vazquez and Dylan Wells | The Washington Post)

Amid backlash, FDA changes course over shortage of weight-loss drugs (By Daniel Gilbert | The Washington Post)

The Powerful Companies Driving Local Drugstores Out of Business (By Reed Abelson and Rebecca Robbins | The New York Times)

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Biden administration proposes a rule to make over-the-counter birth control free

The Biden administration is proposing a rule that would expand access to contraceptive products, including making over-the-counter birth control and condoms free for the first time for women of reproductive age who have private health insurance.

Under the proposal by the U.S. Department of Health and Human Services (HHS), Labor Department, and Treasury Department, which was announced by the administration on Monday, health insurance companies would be required to cover all recommended over-the-counter contraception products, such as condoms, spermicide and emergency contraception, without a prescription and at no cost, according to senior administration officials.

It would also require private health insurance providers to notify recipients about the covered over-the-counter products.

The proposed rule comes as the Biden administration seeks to expand access to contraceptives and other reproductive health, including access to abortion, has become a central issue in the 2024 presidential election campaign . Republican-led states have restricted access to abortion since the Supreme Court overturned Roe v. Wade in 2022. About half of states now ban or severely restrict abortion, which has coincided with steep declines in prescriptions for birth control and emergency contraception in those states.

HHS Secretary Xavier Becerra said when health care insurers impose burdensome administrative or cost sharing requirements for services, “access to contraceptives become even more difficult.”

“We have heard from women who need a specific brand of birth control but the cost of their prescription isn’t covered by their health insurance. We have made clear that in all 50 states the Affordable Care Act guarantees coverage of women’s preventive services without cost sharing, including all birth control methods approved by the Food and Drug Administration,” Becerra told reporters. “This proposed rule will build on the progress we have already made under the Affordable Care Act to help ensure that more women can access the contraceptive services they need without out-of-pocket costs.”

The products would be able to be accessed the same way prescription medicines are accessed, such as at the pharmacy counter, according to senior administration officials. Getting the products through reimbursement would also be an option, depending on the health insurance plan, officials said.

Birth control became available to those with insurance without a copay because of the Affordable Care Act, but that required a prescription.

In July 2023, a daily oral birth control pill, Opill, became the first over-the-counter birth control pill to be approved by the Food and Drug Administration. It became available for purchase online in March and can be purchased for $19.99.

The Biden administration in January announced several actions aimed at strengthening access to abortion and contraceptives, including the Office of Personnel Management issuing guidance to insurers that will expand access to contraception for federal workers, families and retirees.

There will be a comment period on the proposed rule and if approved, it could go into effect in 2025, according to senior administration officials.

However, if former President Donald Trump wins the election, he could reverse the rule.

NPR’s Sydney Lupkin and Bill Chappell contributed to this report. Copyright 2024 NPR

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press release

Nwlc applauds the biden administration for proposing broader access to free birth control.

October 21, 2024 – Today, the Biden Administration announced plans to expand access to no-cost birth control by ensuring coverage of over-the-counter contraceptives without cost-sharing, making sure insurance plans provide coverage without cost-sharing for the particular method an individual needs, and making it easier for individuals to learn about their contraceptive coverage. 

In response, Fatima Goss Graves, president and CEO of the National Women’s Law Center, issued the following statement:

“Everyone deserves the freedom to make decisions about their bodies and futures. That includes being able to access the birth control they want or need, without any barriers in their way. We applaud the Biden Administration’s proposed rule building on the historic gains of the Affordable Care Act, which first guaranteed birth control coverage without out-of-pocket costs for millions. This new proposed rulemaking expands birth control coverage in critical ways and helps to end insurance company practices that denied people–including our many CoverHer clients–the coverage they are entitled to by law.”

“This new effort is especially critical as we confront rising threats from anti-abortion, anti-reproductive health extremists, such as those behind the Project 2025 agenda, which seek to undo important gains we’ve made, including for contraceptive coverage. In the face of these threats, the Biden Administration’s action will help remove barriers and ensure that people can get the birth control they need, when they need it. NWLC is ready to work with the Biden administration and other stakeholders to make sure that this leads to meaningful change for people across the country.”

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Should oral contraceptive pills be available without a prescription? A systematic review of over-the-counter and pharmacy access availability

Caitlin e kennedy, ping teresa yeh, lianne gonsalves, hussain jafri, mary eluned gaffield, james kiarie, manjulaa l narasimhan.

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Correspondence to Dr Manjulaa L Narasimhan; [email protected]

Corresponding author.

Received 2019 Jan 8; Revised 2019 Jun 7; Accepted 2019 Jun 8; Collection date 2019.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

Introduction

Making oral contraceptives (OC) available over the counter (OTC) could reduce barriers to use. To inform WHO guidelines on self-care interventions, we conducted a systematic review of OTC availability of OCs.

We reviewed data on both effectiveness and values and preferences surrounding OTC availability of OCs. For the effectiveness review, peer-reviewed articles were included if they compared either full OTC availability or pharmacist-prescribing (behind-the-counter availability) to prescription-only availability of OCs and measured an outcome of interest. For the values and preferences review, we included peer-reviewed articles that presented primary data (qualitative or quantitative) examining people’s preferences regarding OTC access to OCs. We searched PubMed, CINAHL, LILACS and EMBASE through November 2018 and extracted data in duplicate.

The effectiveness review included four studies with 5197 total participants. Two studies from the 2000s compared women who obtained OCs OTC in Mexico to women who obtained OCs from providers in either Mexico or the USA. OTC users had higher OC continuation rates over 9 months of follow-up (adjusted HR: 1.58, 95 % CI 1.11 to 2.26). One study found OTC users were more likely to report at least one WHO category 3 contraindication (13.4% vs 8.6%, p=0.006), but not category 4 contraindications; the other study found no differences in contraindicated use. One study found lower side effects among OTC users and high patient satisfaction with both OTC and prescription access. Two cross-sectional studies from the 1970s in Colombia and Mexico found no major differences in OC continuation, but some indication of slightly higher side effects with OTC access. In 23 values and preference studies, women generally favoured OTC availability. Providers showed more modest support, with pharmacists expressing greater support than physicians. Support was generally higher for progestogen-only pills compared with combination OCs.

A small evidence base suggests women who obtain OCs OTC may have higher continuation rates and limited contraindicated use. Patients and providers generally support OTC availability. OTC availability may increase access to this effective contraceptive option and reduce unintended pregnancies.

Systematic review (PROSPERO) registration number

CRD42019119406.

Keywords: systematic review, oral contraceptives, over-the-counter, pharmacy access

Key questions.

What is already known.

Making oral contraceptives (OC) available over the counter (OTC) may increase access.

What are the new findings?

A systematic review of the literature identified four studies using comparative designs to examine the effect of OTC availability of OCs and 23 studies examining values and preferences of patients and providers, mostly from the USA and Mexico.

The more recent and rigorous studies suggested OTC users had higher rates of OC continuation over time; there was some indication that OTC users had lower rates of side effects but slightly higher rates of use of OCs despite contraindications.

Values and preferences suggested general support for OTC availability or pharmacy access, with more support among women and pharmacists than among physicians.

What do the new findings imply?

Making OCs available OTC, perhaps with progestogen-only pills that have fewer contraindications to use, may be an approach to increasing access to and use of this effective contraceptive option.

Ensuring access to contraceptive methods, including for vulnerable populations and young people, is essential for the well-being and autonomy of women and girls. Oral contraceptives (OC), both combined oral contraceptives (COC) and progestogen-only pills (POP), are widely used effective methods of birth control. However, access to OCs varies globally—in some countries, OCs are available over the counter (OTC), while other countries restrict access to OCs either by requiring eligibility screening by trained pharmacy staff before dispensation (pharmacy access, or behind-the-counter availability), or by requiring a healthcare provider’s prescription. A 2015 review of OC access across 147 countries found that 35 countries had OCs legally available OTC, 11 countries had OCs available without a prescription but only after eligibility screening by trained pharmacy staff, 56 countries had OCs available informally without a prescription and 45 countries required a prescription to obtain OCs. 1 Given the persistently high proportion of unintended pregnancies globally—44% according to some estimates 2 —making OCs available OTC in more settings has the potential to reduce barriers to access, thereby increasing use of this effective contraceptive option and reducing unintended pregnancies.

While different regulatory criteria are needed in different countries to make a specific medication available OTC or with eligibility screening by pharmacy staff, the WHO is responsible to provide overall guidance to critical questions of whether interventions should be recommended or not. We conducted this systematic review in the context of developing WHO normative guidance on self-care interventions for sexual and reproductive health and rights. We included both a review of effectiveness data and a review of data on values and preferences.

Effectiveness review: PICO question and inclusion criteria

We sought to answer the following question: should contraceptive pill/oral contraceptives be made available over the counter without a prescription?

Our effectiveness review followed the PICO question format:

Individuals using contraceptive pill/oral contraceptives.

Intervention

Availability of contraceptive pill/oral contraceptives OTC (without a prescription) or behind the counter (pharmacy access, including dispensing from trained pharmacy personnel and pharmacist prescribing of hormonal birth control).

Availability of contraceptive pill/oral contraceptives by prescription only.

Uptake of OCs (initial use).

Continuation of OCs (or, conversely, discontinuation).

Adherence to OCs (correct use).

Comprehension of instructions (product label).

Health impacts (unintended pregnancy, side effects, adverse events or use of OCs despite contraindications).

Social harms (eg, coercion, violence (including intimate partner violence, violence from family members or community members, and so on), psychosocial harm, self-harm, and so on), and whether these harms were corrected/had redress available.

Client satisfaction.

To be included in the effectiveness review, a study had to meet the following criteria:

Employ a study design comparing OTC availability of OCs (with or without pharmacist dispensation) to prescription-only availability of OCs.

Measured one or more of the outcomes listed above.

Published in a peer-reviewed journal.

We focused on daily contraceptive pill/oral contraceptives for routine pregnancy prevention and did not include studies examining pills specifically for emergency contraception.

Where data were available, we stratified all analyses by the following subcategories:

Behind-the-counter (pharmacy access) versus OTC availability without a prescription.

COCs versus POPs.

Point of access (eg, stores, pharmacies, and so on).

Prior use of contraception.

Age: adolescent girls and young women (aged 10–14, 15–19 and 15–24) and adult women (aged 25+).

Vulnerabilities (ie, poverty, disability, religion).

High-income versus low/middle-income countries.

Literacy/educational level.

Study inclusion was not restricted by location of the intervention or language of the article. We planned to translate articles in languages other than English if identified. The complete protocol was registered and is available in PROSPERO (CRD42019119406).

Values and preferences review: inclusion criteria

The same search strategy was used to search and screen for study inclusion in a complementary review of values and preferences related to OTC access to OCs (including pharmacy access). We included studies in the values and preferences review if they presented primary data (qualitative or quantitative) examining people’s preferences regarding OTC access to OCs. We included studies examining the values and preferences of both people who have used or potentially would use OCs themselves as well as providers (including pharmacists) and other stakeholders, such as male partners, policymakers and insurance providers.

Search strategy

The same search strategy was used for both the effectiveness review and the values and preferences review. We searched four electronic databases (PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Health Sciences Literature (LILACS) and Embase) through the search date of 30 November 2018. The following search strategy was developed for PubMed and adapted for entry into all computer databases; a full list of search terms for all databases is available from the authors on request.

(‘Contraceptives, Oral’ [Mesh] OR ‘oral contraceptive pill’ [tiab] OR ‘oral contraceptive pills’ [tiab] OR ‘birth control pill’ [tiab] OR ‘birth control pills’ [tiab] OR ‘oral contraceptives’ [tiab] OR ‘oral contraception’ [tiab] OR ‘hormonal birth control’ [tiab] OR ‘hormonal contraception’ [tiab] OR ‘the pill’ [tiab]) AND (‘Nonprescription Drugs’ [Mesh] OR ‘nonprescription’ [tiab] OR ‘over the counter’ [tiab] OR ‘over-the-counter’ [tiab] OR ‘without a prescription’ [tiab] OR ‘pharmacist-prescribed’ [tiab] OR ‘pharmacy access’ [tiab] OR ‘clinician-prescribed’ [tiab] OR ‘physician-prescribed’ [tiab] OR ‘without prescription’ [tiab] OR ‘community pharmacy services’ [Mesh] OR ‘community center’ [tiab] OR ‘community centre’ [tiab] OR store [tiab] OR online [tiab] OR mobile [tiab] OR telehealth [tiab])

To identify articles that may have been missed through online database searching, we used several complementary approaches. We reviewed the resources section of the OCs OTC working group website, 3 which gathers scientific articles and reviews on this topic, and reviewed the citations included in several related recent reviews. 1 4 5 Secondary reference searching was also conducted on all studies included in the review. We searched for ongoing trials through ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, the Pan African Clinical Trials Registry, and the Australian New Zealand Clinical Trials Registry. Finally, selected experts in the field were presented with our list of included articles and asked to share any additional article we had missed.

Titles, abstracts, citation information and descriptor terms of citations identified through the search strategy were initially screened by a member of the study staff. Remaining citations were then screened in duplicate by two reviewers (CEK and PTY) with differences resolved through consensus. Final inclusion was determined after full-text review.

Data extraction and analysis

For each included article, data were extracted independently by two reviewers using standardised data extraction forms. Differences in data extraction were resolved through consensus.

For the effectiveness review, data extraction forms covered the following categories:

Study identification: author(s); type of citation; year of publication, funding source.

Study description: study objectives; location; population characteristics; type of oral contraceptives; description of OTC access; description of any additional intervention components (eg, any education, training, support provided); study design; sample size; follow-up periods and loss to follow-up.

Outcomes: analytical approach; outcome measures; comparison groups; effect sizes; CIs; significance levels; conclusions; limitations.

Risk of bias: assessed for randomised controlled trials with the Cochrane Collaboration’s tool for assessing risk of bias, 6 and for non-randomised trials but comparative studies with the Evidence Project risk of bias tool. 7

For the values and preferences review, data extraction forms included sections on study location, population, study design and key findings.

We did not conduct meta-analysis due to the small number and heterogeneous nature of included studies. Instead, we report findings based on the coding categories and outcomes.

Patient and public involvement

Several of the authors are current or past OC users. HJ, chair of the advisory group for the WHO Patients for Patients Safety Program, was involved as a community representative starting with the phase of protocol development. He commented on the overall study design and protocol, including patient-relevant outcomes, interpretation of results and writing/editing the document for readability and accuracy. Patients were involved in a global survey of values and preferences and in focus group discussions with vulnerable communities conducted to inform the WHO guideline on self-care interventions 8 ; they thus play a significant role in the overall recommendation informed by this review.

Search results

Figure 1 presents a flow chart showing study selection for both the effectiveness and values and preferences reviews. The initial database search yielded 929 records, with 15 records identified through other sources; 782 remained after removing duplicates. After the initial title/abstract review, 68 articles were retained for full-text screening. Ultimately, six articles reporting data from four studies met the inclusion criteria and were included in the effectiveness review. 9–14 An additional 24 articles from 23 studies were included in the values and preferences review. 13 15–37

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart showing disposition of citations through the search and screening process.

One study was considered for the effectiveness review but ultimately judged to not meet the inclusion criteria. 38 In Kuwait, where OCs are available OTC, the study compared women who consulted with a physician and those who did not. We excluded the study because it was not clear whether women received OCs from these physicians or not. However, we note that the study found no difference across groups in OC continuation, duration of first OC use, method failure and reasons for discontinuation.

Effectiveness review

Table 1 shows the characteristics of the four studies included in the effectiveness review. 9–14 The first study, the Border Contraceptive Access Study, was a longitudinal cohort study conducted among women living in El Paso, Texas, USA, from 2006 to 2008 with results reported in a number of articles. 10 12 13 The study used convenience sampling to enrol 1046°C users who obtained OCs either OTC from a Mexican pharmacy (n=532) or from a family planning clinic in El Paso (n=514). These women were interviewed at baseline and then followed in three additional surveys over 9 months. The second study, an analysis of data from the 2000 Mexican National Health Survey 14 by an overlapping group of researchers, was a cross-sectional comparison of women who reported obtaining OCs OTC to women who reported obtaining them from a healthcare provider. The third and fourth studies were significantly older, drawing on data from the 1970s. They presented cross-sectional comparisons of women whose initial contraceptive method was OCs, obtained OTC from a pharmacy/drugstore, from a private provider/clinician or the national family planning programme: one analysed data from the 1979 Mexico National Fertility and Mortality Study among 2063 women 9 and the other was a 1974 Fertility and Contraceptive Use survey in Bogotá, Colombia, among 893 women. 11 All studies included mainly women using COCs, rather than POPs, although pill formulations likely differed by time.

Descriptions of studies included in the effectiveness review

OC, oral contraceptive; OTC, over the counter.

As all studies were observational, table 2 shows the risk of bias assessments using the Evidence Project tool. The Border Contraceptive Access and Mexican National Health Survey studies found that women who obtained their OCs OTC were different in at least some sociodemographic characteristics than those who obtained them from clinics; however, both studies employed analyses that adjusted for confounders to address this discrepancy. 10 12–14 The Mexico National Fertility and Mortality Study and Colombian Fertility and Contraceptive Use Survey said there were only minor sociodemographic differences between groups but did not present actual statistics to support these statements; neither study adjusted for confounders. 9 11 The Border Contraceptive Access Study relied on convenience sampling, but was strengthened by its longitudinal design. 10 12 13 Conversely, while the other three studies were cross sectional in nature, they were strengthened by their multistage sampling strategies. 9 11 14

Evidence Project risk of bias assessment 7 for studies included in the effectiveness review

*Four-stage probability proportionate to size sampling.

†Authors state that the comparison groups were similar, but no comparative data provided to assess this.

‡Three-stage probability sampling.

N/A, not applicable; NR, not reported.

The included studies reported on three of the PICO outcomes: continuation of OCs, health impacts (specifically, use of OCs despite contraindications and side effects) and client satisfaction. For the other PICO outcomes, we found no studies. Results from each study are presented in table 3 and described below.

Outcomes of studies included in the effectiveness review

OC, oral contraceptive;OTC, over the counter.

Continuation of OCs

The Border Contraceptive Access Study reported the proportion of women who continued OC use over the 9-month study period. 12 Overall, 25.1% of clinic users discontinued by the end of the study period compared with 20.8% of OTC users (p=0.12). In an unadjusted Cox proportional hazards model, OTC users were more likely to continue OC use than clinic users (unadjusted HR: 1.48, 95% CI 1.07 to 2.04); this estimate changed only slightly in the adjusted model and remained statistically significant (adjusted HR: 1.58, 95% CI 1.11 to 2.26).

The two studies from the 1970s also examined continuation. The Mexico National Fertility and Mortality Study presented continuation rates at 12 months per 100 women who accepted OCs as their first contraceptive method. 9 No difference by OC source was found: 59% of private physician or clinic users, 57% of government family planning programme users and 60% of OTC users remained on OCs after 12 months. The Colombian Fertility and Contraceptive Use Survey presented first contraceptive method continuation rates for women who chose OCs at 12 and 24 months. 11 Though a validation survey found that the continuation rates were overestimated by approximately 10%–15%, the study found that at both 12 and 24 months, OC continuation was approximately 5% higher for clinic users than OTC users.

Use of OCs despite contraindications

The two studies from the 2000s reported on the use of OCs despite contraindications.

The Border Contraceptive Access Study reported use of OCs despite contraindications using the WHO Medical Eligibility Criteria (MEC) (third edition) relative (category 3) and absolute (category 4) contraindications. 10 At the baseline survey, at least one category 3 or 4 contraindication was reported by 21.4% of OTC users and 13.8% of clinic users (p=0.002). OTC users were more likely to have any category 3 contraindication (13.4% vs 8.6%, p=0.006), but there was no difference in category 4 contraindications (7.4% vs 5.3%, p=0.162). The study also provided a list of specific contraindications. For most contraindications there was no significant difference for OTC and clinic users; however, OTC users were significantly more likely than clinic users to have category 3 hypertension (140–159/90–99) (8.4% vs 4.5%, p=0.036) or to both smoke (<15 cigarettes per day) and be 35 years or older (6.4% vs 3.1%, p=0.017).

The 2000 Mexican National Health Survey analysis reported use of OCs despite category 3 contraindications using the WHO MEC Criteria from 1996 based on hypertension and smoking at or over age 35. 14 Overall, the study found no significant differences in contraindications between OC users who obtained their pills OTC versus those who obtained them at a clinic ( table 3 ). This finding held true when comparing OTC to clinic users on contraindications related to hypertension (≥160/100) (1.7% vs 1.8%), smoking and age 35 or older (9.4% vs 7.5%), and both contraindications combined (4.5% vs 3.6%).

Side effects

Two studies reported on side effects related to OC use. The Border Contraceptive Access Study found that, at baseline, 22.3% (104/466) of OTC users reported side effects compared with 30.4% (144/474) of clinic users (p<0.01). 12 The Colombian Fertility and Contraceptive Use Survey found that 51% of OTC users and 44.4% of clinic users reported any side effect from initial OC use. 11 Neither group reported the most important complications of OC use (thrombophlebitis and thromboembolism), and similar proportions reported the most common side effect (headache). OTC users were more likely to mention nervousness, skin problems, pain and bleeding problems, while clinic users were more likely to complain of weight changes, varices and other side effects (not specified).

Satisfaction

One study—the Border Contraceptive Access Study—reported client satisfaction but did not present exact results. They stated, ‘three quarters of clinic users and more than 70% of pharmacy users said they were very satisfied with their source (results not shown). Only about 4% of each group said they were either somewhat or very unsatisfied with their source.’ 13

Values and preferences review

We identified 24 articles from 23 studies that met the inclusion criteria for the values and preferences review. Of these, 13 articles focused on the perspectives of female OC users, potential users, or women in general, 13 15 16 18 19 21–24 29–31 37 9 focused on the perspectives of healthcare providers (particularly physicians) and pharmacists 17 25 26 28 32–36 38 , 39 and 1 focused on the general public; 27 one article included both women and healthcare providers. 20 Almost all studies were conducted in the USA, except for one each in Canada, 32 France 17 and Ireland 15 ; one publication from the Border Contraceptive Access Study included in the values and preferences review included women residing in El Paso, Texas, who accessed OCs in both the USA and Mexico. 13 Studies used both quantitative and qualitative methodologies.

Studies covered both OTC and pharmacy access. While most studies of women asked about hypothetical values and preferences around OTC availability, a few studies reported the perspectives of women who had actually used OTC or pharmacy access services. 13 20 Most studies distinguished between pharmacy access and OTC availability, although a few were less clear about which approach they were studying, using terms such as ‘access to oral contraceptives without a prescription,’ which we assumed to be OTC availability. Using our best assessment of which model studies were examining, we present data for the values and preferences studies separated by true OTC access ( table 4 ) and pharmacy access ( table 5 ), and present results accordingly below. Two studies examined perspectives on both OTC and pharmacy access, so are presented in both tables 4 and 5 . One cross-sectional survey among young women aged 14–17 in the USA found slightly higher support for dispensation in pharmacies compared with full OTC availability (79% vs 73%), but slightly higher potential use of full OTC availability compared with pharmacy access (61% vs 57%). 30 Another cross-sectional survey among healthcare providers in the USA found much higher rates of support for pharmacy access (74%) compared with full OTC access (28%), although this study combined the pill, patch and ring together in one question about hormonal contraceptives. 35

Study descriptions and key findings of studies included in the values and preferences review examining OTC access

OC, oral contraceptive; OCP, Oral Contraceptive Pill; OTC, over the counter;POP, progestogen-only pill; STI, sexually transmitted infection; aOR, adjusted OR.

Study descriptions and key findings of studies included in the values and preferences review examining pharmacy access

OC, oral contraceptive;OTC, over the counter;STI, sexually transmitted infection.

Across studies using both quantitative and qualitative methods, women generally expressed high interest in hypothetical OTC availability of OCs. In quantitative studies, support for OTC availability of OCs ranged from a third of female students in two US colleges/universities 19 31 to 89% of current OC users aged 18–50 in Ireland. 15 However, most quantitative surveys of potential OC users found that a majority of participants supported OTC availability. 15 18 21 24 30 Slightly lower but still sizeable proportions of women said they would obtain OCs OTC if available. 23 24 30 Ease of access, convenience, privacy and time saved from clinician visits for prescriptions were the main benefits women anticipated from OTC availability. 13 16 18 30 However, across studies, participants noted concerns about cost, continued use of other preventive screening options (eg, for Pap smears, pelvic exams, clinical breast exams and sexually transmitted infections) and the safety of such access, particularly for young people, first-time pill users and women with medical conditions. 13 16 18 19 23 30 31

Healthcare professionals from France and the USA, particularly medical doctors, voiced moderate to low support for OTC availability of OCs, often citing safety concerns, OC efficacy, concerns about correct OC use or missed examinations for medical contraindications. 17 28 35 Providers generally supported making POPs available OTC more than they supported making COCs available OTC. 26

Pharmacy access

Among potential or current OC users, most women were in favour of pharmacy access, and substantial proportions said they would obtain OCs through pharmacy access if it were available. 29 30 37 Some women currently not using any contraception said they would begin using a hormonal contraceptive if pharmacy access were available. 29 One study found that women (and pharmacists) were satisfied with pharmacist-led OC use and expressed willingness to continue seeing pharmacist prescribers. 20 While young women appreciated their traditional healthcare providers, they liked the increased access and convenience of obtaining OCs directly from a pharmacy. 37

In studies among healthcare providers, pharmacists were generally very supportive of pharmacy access to OCs, while physicians tended to be more moderately supportive. 20 25 28 32–36 Increased access to care, preventing unintended pregnancies and convenience for patients were the most frequently identified potential benefits. 25 33–35 Safety, time constraints, lack of private space in the pharmacy, increased liability and reimbursement were identified as potential barriers. 25 28 33 36 There was also concern from pharmacists about physician’s resistance to making OCs available at pharmacies 28 and concern from physicians about pharmacist’s refusal to provide services. 34

Finally, in a study of digital comments on online media articles about pharmacy access to OCs in the USA, commentators were generally positive and cited benefits including increasing access to healthcare, reducing unintended pregnancies and supporting individual autonomy, but noted these must be balanced with potential safety and logistical concerns. 27

In this systematic review, we identified four studies using comparative designs to examine the impact of OTC availability of OCs. Two studies conducted in the 2000s examined women who obtained OCs OTC in Mexico and compared them with women who obtained OCs from providers in either Mexico or the USA. The other two studies were significantly older (from the 1970s) and compared first contraceptive method users who either obtained OCs OTC from a pharmacy or drugstore or through a provider or family planning programme; the OC formulations in these studies were likely different, and women 45 years ago potentially differ from women today in terms of desired fertility, decision-making around contraceptive methods and perception/tolerance of and tendency to report side effects. While the more recent studies suggested OTC users had higher rates of OC continuation over time and fewer side effects, there was some indication that OTC users had slightly higher rates of use of OCs despite contraindications. Contraindications are an important concern; however, research has indicated that women can self-screen for contraindications fairly well using a simple checklist. 40 41 Despite the strengths of the studies included in the review, the small evidence base provides limited guidance for countries considering OTC availability of OCs.

We identified a much larger evidence base on the values and preferences of potential users, providers and the public. However, this evidence was also limited, since almost all studies were conducted in the USA. Women were generally in favour of OTC availability; healthcare providers were as well, with pharmacists expressing higher support than physicians for pharmacy access. Among both women and providers, support was generally higher for dispensation in pharmacies compared with full OTC availability, and for OTC access to POPs rather than COCs. Given the near-universal use of COCs at the times and locations where the studies included in the main review were conducted, we had no comparative effectiveness data on POPs. This is unfortunate, as POPs have been suggested as a good option for initial OTC availability, given that they have fewer contraindications to use.

An additional concern about OTC availability is that the concomitant reduced visits to clinicians may also translate to a reduction in routine preventive screening (including for Pap smears, pelvic exams, clinical breast exams and screening for sexually transmitted infections). This was not one of our prespecified PICO outcomes since such exams are not required to receive OCs per the WHO’s Selected Practice Recommendations for Contraceptive Use. 42 However, the Border Contraceptive Access Study did report on preventive screening; while women who obtained their OCs from a clinic reported slightly higher rates of some screenings, both groups (OTC and clinic users) had high overall rates of reported screenings with relatively minimal differences between groups. 43 One values and preferences study also found that US women said they would continue to get screened if OCs were made available OTC, 23 although clinicians were afraid they would not. 35 These findings offer some indication that OTC access for OCs may not necessarily result in reduced use of other preventive services.

OTC availability is only one way to increase access to OCs. A previous systematic review found that increasing the number of OC pill packs dispensed or prescribed increased OC continuation, although it also resulted in increased pill wastage. 44 There are also internet-based platforms for ordering OCs, which comply with clinician prescriptions or pharmacist screening, but conduct all screenings online. 45 A modelling study found that making out-of-pocket pill pack costs low or free would increase OC use. 46 Finally, increased insurance coverage for OCs should also reduce access barriers to OC use, regardless of access point. Although moving OCs to OTC status should lead to fewer clinician visits for women, thus decreasing costs related to travel, time and other medical expenses associated with those visits, OTC access could potentially increase the cost of OCs if insurance does not cover OTC purchases, or if women are unaware that they can use insurance in OTC purchases. Insurance considerations should be explicitly considered in policy discussions of OTC availability, as insurance coverage will be particularly important for some of the most vulnerable groups, such as low-income women and girls.

Our review has several strengths, including our broad search strategy and our inclusion of both effectiveness and values and preferences studies. However, conclusions from our review are limited by the small evidence base in this area. We identified four observational studies in our main effectiveness review, from the same global region, and there may have been residual confounding in comparing OTC and clinic OC users despite some analyses being adjusted. Although there were more studies in the values and preferences review, they were also geographically limited, and many relied on participants’ responses to hypothetical questions about OTC availability. While it is challenging to conduct randomised trials of what is fundamentally a policy intervention, researchers should be encouraged to take advantage of natural experiments such as the Border Contraceptive Access Study or to study changes to policies such as those recently allowing pharmacy access to OCs in the US states of Oregon and California. Further, many countries already allow OTC availability of OCs, so policy decisions can also take into consideration the wide range of country experience in this area.

Despite the limitations of the evidence base, this review provides important information to guide policy decisions around OTC availability of OCs. This evidence has been used to inform the development of WHO recommendations for self-care interventions for sexual and reproductive health and rights in relation to OTC availability of OCs. The benefits and harms of OTC availability of OCs and the values and preferences of patients and providers found in the present review, along with a separate survey of community values and preferences and consideration of resource use, human rights and feasibility, will shape the recommendation. Additional research into outcomes critical to decision-makers where little comparative data currently exist should be done to address the gaps identified.

Acknowledgments

We thank Laura Ferguson and Nandi Siegfried for their comments on the review protocol. We also thank Johns Hopkins research assistants Rui (Renee) Ling, Kaitlyn Atkins, Priyanka Mysore, Molly Petersen and Anita Dam for help with screening the initial database search results, conducting hand searching and secondary reference searching, and duplicate data extraction. Finally, we thank Daniel Grossman and Sara Yeatman for their timely and thorough responses to questions about their studies, and the excellent comments from the anonymous reviewers who really helped improve the manuscript.

Handling editor: Soumyadeep Bhaumik

Contributors: MN conceptualised the study. CEK and PTY designed the protocol with input from JK, MLG, LG, HJ and MLN. PTY ran the search and oversaw screening, data extraction and assessment of bias. CEK drafted the manuscript, while all authors reviewed the draft and provided critical feedback. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. All authors read and approved the final manuscript. The corresponding author, as guarantor, accepts full responsibility for the finished article, has access to any data and controlled the decision to publish.

Funding: This study received financial support from the UNDP-UNFPA-Unicef-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) and the Children's Investment Fund Foundation (CIFF). HRP was involved in the study design.

Disclaimer: The funders played no part in the decision to submit the article for publication, nor in the collection, analysis and interpretation of data.

Competing interests: None declared.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement: All data come from published journal articles. Extracted data are available on request to the corresponding author.

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Biden administration proposes free over-the-counter birth control

By ahmed aboulenein, reuters | posted - oct. 21, 2024 at 11:24 a.m..

Jennifer Klein, director of the White House Gender Policy Council, speaks at the White House Jan. 22. The Biden administration on Monday is proposing a rule to provide contraceptives at no cost to those with private insurance. (Evelyn Hockstein, Reuters)

Estimated read time: 1-2 minutes

WASHINGTON — The Biden administration is proposing a rule that would provide women with private insurance access to over-the-counter birth control pills and other contraceptives at no cost, the White House said on Monday.

The rule, which expands a federal mandate requiring health insurers to cover preventative care services at no cost to patients under the Affordable Care Act, is being proposed by the departments of Health and Human Services, Labor, and the Treasury and would come into effect in 2025 if finalized.

"This rule, once finalized, will expand contraception coverage for 52 million women of reproductive age with private health insurance," White House Gender Policy Council Director Jennifer Klein said during a briefing.

"For the first time ever, women would be able to obtain over-the-counter contraception without a prescription at no additional cost, and health plans would have to cover even more prescribed contraceptives without cost sharing," she said.

Perrigo's Opill is currently the only daily birth control pill approved for sale without a prescription by the U.S. Food and Drug Administration, but the proposed rule covers other forms of over-the-counter contraceptives.

The rule will also require that health plans cover all FDA-approved contraceptive drugs and some devices, including intrauterine devices, without cost sharing in many cases.

The rule will also require health plans to cover every FDA-approved contraceptive drug or drug-led combination product without cost sharing unless the plan also covers a therapeutic equivalent without cost sharing, and would require plans to disclose that over-the-counter contraceptives are covered with cost sharing or a prescription.

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Why aren't there hormone-free birth control pills? Roe puts spotlight on contraceptives

The overturn of Roe v. Wade has put a spotlight on the availability of affordable, highly effective birth control in the U.S. Many younger women, however, don’t want their mothers’ contraceptives.

Even before the Supreme Court decision , more women had been asking about nonhormonal birth control options, said Dr. Aviva Romm, a family medicine physician in West Stockbridge, Massachusetts.

“People are more educated than ever about the importance of what they put in their bodies,” said Romm, author of “Hormone Intelligence.” “Hormonal birth control has barely changed since it was first discovered, and women want an alternative.”

By some measures, there's no shortage of birth control. The Food and Drug Administration has approved more than 250 contraceptives, and the Affordable Care Act mandates insurance coverage, at least for the generic versions. In addition, the FDA is considering a French pharmaceutical company's request to sell over-the-counter birth control pills .

Yet, out of the long list of brands and devices, only a handful are free of hormones. Scientists and biotech startups have started to develop new nonhormonal birth control methods, but they're still in the lab and animal study stage, and face a lack of funding. Available products are likely years away.

Most hormonal contraceptives — which include the birth control pill , the long-acting patch , injections, the vaginal ring, the implant and the intrauterine device, or IUD — contain synthetic versions of the same two sex hormones, progesterone and estrogen.

Hormonal pills, second only to permanent sterilization, are the most common female contraceptives in the U.S. and are highly effective at preventing pregnancy. The handful of hormone-free contraceptives, such as diaphragms or cervical caps, don't work as well. Condoms can have a high failure rate.

Phexxi, a vaginal gel meant to be inserted an hour before sex, was approved by the FDA in 2020 — the first new nonhormonal option cleared by the agency since the 1980s. Assuming typical use, Phexxi prevents pregnancy at about the same rate as condoms.

Research on hormone-free birth control

Effective, nonhormonal choices are important, said Daniel Johnston, chief of the National Institutes of Health Contraception Research Branch . There was excitement in his voice as he talked about promising, albeit extremely early, research: Scientists have discovered antibodies that glom on to sperm to stop them from swimming, and have targeted drugs that would block receptors needed to make sperm. 

One sperm-blocking drug, which the startup YourChoice Therapeutics, in Berkeley, California, is developing as the first “male birth control pill,” has generated buzz, especially among those who believe the responsibility of birth control shouldn’t fall exclusively on those with uteruses. 

Recent studies showed the pill worked in mice, monkeys, rats and dogs. It will take years to see whether it’s safe and effective for humans. On average, developing a drug takes about a decade, and the “male birth control pill” is too early in that timeline to even get a name. For now, it’s known as YCT529 .

YourChoice chief executive Akash Bakshi and co-founder Nadja Mannowetz launched the company to develop nonhormonal options for both biological sexes, Bakshi said. It just happened that the science was more advanced for the drug targeting male sperm. 

That has to do with biology. The male body generates about 1,500 sperm per second, whereas the female body is born with a finite number of eggs, Johnston said. Drugs targeting the male sperm without harming the stem cells that make more, or blocking a receptor needed to make sperm the way YCT529 does, could, in theory, be reversible. A male body could make more sperm afterward. 

In female bodies, on the other hand, “if you destroy the pool of eggs, show’s over,” Johnston said. This doesn’t mean nonhormonal contraceptives designed to act on the female body aren’t possible, but the ones targeting male sperm could come first.  

Another company, Mucommune in Durham, North Carolina, is developing a monoclonal antibody that makes sperm unable to swim. Rather than giving the antibody to men, though, the company’s founder, Samuel Lai, wants to give women a vaginal ring they could wear for their whole menstrual cycle that releases the antibody. When sperm enter the vagina, they’d be frozen in their tracks, unable to reach the egg for fertilization.

The antibodies worked well in animals, but like YourChoice’s male pill, the sperm-stopping antibody still has many years of testing ahead. Lai said the whole process could be faster with more funding.

“There is nowhere near the type of investment in the reproductive health space as anywhere else,” he said. 

Where's the demand for new birth control?

The Roe decision amplifies the urgency. 

With more open conversation about contraceptive needs, the next decade could be “an exciting time for nonhormonal contraception,” Lai said. These conversations, he believes, could help pharmaceutical investors see a real demand.

NIH funds early stage nonhormonal birth control research, but Johnston agreed that investment in the methods isn’t where it needs to be. Products can’t get to pharmacy shelves unless the biopharma industry steps in to fund drug development, but it’s difficult to determine how many women want hormone-free birth control options. Pharmaceutical companies usually want to see clear demand before investing in a product.

Worldwide, there were more than 151 million users on the hormonal pill in 2019, according to to a report from the United Nations. Analysts say sales of all hormonal contraceptives made the global market for these options worth more than $15 billion in 2020 — a value that’s estimated to grow to more than $20 billion by 2030. 

“From a business perspective, the contraceptive market seems to be healthy and growing,” reads a 2020 commentary in the journal Nature . “Yet the demand from women for transformational change is not reflected as a reduction in sales.” 

Side effects of hormone contraceptives are minimal, but they can, in rare cases, cause blood clots or other serious conditions. A survey published in the  Journal of Women’s Health in 2021 found that although most were satisfied with their birth control options, the highest proportion of women who wanted a different method were those using hormonal contraceptives. Those using nonhormonal methods were close to six times as likely to say they were satisfied with their current methods than those on hormonal methods, according to the survey.

“Hormonal contraceptives work tremendously well,” said Johnston. “But they basically involve the changing of the expression of hundreds, if not thousands, of genes, to give you the effect.” 

The hormones do more than control when women — or trans men, nonbinary people and others who ovulate — can get pregnant. They regulate everything from sleep patterns to metabolism , blood pressure, bone density, hair growth, skin and the brain.

“It’s not something that needs to be scary, but it does need to be taken seriously,”  said Sarah Hill, a psychology professor at Texas Christian University in Fort Worth, of hormonal birth control’s effect on the brain. Hill is author of “This Is Your Brain on Birth Control.”

When hormones aren't an option

According to the Nature commentary, about one-third of women globally discontinue hormonal birth control methods within the first year of taking them, often because of side effects.

That was the case for Lenise “Sunny” Wilson, who attributes severe depression to the birth control pills she had been taking. 

“It completely changed who I was as a person,” said Wilson, 38, of Tucson, Arizona. “It messed with my emotions and my mental health so intensely.”

Wilson has since stopped taking the pill and, for the most part, she said, has returned to her sunny self. 

Some women, including those with certain cancers and heart conditions, can’t take hormonal birth control. Erica Twidle, 33, from Gallatin, Tennessee, was diagnosed with a rare heart condition called peripartum cardiomyopathy while pregnant with her daughter, Della. The condition made Twidle’s heart weak and enlarged, and although she eventually recovered, Twidle’s doctors told her she shouldn’t take hormonal birth control, or get pregnant, ever again. Both would jeopardize her heart. 

Twidle, who’d had a bad experience with the copper IUD in the past, decided to track her cycle. But nine months after having Della, she was pregnant again. “I cried when I found out,” she said. “I was terrified. I had a child I needed to stay alive for.”

Twidle calls herself “one of the lucky ones,” since her heart stayed strong enough to support pregnancy. But had things taken a turn, Twidle was prepared to get an abortion to stay alive.

This was three years ago, but Twidle would have fewer choices now.

In Tennessee, abortion is now a crime . The  state makes exceptions for the life of the mother, but Twidle wishes women in her position — including the 1,000 to 1,300 women affected by peripartum cardiomyopathy each year — had more hormone-free options. 

“As simple as it sounds to ‘just take birth control,’” she said. “Sometimes you can’t.” 

Follow  NBC HEALTH  on  Twitter  &  Facebook .

NBC News contributor Caroline Hopkins is a health and science journalist who covers cancer treatment for Precision Oncology News. She is a graduate of the Columbia University Graduate School of Journalism.  

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Access to free birth control reduces abortion rates

A study from Washington University School of Medicine shows that providing free birth control to women reduces unplanned pregnancies and abortions

by Diane Duke Williams • October 12, 2012

Jeffrey Peipert, MD, PhD (left) with resident Lindsay Kuroki, MD. Peipert leads a study showing free contraception reduces unplanned pregnancies.

Unplanned pregnancies are a significant problem in the United States. According to a 2012 Brookings Institution report, more than 90 percent of abortions occur due to unintended pregnancy.

Each year, about 50 percent of all pregnancies that occur in the US are not planned, a number far higher than is reported in other developed countries. About half of these pregnancies result from women not using contraception and the other half from incorrect or irregular use.

A new study by investigators at Washington University reports that providing birth control to women at no cost substantially reduces unplanned pregnancies and cuts abortion rates by a range of 62 to 78 percent compared to the national rate.

Contraceptive choice

This study, called the Contraceptive CHOICE Project , enrolled 9,256 women and adolescents in the St. Louis area between 2007 and 2011. Participants were 14 to 45 years of age, at risk for unintended pregnancy and willing to start a new contraceptive method.

Participants had their choice of birth control methods, including:

• longer-acting birth control such as intrauterine devices (IUDs) and implants
• shorter-acting methods like birth control pills, patches and rings.

The women were counseled about the different methods, including their effectiveness, risks and benefits. The extremely low failure rate (less than 1 percent) of IUDs and implants over that of shorter-acting forms (8-10 percent) was emphasized. In all, about 75 percent of women in the study chose IUDs or implants.

Drop in abortion rates

From 2008 to 2010, annual abortion rates among study participants ranged from 4.4 to 7.5 per 1,000 women. This is a substantial drop (ranging from 62 to 78 percent) compared to the national rate of 19.6 abortions per 1,000 women in 2008, the latest year for which figures are available.

The lower abortion rates among Choice study participants also is considerably less than the rates in St. Louis city and county, which ranged from 13.4 to 17 per 1,000 women for the same years.

Among girls ages 15 to 19 who had access to free birth control provided in the study, the annual birth rate was 6.3 per 1,000, far below the U.S. rate of 34.3 per 1,000 for girls the same age.

Short vs. long term methods

While birth control pills are the most commonly used reversible contraceptive in the United States, their effectiveness hinges on women remembering to take a pill every day and having easy access to refills.

In contrast, IUDs and implants are inserted by health-care providers and are effective for 5 to 10 years and 3 years, respectively. Despite their superior effectiveness over short-term methods, only a small percentage of U.S. women using contraception choose these methods. Many can’t afford the cost of IUDs and implants, which can cost more than $800 and may not be covered by insurance.

“Unintended pregnancy remains a major health problem in the United States, with higher proportions among teenagers and women with less education and lower economic status,” says lead author  Jeffrey Peipert, MD, PhD , a Washington University obstetrician and gynecologist at Barnes-Jewish Hospital. “The results of this study demonstrate that we can reduce the rate of unintended pregnancy, and this is key to reducing abortions in this country.”

View a video about the  Contraceptive CHOICE Project .

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Birth Control’s Slow Path to the Mainstream

A look at changing public opinion of birth control.

Colorado’s teen birth rate dropped 40 percent between 2009 and 2013 after the state began providing free or low-cost long-term birth control to many women. Meanwhile, the expansion of free birth control under the Affordable Care Act remains controversial.

Birth control has always been a force for massive change and a subject of controversy. In this 1970 paper for The Family Coordinator, Rosanna L. Barnes goes through magazines and journals from 1915 to 1968 to find clues about changes in public opinion on the topic.

In the early twentieth century, Barnes writes, the idea of intentionally limiting family size was roundly rejected by most Americans, and it was rare for popular media to even address the subject. Between 1915 and 1929, she finds, most coverage came from serious political journals backed by philanthropists rather than subscribers and advertisers. These included the New Republic and the Nation . In 1925, Catholic World ran an item opposing the relaxation of a law banning contraception from the U.S. mail, suggesting the Catholic Church’s growing interest in the topic as an important social issue.

In the 1930s, the Depression made struggling families wary of adding more children. Barnes notes that this may explain why this was the decade when the birth control movement found its way into mainstream magazines. Newsweek and Time ran stories about it. Scientific American and Science tracked research on birth control, and in 1935, the American Journal of Public Health raised the question of whether government health services should include offering contraception.

In 1937, the American Medical Association sanctioned the use of birth control, and the Birth Control Federation of America was formed to encourage state public-health programs to provide it. A Life Magazine story published in 1940 praised South Carolina officials for using public money to offer contraception to poor mothers.

In 1938, the business magazine Fortune reported that contraceptives were a lucrative business but a secretive one that sometimes produced dangerous products. It called for bringing the industry into the light and providing government oversight.

In the 1940s and early ’50s, public attention to birth control declined. But it in the late 1950s and the 1960s, concerns about rising population levels prompted new attention. As research on contraceptives ramped up, science magazines increased their coverage. Meanwhile, Catholic magazines, finding their views under increasing attack, also published frequently on the subject.

Barnes concludes her account close to her own historical moment in 1970, a time we now associate with rapid changes in attitudes toward sex and “The Pill.” But the history she examines makes it clear that change in public opinion had already been unfolding for a long time. And the current conversation about Colorado and the ACA makes it clear that it still is.

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• Introduction
• Conclusions
• Article Information

This algorithm has not been validated for clinical use. IUD indicates intrauterine device; PATH, Pregnancy Attitudes, Timing, and How important is pregnancy prevention.

This algorithm has not been validated for clinical use. BMI indicates body mass index (calculated as weight in kilograms divided by height in meters squared); MEC, Medical Eligibility Criteria for Contraceptive Use.

• Selection, Effectiveness, and Adverse Effects of Contraception—Reply JAMA Comment & Response April 19, 2022 Stephanie Teal, MD, MPH; Alison Edelman, MD, MPH
• Selection, Effectiveness, and Adverse Effects of Contraception JAMA Comment & Response April 19, 2022 Ekaterina Skaritanov, BS; Gianna Wilkie, MD; Lara C. Kovell, MD
• Contraception in Women With Cardiovascular Disease JAMA JAMA Insights August 9, 2022 This JAMA Insights in Women’s Health series summarizes the prevalence of cardiovascular disease among women of childbearing age, the most effective forms of contraception based on the patient’s medical condition and preference, and the risks and adverse effects associated with contraindicated forms of contraception. Kathryn J. Lindley, MD; Stephanie B. Teal, MD, MPH
• Patient Information: Long-Acting Reversible Contraception JAMA JAMA Patient Page October 4, 2022 This JAMA Patient Page describes types of long-acting reversible contraception, how they are placed and removed, and their potential side effects. Elisabeth L. Stark, MD; Aileen M. Gariepy, MD, MPH, MHS; Moeun Son, MD, MSCI
• Patient Information: Medication Abortion JAMA JAMA Patient Page November 1, 2022 This JAMA Patient Page describes medication abortion and its risks and effectiveness. Rebecca H. Cohen, MD, MPH; Stephanie B. Teal, MD, MPH

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Teal S , Edelman A. Contraception Selection, Effectiveness, and Adverse Effects : A Review . JAMA. 2021;326(24):2507–2518. doi:10.1001/jama.2021.21392

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Contraception Selection, Effectiveness, and Adverse Effects : A Review

• 1 Department of OB/GYN, University Hospitals Medical Center and Case Western Reserve University, Cleveland, Ohio
• 2 Department of OB/GYN, Oregon Health & Science University, Portland
• Comment & Response Selection, Effectiveness, and Adverse Effects of Contraception—Reply Stephanie Teal, MD, MPH; Alison Edelman, MD, MPH JAMA
• Comment & Response Selection, Effectiveness, and Adverse Effects of Contraception Ekaterina Skaritanov, BS; Gianna Wilkie, MD; Lara C. Kovell, MD JAMA
• JAMA Insights Contraception in Women With Cardiovascular Disease Kathryn J. Lindley, MD; Stephanie B. Teal, MD, MPH JAMA
• JAMA Patient Page Patient Information: Long-Acting Reversible Contraception Elisabeth L. Stark, MD; Aileen M. Gariepy, MD, MPH, MHS; Moeun Son, MD, MSCI JAMA
• JAMA Patient Page Patient Information: Medication Abortion Rebecca H. Cohen, MD, MPH; Stephanie B. Teal, MD, MPH JAMA

Importance   Many women spend a substantial proportion of their lives preventing or planning for pregnancy, and approximately 87% of US women use contraception during their lifetime.

Observations   Contraceptive effectiveness is determined by a combination of drug or device efficacy, individual fecundability, coital frequency, and user adherence and continuation. In the US, oral contraceptive pills are the most commonly used reversible method of contraception and comprise 21.9% of all contraception in current use. Pregnancy rates of women using oral contraceptives are 4% to 7% per year. Use of long-acting methods, such as intrauterine devices and subdermal implants, has increased substantially, from 6% of all contraceptive users in 2008 to 17.8% in 2016; these methods have failure rates of less than 1% per year. Estrogen-containing methods, such as combined oral contraceptive pills, increase the risk of venous thrombosis from 2 to 10 venous thrombotic events per 10 000 women-years to 7 to 10 venous thrombotic events per 10 000 women-years, whereas progestin-only and nonhormonal methods, such as implants and condoms, are associated with rare serious risks. Hormonal contraceptives can improve medical conditions associated with hormonal changes related to the menstrual cycle, such as acne, endometriosis, and premenstrual dysphoric disorder. Optimal contraceptive selection requires patient and clinician discussion of the patient’s tolerance for risk of pregnancy, menstrual bleeding changes, other risks, and personal values and preferences.

Conclusions and Relevance   Oral contraceptive pills are the most commonly used reversible contraceptives, intrauterine devices and subdermal implants have the highest effectiveness, and progestin-only and nonhormonal methods have the lowest risks. Optimal contraceptive selection incorporates patient values and preferences.

Contraception is defined as an intervention that reduces the chance of pregnancy after sexual intercourse. According to a report from 2013, an estimated 99% of women who have ever had sexual intercourse used at least 1 contraceptive method in their lifetime. 1 Approximately 88% of sexually active women not seeking pregnancy report using contraception at any given time. 2 All nonbarrier contraceptive methods require a prescription or initiation by a clinician. Therefore, contraception is a common reason women 15 to 50 years of age seek health care. 3 This review summarizes current evidence regarding efficacy, adverse effects, and optimal selection of reversible contraceptives. This review uses the terms women and men when the biological expectation for the individual is ovulation or sperm production, respectively.

A search of OVID Medline All, Embase.com, and Ovid Evidence-Based Medicine Reviews–Cochrane Central Register of Controlled Trials for English-language studies was conducted for articles published between January 1, 2000, and June 28, 2021, to identify randomized clinical trials, systematic reviews, and practice guidelines related to contraception or contraceptives. After excluding duplicates and articles not relevant to this review, 2188 articles were identified as potentially relevant via title or abstract content. Thirty-seven articles, consisting of 13 randomized clinical trials, 22 systematic reviews, and 2 guidelines were included. Evidence-based guidelines that used GRADE and systematic reviews were selected for inclusion over individual studies. Clinical practice guidelines from the Society of Family Planning, the World Health Organization, and the American College of Obstetricians and Gynecologists on selected topic areas were reviewed to identify additional key evidence.

The mean age of first sexual intercourse among females in the US is 17 years. 4 Many women typically use contraceptives for approximately 3 decades. 2 The choice of contraceptive is determined by patient preferences, tolerance for contraceptive failure, and adverse effects. Clinicians should elicit patient preferences, identify possible contraindications to specific contraceptives, and facilitate contraceptive initiation and continuation. Clinicians should also be prepared to address misperceptions ( Box ). Some experts recommend screening for contraceptive need at each visit. Two validated screening options, with toolkits available online, are One Key Question and the PATH questions (Pregnancy Attitudes, Timing, and How important is pregnancy prevention). 5 , 6

Commonly Asked Questions About Contraception

What options are available for male contraception? There are currently no Food and Drug Administration–approved contraceptive options for men except condoms. Current male contraceptive methods under evaluation attempt to suppress sperm count to <1 million/mL and include a testosterone plus progestin topical gel.

Are contraceptives associated with increased rates of cancer? Combined hormonal contraceptives, such as combined oral contraceptive pills, protect against endometrial and ovarian cancer. They are associated with an increased risk of early breast cancer diagnosis in current or recent users (ie, within the past 6 mo). The incidence is 68 cases per 100 000 person-years compared with 55 cases per 100 000 nonuser-years. There are no associations of past contraceptive use with increased rates of cancer and there is no association of past contraceptive use and mortality.

Can teenagers use intrauterine devices (IUDs)? Prior guidance suggested restricted use of IUDs by teenagers, nonmonogamous or unmarried, and nulliparous women, but there is no high-quality evidence to support this recommendation. None of these characteristics are true contraindications.

Should all women use the most effective form of contraception? The choice of contraceptive is determined by patient preferences and tolerance for failure. Patients may value other attributes of a method (such as route of administration or bleeding patterns) more highly than effectiveness, and may prefer to have a slightly higher risk of unplanned pregnancy to avoid other adverse effects.

Is the pill as effective for individuals with obesity? Obesity adversely influences contraceptive steroid levels but determining whether this affects contraceptive effectiveness is difficult. The primary reason for contraceptive failure is suboptimal adherence. The use of any method for individuals no matter their weight will prevent more pregnancies than not using a method.

Why are pills not available over the counter (OTC)? Combined hormonal contraceptives are unlikely to be available OTC in the US due to concerns regarding increased rates of thrombosis. Efforts to bring progestin-only pills OTC are progressing.

Quiz Ref ID Reversible contraceptive methods are typically grouped as hormonal (such as progestin-only pills or estrogen-progestin patches) or nonhormonal (condoms, diaphragms) and long-acting (such as intrauterine devices [IUDs]) or short-acting (such as pills). Reversible contraceptive methods can also be grouped by level of effectiveness for pregnancy prevention. Except for behavioral methods, condoms, and spermicide, contraceptive methods are only available by prescription in the US.

Progestins and estrogens are steroid or lipid hormones. Hormonal contraception contains a progestin with or without an estrogen. Progesterone is the only naturally occurring progestin; most contraceptive progestins, such as levonorgestrel and norethindrone, are synthesized from testosterone. Progestins provide a contraceptive effect by suppressing gonadotropin-releasing hormone from the hypothalamus, which lowers luteinizing hormone from the pituitary, which in turn prevents ovulation. 7 , 8 In addition, progestins have direct negative effects on cervical mucus permeability. Progestins reduce endometrial receptivity and sperm survival and transport to the fallopian tube. 9 - 11 Estrogens enhance contraceptive effectiveness by suppressing gonadotropins and follicle-stimulating hormone, preventing the development of a dominant follicle. However, the most important contribution of estrogens to progestin-based contraceptives is the reduction of irregular bleeding. The estrogen component in most combined hormonal contraceptives is ethinylestradiol.

A variety of progestin-only contraceptive methods exists ( Table 1 ). Their effectiveness varies based on dose, potency, and half-life of the progestin as well as user-dependent factors, such as adherence to the prescription schedule. 12 , 13

Progestin-only pills include norethindrone- and drospirenone-containing formulations, which differ in their ability to suppress ovulation. Norethindrone pills contain 300 µg of norethindrone compared with 1000 µg in a typical combined contraceptive pill. The lower amount of progestin in norethindrone pills results in less consistent ovulation suppression and more potential for breakthrough bleeding. The contraceptive efficacy is maintained by other progestin-mediated effects. Drospirenone-only pills contain slightly more progestin than an estrogen and progestin combined hormonal contraception, which aids in ovulation suppression. In one study in which participants delayed their drospirenone-containing pill intake by 24 hours, mimicking a missed dose, ovulation suppression was maintained with only 1 participant of 127 having evidence of ovulation. 14 The benefits of progestin-only contraceptive pills include ease of initiation and discontinuation, fertility return within 1 cycle, safety profile, and minimal effect on hemostatic parameters. 15

Quiz Ref ID Depot medroxyprogesterone acetate (DMPA) is an injectable progestin available in intramuscular (150 mg) and subcutaneous (104 mg) formulations, which are administered at 12- to 14-week intervals. While DMPA is associated with irregular uterine bleeding, this pattern improves with longer duration of use. A systematic review of DMPA-related bleeding patterns (13 studies with 1610 patients using DMPA) found that 46% of those using DMPA were amenorrheic in the 90 days following the fourth dose. 16 DMPA is the only contraceptive method that can delay return to fertility. The contraceptive effect and cycle irregularity can persist for up to 12 months after the last dose, 17 likely due to persistence in adipose tissue and its effectiveness in suppressing the hypothalamic-pituitary-ovarian (HPO) axis. DMPA may be best suited for those who benefit from amenorrhea (eg, patients with developmental disabilities, bleeding diatheses) but not by those who want to conceive quickly after discontinuation. Typical effectiveness of DMPA and progestin-only contraceptive pills is 4 to 7 pregnancies per 100 women in a year. 12 , 18

Quiz Ref ID Progestin-only long-acting methods, such as the levonorgestrel (LNG) IUD and the subdermal implant, have typical effectiveness rates of less than 1 pregnancy per 100 women per year similar to permanent methods, such as tubal ligation or vasectomy ( Table 2 ). 12 , 18 These methods are also associated with return to fertility within 1 cycle after discontinuation. The LNG IUD maintains efficacy for at least 7 years, with amenorrhea rates of up to 20% at 12 months and 40% at 24 months. 19 However, initiation requires an in-person visit with a clinician trained in IUD placement. The etonogestrel subdermal implant is effective for up to 5 years 20 and is easily placed or removed. Initiation and discontinuation also require in-person visits. The bleeding profile of the implant is less predictable and up to 11% of users remove it in the first year due to irregular bleeding. 21 An analysis of 11 studies (923 participants) from Europe, Asia, South America, and the US found that the bleeding pattern in the first 3 months (such as prolonged, frequent, or irregular episodes) is consistent with future bleeding patterns. 21 However, those with frequent or prolonged bleeding in the first 3 months have a 50% chance of improvement in the subsequent 3 months. 21

Combined hormonal methods that contain both estrogen and progestin include the daily oral pill, monthly vaginal ring, and weekly transdermal patch. With full adherence, effectiveness of these methods is 2 pregnancies per 100 users per year. However, typical effectiveness is 4 to 7 pregnancies per 100 women per year, with variability in effectiveness related to the user’s adherence. 12 , 18 The importance of patient adherence to hormonal contraception was recently demonstrated by a cohort study of approximately 10 000 individuals in the US. Pregnancy rates were 4.55 per 100 participant-years for short-acting methods (pills, patch, ring) compared with 0.27 for long-acting reversible methods (IUD, implant). 13 Women younger than 21 years using short-acting methods had higher pregnancy risk as women 21 or older (adjusted hazard ratio, 1.9 [95% CI, 1.2-2.8]). 13 No risk differences by age were observed for the long-acting reversible methods of IUD or implant. Absolute rates were not reported by age stratum.

Combined hormonal contraceptives prevent pregnancy through the same mechanisms as progestin-only methods. Their greatest advantage over progestin-only methods is their ability to produce a consistent, regular bleeding pattern. In a study that compared bleeding diaries from 5257 women using 9 different methods of contraception (nonhormonal, combined hormonal contraception, and progestin-only), approximately 90% of combined hormonal contraception pill users (n = 1003) over a 90-day standard reference period reported regular scheduled withdrawal bleeds while no one experienced amenorrhea. 22 Occasionally, patients do not have a withdrawal bleed during the placebo week. A pregnancy test can be performed if the patient or clinician is concerned about the possibility of pregnancy as the reason for not bleeding. If pregnancy is ruled out, the lack of withdrawal bleeding is due to HPO axis suppression and patients can be reassured that lack of withdrawal bleeding does not indicate a health problem or reduced fertility.

Regardless of the route of delivery, ethinylestradiol and other estrogens are metabolized by the liver and activate the hemostatic system. The most significant risk of combined hormonal contraception is estrogen-mediated increases in venous thrombotic events. 23 - 25 Large international cohort studies have identified the risk of deep vein thrombosis at baseline in reproductive-aged women to be approximately 2 to 10 per 10 000 women-years. The risk associated with combined hormonal contraception is approximately 7 to 10 venous thrombotic events per 10 000 women-years. 26 - 28 The risk of venous thromboembolism is substantially greater in pregnancy. One UK study of 972 683 reproductive-aged women with 5 361 949 person-years of follow-up found a risk of deep vein thrombosis of 20 per 100 000 in women who were not pregnant. This rate increased to 114 per 100 000 women-years in the third trimester of pregnancy and to 421 per 100 000 in the first 3 weeks postpartum. 29 The absolute risk of ischemic stroke in reproductive-aged women not taking combined hormonal contraception is 5 per 100 000 women-years. 25 Combined hormonal contraception is associated with an additional absolute risk of approximately 2 per 100 000 (ie, overall risk of 7 per 100 000). 25 This study did not exclude women who smoked cigarettes or had hypertension. 25

Clinicians who prescribe combined hormonal contraception should counsel women regarding signs and symptoms of arterial and venous thrombosis, especially for women with multiple additional risk factors, including body mass index (calculated as weight in kilograms divided by height in meters squared) at or over 30, smoking, and age older than 35 years. While progestins are not associated with an increase in thromboembolic risks, 30 , 31 US Food and Drug Administration package inserts for these methods contain “class labeling” or the same risks as estrogen and progestin combined hormonal contraceptive methods. Patients at increased risk of thrombosis can be provided a progestin-only, nonestrogen-containing method because this method of contraception does not increase risk of venous thromboembolism. 32

Behavioral contraceptive methods include penile withdrawal before ejaculation and fertility awareness–based methods. Imprecise terms, such as natural family planning , the rhythm method , or other euphemisms may be used by patients when referring to these methods. The effectiveness of withdrawal and fertility awareness depends on patient education, cycle regularity, patient commitment to daily evaluation of symptoms (first morning temperature, cervical mucus consistency), and the patient’s ability to avoid intercourse or ejaculation during the time of peak fertility. Data on pregnancy rates are frequently of poor quality and highly dependent on study design. 33 A meta-analysis of higher-quality prospective studies of women at risk for undesired pregnancy reported failure rates of 22 pregnancies per 100 women-years for fertility awareness methods. 34

Other nonhormonal methods prevent sperm from entering the upper reproductive tract through a physical barrier (condoms and diaphragms) or through agents that kill sperm or impair their motility (spermicides and pH modulators). First-year typical use effectiveness for these methods is 13 pregnancies per 100 women in a year. 12 , 18

The copper-bearing IUD is a highly effective nonhormonal reversible method. 12 , 18 Typical use pregnancy rates are 1% per year. 12 , 18 There is no effect on a user’s HPO axis and thus ovulation and menstrual cyclicity continues. The primary mechanism of action is spermicidal, through direct effects of copper salts and endometrial inflammatory changes. 35 The major challenge with the copper IUD is that it can increase the amount, duration, and discomfort of menses mostly during the first 3 to 6 months of use. 36 IUD use does not increase later risk of tubal infertility. 37 If sexually transmitted infection (STI) testing is indicated, testing can be performed concurrently with IUD placement. 38 - 40 This expedited process of testing for STIs at the time of IUD placement does not increase the risk of pelvic inflammatory disease. The absolute risk of pelvic inflammatory disease after IUD insertion is low in those with (0%-5%) or without (0%-2%) existing gonorrhea or chlamydial infection. 41

Emergency contraception (EC) reduces pregnancy risk when used after unprotected intercourse. The most effective method of EC is a copper IUD, which reduces pregnancy risk to 0.1% when placed within 5 days of unprotected intercourse. 42 A copper IUD also has the added advantage of providing patients with ongoing contraception. LNG IUDs were not previously considered an option for EC. However, in a recent randomized noninferiority trial, women requesting EC who had at least 1 episode of unprotected intercourse within the prior 5 days were randomized to receive a copper IUD (n = 356) or a 52-mg LNG IUD (n = 355). 43 LNG IUD was noninferior to copper IUD (between-group absolute difference, 0.3% [95% CI, −0.9% to 1.8%]). However, the proportion of study participants who had unprotected intercourse midcycle (and therefore were at risk of pregnancy) was not reported. If a patient needs EC and wishes to initiate a 52-mg LNG IUD, it is reasonable to immediately place the IUD plus give an oral EC, 44 given the limited and indirect evidence supporting the LNG IUD alone for EC.

Quiz Ref ID Oral EC consists of a single dose of either a progestin (LNG, 1.5 mg) or an antiprogestin (ulipristal acetate, 30 mg). Both of these agents work by blocking or delaying ovulation. Neither is abortifacient. LNG EC is available over-the-counter; a prescription is needed for ulipristal acetate. The medication should be taken as soon as possible after unprotected intercourse for maximum efficacy but can be taken up to 5 days afterward for ulipristal acetate. 45 - 47 LNG efficacy is diminished after 3 days. Efficacy appears similar between the 2 agents when ingested within the first 72 hours after intercourse (ulipristal acetate EC: 15 pregnancies of 844, LNG EC: 22 pregnancies of 852; reduction in pregnancy without EC use estimated to be 90% less) but pharmacodynamic and clinical studies demonstrated that the ulipristal acetate treatment effect persists up to 120 hours with no pregnancies (0/97). 46 Actual use studies of EC that included 3893 individuals found lower pregnancy prevention rates than expected, which appears to be related to multiple acts of unprotected intercourse both before and after the EC use. 48 , 49 If further acts of unprotected intercourse occur 24 hours after EC use and a regular method of contraception has not been started, EC needs to be taken again. 49 Repeat use of LNG EC results in no serious adverse events; repeat dosing for ulipristal acetate EC has not been specifically studied. 50 Clinicians should review the options for EC with all patients starting a user-controlled method, such as condoms. These patients may be prescribed oral EC to keep at home for immediate use if needed.

Two evidence-based guidelines are available to assist clinicians in evaluating the safety of contraception initiation and use. 32 , 42 These guidelines were developed by the US Centers for Disease Control and Prevention, are updated regularly, and are freely available online and in smartphone apps.

The first is the US Medical Eligibility Criteria for Contraceptive Use 32 (US MEC), which provides information on the safe use of contraceptive methods for women with various medical conditions (eg, diabetes, seizure disorder) and other characteristics (eg, elevated body mass index, tobacco use disorder, postpartum). The US MEC uses a 4-tiered system to categorize level of risk for each disease/contraceptive method combination. 32 The risk tiers are (1) no restrictions exist for use of the contraceptive, (2) advantages generally outweigh theoretical or proven risks although careful follow-up might be required, (3) theoretical or proven risks outweigh advantages of the method and the method usually is not recommended unless other more appropriate methods are not available or acceptable, and (4) the condition represents an unacceptable health risk if the method is used. 32

All clinicians, including advanced practice clinicians, should be familiar with prescribing within US MEC categories 1 and 2 (no restrictions or benefits outweigh risks). For women with underlying health conditions who want to use a category 3 method, such as a woman with a history of breast cancer choosing combined hormonal contraceptives, primary care physicians or specialists should review the detailed evidence listed in the US MEC to advise their patients. Subspecialists in complex family planning who have completed extra fellowship training may provide helpful consultation for patients with multiple contraindications or unusual situations. The US MEC is a guideline, not a mandate. Situations may arise in which specialists recommend an MEC category 3 or 4 method because the alternative to the contraceptive method, pregnancy, places the patient at even greater risk. 32 The US MEC does not include conditions for which there is insufficient evidence to make recommendations, such as aortic aneurysms, Marfan syndrome, or chronic marijuana use. For these patients, clinicians should consider referral to a complex family planning specialist. If the patient needs a method immediately, a progestin-only pill should be considered as a “bridging” method, because these can be used safely by most patients 32 and are more effective than barrier methods such as condoms.

The US MEC addresses common drug interactions with hormonal contraceptives. 32 Contraceptive steroid hormones are metabolized via the hepatic cytochrome P450 pathway. 51 , 52 Drugs that induce this pathway, such as rifampin and barbiturates, or chronic alcohol can impair contraceptive efficacy and drugs that inhibit the pathway, such as valproic acid, cimetidine, or fluconazole, may increase adverse effects. The FDA recognizes a drug-drug interaction as clinically significant if it causes at least a 20% difference in drug levels 53 but an interaction does not necessarily affect contraceptive failure rates. Adherence, continuation, fecundity, and frequency of intercourse also contribute to contraceptive effectiveness. Additionally, most pharmacokinetic studies do not have sufficient statistical power to determine differences in pregnancy rates. The most common drug classes that may interact with hormonal contraceptives are antiretroviral drugs (including efavirenz and ritonavir-boosted protease inhibitors) and anticonvulsant therapies (including carbamazepine, phenytoin, and others). 54 , 55 Evidence from both clinical and pharmacokinetic studies of routinely used antibiotics do not support impaired contraceptive efficacy with concomitant antibiotic prescription, 56 except for rifampin with which ethinylestradiol and progestin area under the curve levels are at least 40% lower. 57 Because the local progestin dose in the LNG IUD is so high, its efficacy is not reduced by drugs that may affect combined hormonal contraceptives, progestin-only contraceptive pills, or the progestin implant. While hormonal contraceptive use can change concentrations of some drugs, 58 this is rarely clinically relevant, except for the reduction in serum concentration of the anticonvulsant lamotrigine.

Another major guideline is the US Selected Practice Recommendations for Contraceptive Use 42 (US SPR, available online or via a smartphone app). The US SPR is organized by contraceptive method. It includes method-specific, up-to-date guidelines, such as how to initiate the method, how to manage bleeding irregularities, and recommended follow-up. For example, the guidelines on IUDs include evidence on medications to ease IUD insertion or IUD management if a pelvic infection occurs. Recommendations related to combined hormonal contraceptives include the number of pill packs that should be provided at initial and return visits or management of vomiting or severe diarrhea while using combined oral contraceptives.

Much of the data on noncontraceptive benefits of hormonal methods come from case-control studies or small comparative trials. However, fair evidence exists that methods that suppress ovulation can be effective in reducing benign ovarian tumors 59 and functional ovarian cysts. 60 Combined hormonal contraceptives diminish hormonally mediated premenstrual dysphoric disorder, with statistically significant mean differences in symptoms, such as headaches, bloating, and fatigue, and functionality scales. 61 The estrogen component of combined hormonal contraception increases hepatic sex hormone–binding globulin, which reduces free testosterone and improves androgen-sensitive conditions, such as acne and hirsutism. Cochrane systematic reviews of combined hormonal contraceptives and both conditions show significant associations with improvement in a variety of measures of acne and hirsutism. 62 , 63 All progestin-containing contraceptives cause endometrial atrophy and, thus, reduce menstrual blood loss and menstrual pain to varying extents. 64 - 66 While progestin-only methods can promote unscheduled or breakthrough bleeding, the total amount of blood loss is reduced and in those with heavy menstrual bleeding, hemoglobin levels can rise by 10 g/L in 12 months. 67 , 68 The LNG IUD has demonstrated efficacy in reduction of heavy menstrual bleeding 69 , 70 (including for women with anticoagulation, fibroids, 71 or hemostatic disorders), primary dysmenorrhea, 36 , 72 endometriosis, 73 adenomyosis, 74 and protection against pelvic infection. 75

Screening for pregnancy is important prior to prescribing contraception. According to the US SPR, clinicians should be “reasonably certain” that the patient is not pregnant. 42 A clinician can be reasonably certain that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any 1 of the following criteria: (1) is 7 days or less after the start of normal menses; (2) has not had sexual intercourse since the start of last normal menses; (3) has been correctly and consistently using a reliable method of contraception; (4) is 7 days or less after spontaneous or induced abortion; (5) is within 4 weeks’ postpartum; and (5) is fully or nearly fully breastfeeding (exclusively breastfeeding or most [≥85%] of feeds are breastfeeds), amenorrheic, and less than 6 months postpartum.

Quiz Ref ID These criteria have a negative predictive value of 99% to 100%. 76 - 78 A urine pregnancy test (UPT) alone is not sufficient to exclude pregnancy. UPT sensitivity is dependent on when the last act of intercourse occurred, the ovulatory cycle phase, and urine concentration. Sensitivity of UPTs is 90% at the time of a missed period, but only 40% in the week prior. 79 Additionally, a UPT can remain positive up to 4 weeks after delivery, miscarriage, or abortion. 80 , 81 Few other tests are required for safe and effective use of contraception.

Clinicians can offer other indicated preventive health tests at the contraceptive initiation visit, like screening for cervical cancer or STIs. However, these tests are not required for contraceptive use and should not prevent initiation of contraception.

Generally, all methods should be started immediately on prescription regardless of menstrual cycle day—known as the Quick Start protocol. 82 If a hormonal method is initiated within 5 days of the first day of menses, no additional backup method is needed. At other times in the cycle, or when switching from a nonhormonal to a hormonal method, a backup is necessary for 7 days to ensure ovulation suppression. If switching from one hormonal method to another, the switch can occur without a withdrawal bleed or backup.

If a woman reports unprotected intercourse within the 5 days before contraceptive initiation, most sources recommend giving emergency contraception, initiating her desired method, and repeating a UPT 2 to 3 weeks later. 82 - 85 Many studies have demonstrated that exposing an early pregnancy to hormonal contraception is not harmful 86 but delayed initiation increases the risk of undesired pregnancy.

Because comparative effectiveness studies to clearly identify the superiority of one contraceptive pill formulation over another are lacking, selecting a contraceptive pill often depends on patient experience. Monophasic regimens, in which each pill has the same hormone doses, have significant advantages over bi- and triphasic regimens. Cycles can be extended easily by skipping the placebo week and starting the next pack of active pills. If this is attempted with multiphasic regimens, the drop in progestin between phases typically results in breakthrough bleeding. In terms of ethinylestradiol, few patients require a pill containing more than 35 µg/d to prevent breakthrough bleeding. 87 Many clinicians advocate starting with the lowest ethinylestradiol dose to minimize risks. However, there are no data demonstrating that 10- to 20-µg/d ethinylestradiol doses are safer than 35 µg daily, and lower ethinylestradiol doses are associated with more unscheduled vaginal bleeding. 88 Thus, starting with a monophasic preparation containing 30 µg to 35 µg of ethinylestradiol provides the greatest likelihood of a regular bleeding pattern without increasing risk. Ethinylestradiol can be reduced if patients have estrogen-associated adverse effects, such as nausea or breast tenderness.

Many different progestins exist. Progestins differ in in vitro androgenicity, effects on surrogate metabolic markers, or similarity to testosterone. 89 While molecular structures differ, there is no evidence demonstrating that a particular progestin is superior to others. Traditionally, progestins were classified into “generations” by their parent compound and decade of development. This classification is not clinically useful and should be abandoned. 90 Patients sometimes prefer a pill that they used previously, and if no contraindications exist and the cost is acceptable to the patient, it is reasonable to prescribe it ( Figure 1 and Figure 2 ).

Combined hormonal contraceptives can be dosed in a cyclic or continuous fashion. Originally, birth control pills were dosed with 21 days of active drug and a 7-day placebo week to trigger a monthly withdrawal bleed, meant to mimic the natural menstrual cycle. However, many women prefer less frequent withdrawal bleeds. 91 Some women report significant adverse effects 92 during this placebo week, such as migraine, bloating, and pelvic pain, and extended use provides an easy way to manage or eliminate these problems. 61 During the placebo week, there is less suppression of the HPO axis. 93 - 95 For these reasons, many newer contraceptive pills have shorter (eg, 4-day) placebo periods. Further, most monophasic combined hormonal contraceptives can be used as extended use (fewer withdrawal bleeds) by having a 4-day placebo period quarterly or continuously (no withdrawal bleed) by eliminating the placebo altogether. Extended and continuous use are associated with improved typical use efficacy, likely because greater overall HPO axis suppression is achieved, which may offset lapses in user adherence. 96 A new vaginal ring (segesterone acetate/ethinyl estradiol vaginal system) is also available, which is prescribed for 1 year, with the patient removing the ring each month for 7 days. 97

This review has several limitations. First, relatively few randomized clinical trials that directly compared contraceptive methods were available. Therefore, contraceptive methods are typically evaluated by their individual efficacy (pregnancies per person-cycles) and not typically by their relative effectiveness compared with another method. Second, the quality of summarized evidence was not evaluated. Third, some aspects of contraception, such as counseling, noncontraceptive health benefits, ongoing contraceptive innovations, and the effect of cultural values, and patient preferences were not covered in this review.

Oral contraceptive pills are the most commonly used reversible contraceptives, IUDs and subdermal implants have the highest effectiveness, and progestin-only and nonhormonal methods have the lowest risks. Optimal contraceptive selection incorporates patient values and preferences.

Corresponding Author: Stephanie Teal, MD, MPH, Department of OB/GYN, University Hospitals Medical Center and Case Western Reserve University, 11100 Euclid Ave, MAC-5304 Cleveland, OH 44106 ( [email protected] ).

Accepted for Publication: November 10, 2021.

Author Contributions: Drs Teal and Edelman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design : Both authors.

Acquisition, analysis, or interpretation of data : Both authors.

Drafting of the manuscript : Both authors.

Critical revision of the manuscript for important intellectual content : Edelman.

Administrative, technical, or material support : Both authors.

Supervision : Both authors.

Conflict of Interest Disclosures: Dr Teal reported receiving grants from Merck & Co, Bayer Healthcare, Sebela, and Medicines360, and personal fees from Merck & Co and Bayer Healthcare outside the submitted work. Dr Edelman reported receiving grants from Merck, research funds from HRA Pharma, and royalties from UpToDate outside the submitted work.

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Take Control of Your Birth Control

Connecting Michigan residents to safe, effective birth control, STI prevention and insurance coverage

MDHHS, in partnership with the Office of Governor Gretchen Whitmer, is making birth control and sexually transmitted infection (STI) prevention supplies available for free across the state of Michigan in November. No matter your relationship status or personal choices, access to contraception empowers individuals to make informed decisions about their reproductive health and keeps people healthy. This campaign raises awareness of how men and women can access contraception through their insurance provider, or sign up for insurance.

Locations across Michigan will have supplies at no cost available on a first come, first served basis beginning in November. Sites will have condoms, over-the-counter (OTC) emergency contraception, and over-the-counter oral contraceptive pill available while supplies last at no cost, and will not require individuals to provide any insurance information. Information will also be available on family planning services and health insurance coverage. You can also find information on insurance options below. A list of locations will be added in the coming weeks.

The goal of this campaign is to provide interim birth control and STI prevention supplies while connecting eligible individuals to insurance coverage. In additional to full Medicaid coverage, MDHHS offers family planning services through Plan First, a limited Medicaid benefit, that covers birth control, STI testing and treatment, doctor’s office visits, and vaccinations among other services. For those who are not eligible for Medicaid, affordable health insurance is available on the Health Insurance Marketplace.

Contraception Insurance Coverage

What Is Plan First?

For those who do not qualify for full Medicaid, the Plan First program is available to all ages and genders and is a limited Medicaid benefit that covers family planning services such as birth control and STI testing and treatment.

What Is Covered Under Plan First?

Services included under Plan First:

• Office visits for family planning.
• All FDA-approved contraception supplies and devices to prevent or delay pregnancy.
• OTC contraceptives and supplies such as condoms, spermicides and sponges.
• Testing and treatment for STIs, including pharmaceuticals.
• Cervical cancer screening.
• HIV post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP).
• There are no gender or age requirements to be eligible for Plan First.
• Individuals qualify by meeting the income requirement of being at or below 195% of the Federal Poverty Line.
• Be a Michigan resident and US citizen or qualified immigrant.

How do I Apply?

An individual needs to complete a Medicaid application, which is available on the MI Bridges portal or via a paper form that can be downloaded here .

You can apply to Plan First at any time – there is no open-enrollment period.

How Much Does Plan First Cost?

People with Plan First health care coverage generally will not have to pay for family planning services including copays.

What If I Need More Comprehensive Health Insurance?

Individuals in Plan First do not qualify for full Medicaid coverage and are eligible to apply for additional coverage on the Health Insurance Marketplace.

What If I Would Like More Information?

Additional information about Plan First, including FAQs are available at Michigan.gov/PlanFirst .

A brochure about Plan First is available here .

What Is Medicaid?

Medicaid is the nation’s largest public health insurance program for people with low income. It is a health care program jointly financed by states and the federal government. States have flexibility to design and administer their Medicaid programs within federal guidelines.

What Is Covered Under Medicaid?

Medicaid covers a broad spectrum of family planning care that includes contraceptive service, such as diagnostic evaluation, drugs and supplies for voluntarily preventing or delaying pregnancy. The services covered enable beneficiaries to voluntarily choose to prevent initial pregnancy or to limit the number of and spacing of their children.

In addition to family planning services, Medicaid also covers the full spectrum of medical, dental and behavioral health benefits. 

Medicaid Eligibility Requirements

• For example, the Healthy Michigan Plan, for individuals who are 19 to 64 years old, has an income threshold up to 133% of the Federal Poverty Line.
• A Michigan resident and US citizen or qualified immigrant.

To apply for Medicaid, an individual needs to complete a Medicaid application, which is available on the MI Bridges portal or via a paper form which can be downloaded here .

You can apply to Medicaid at any time – there is no open-enrollment period.

How Much Does Medicaid Cost?

People with Medicaid coverage generally will not have to pay for family planning services including co-pays.

Most individuals enrolled in Medicaid have comprehensive health insurance and therefore do not need to apply for supplemental insurance on the Health Insurance Marketplace.

Additional information about Medicaid is available at MIchigan.gov/Medicaid .

Who This Applies To

Anyone enrolled in a health insurance plan that is generally regulated by the federal government or states. These plans also have certain family planning requirements that they must also abide by. These health plans are:

• Individual, small and large group plans.
• Self-insured plans.
• Federal employee plans.

What Is Covered?

These health insurers are required to provide at least one form of each of the contraceptive methods currently approved by the Food and Drug Administration (FDA), including:

• Barrier methods, like diaphragms and sponges.
• Hormonal methods, like birth control pills and vaginal rings.
• Long-acting reversible contraception, like intrauterine devices (IUDs).
• Emergency contraception, like Plan B.
• Female sterilization procedures.
• Patient education and counseling.

Related health care services, such as an office visit for a contraceptive shot, must also be covered. Private health insurers also cover a wide range of other medical and some behavioral services. Coverage is specific to each plan. Visit the Michigan Department of Insurance and Financial Services (DIFS) for more information.

What Do These Services Cost?

There should be no out-of-pocket cost to consumers. However, if you prefer a type or brand of contraceptive that is not currently covered by your private health insurer, you may have a copay or other out-of-pocket costs for your treatment.

What If My Insurer Refuses to Cover My Family Planning or Contraceptive Care?

If you have questions, DIFS can help consumers with health insurance questions and complaints. For more information visit Michigan.gov/HealthInsurance  or call 877-999-6442, Monday through Friday from 8 a.m. to 5 p.m.

Health insurance plans that can be purchased on the Health Insurance Marketplace through healthcare.gov.

FDA-approved contraceptive methods prescribed by a woman’s doctor are covered, including:

• Implanted devices, like intrauterine devices (IUDs).
• Emergency contraception, like Plan B® and ella®.
• Sterilization procedures.

Health insurance plans in the Marketplace also cover a range of other medical services including preventative health care services and 10 essential health benefits that are required by law.

Visit Healthcare.gov for more information about what is covered.

Health insurance plans must cover contraceptive services without charging a copay or coinsurance when provided by an in-network provider — even if you haven’t met your deductible.

Open enrollment in the Marketplace is Nov. 1, 2024 through Jan. 15, 2025.

• Enroll by December 15 for coverage starting Jan. 1, 2025.
• Enroll by January 15 for coverage starting Feb. 1, 2025.

The Marketplace is available to individuals who do not have health insurance through their job, Medicaid, Medicare, or other qualifying health coverage. To be eligible to enroll in Marketplace health coverage, you must live in the United States, be a U.S. citizen or national (or be lawfully present), and not be incarcerated.

Outside of open enrollment, you can only get coverage in the Marketplace if you:

• Have a life change or income that qualifies for a Special Enrollment Period.
• Qualify for Medicaid. You can enroll any time of year and coverage can start immediately.

What If I Need More Information?

If you need more information, please visit healthcare.gov .

If you need assistance determining what is the most appropriate insurance option for you, local assistors are available to support you. Trained and certified assistors can help you apply and enroll in a Marketplace health plan (with any eligible savings) or apply for Medicaid. Assistors are required to provide fair, impartial and accurate information.

Find local help at  localhelp.healthcare.gov .

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Effect of Magnesium Supplement on Pregnancy Outcomes: A Randomized Control Trial

Elaheh zarean, amal tarjan.

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Address for correspondence: Dr. Amal Tarjan, Department of Obstetrics and Gynecology, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: [email protected]

Received 2016 May; Accepted 2016 Aug; Collection date 2017.

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Background:

Magnesium (Mg) is an essential mineral required to regulate body temperature, nucleic acid, and protein synthesis with an important role in maintaining nerve and muscle cell electrical potentials. It may reduce fetal growth restriction and preeclampsia as well as increase birth weight. This study aimed to assess the effects of consuming Mg supplementation during pregnancy on pregnancy outcomes.

Materials and Methods:

This is a randomized controlled trial with three sixty populated groups of pregnant women. Participants were randomized to treatment or control groups through random table numbers. Participants with Mg serum levels more than 1.9 mg/dl considered as control group A randomly. They just received one multimineral tablet once a day until the end of pregnancy participants with hypomagnesemia consider as Group B and C. Participants in Group B received one multimineral tablet daily until the end of pregnancy. Participants in Group C received 200 mg effervescent Mg tablet from Vitafit Company once daily for 1 month, and also they consumed one multimineral tablet from Alhavi Company, which contains 100 mg Mg, once a day until the end of pregnancy. Intrauterine growth retardation, preterm labor, maternal body mass index, neonatal weight, pregnancy-induced hypertension, preeclampsia, gestational diabetes mellitus, cramps of the leg Apgar score were compared between three groups.

In all pregnancy outcomes, Group C that received effervescent Mg tablet plus multimineral showed a better result than other groups, and frequency of complications of pregnancy was fewer than the other two groups and showed a significant difference.

Conclusion:

Mg supplement during pregnancy likely decrease probability occurrence of many complications of pregnancy.

Keywords: Magnesium Supplement , Pregnancy , Outcomes

Introduction

Magnesium (Mg) is one of the essential minerals needed by humans in substantial large amounts. Mg work with many enzymes to regulate body temperature, synthesis nucleic acids, and proteins as well as maintaining electrical potentials in nerves and muscle membranes.[ 1 , 2 ]

Mg also has an important role in modulating vasomotor tone and cardiac excitability. Mg is used widely in many foods; dairy products, breads and cereals, legumes, vegetables, and meats are all good sources.[ 3 ] It is, therefore, not surprising that frank Mg deficiency has never been reported to occur in healthy individuals who eat varied diets. However, processing of the above foods can lead to high depletion of Mg.[ 4 , 5 ]

Common causes of Mg deficiency include inadequate dietary intake or gastrointestinal absorption, increased losses through the gastrointestinal or renal systems, and increased the requirement for Mg, such as in pregnancy.[ 6 , 7 ]

There are many important complications during pregnancy (gestational diabetes mellitus [GDM], pregnancy-induced hypertension [HTN], leg cramps, and preeclampsia), and a lot of them will occur the first time in pregnancy. Many of these complications are due to pregnancy or risk of occurrence that will increase during pregnancy so there are many diagnosis criteria such as Apgar score, birth weight, intrauterine growth retardation [IUGR], and preterm birth.

A study measuring serum Mg during low-risk pregnancies reported that both ionized and total serum Mg were significantly reduced after the 18 th week of gestation compared to measurements before this time.[ 8 ]

Dietary intake studies during pregnancy consistently demonstrate that many women, especially those from disadvantaged backgrounds, have intakes of Mg below the recommended levels.[ 9 ]

Although present in grains, green vegetables, and seeds, insufficient Mg intake is common, especially in low-income regions. Adolescents and women are more prone to Mg deficiency.[ 10 ] It is recommended that women consume 280 mg of Mg/day,[ 11 ] increasing in pregnancy.[ 12 ] Most Mg (99%) is intracellular, such that serum levels have a low accuracy for Mg deficiency.[ 13 ] Total and ionized Mg ++ are inversely associated with gestational age in pregnancy.[ 14 ] Mg deficiency in pregnancy has been associated with a higher risk of chronic HTN, preeclampsia, placental dysfunction, and premature labor.[ 15 ]

More recent data suggest that maternal Mg supplementation in pregnancy may have other perinatal benefits. Treatment was begun after 22 weeks’ gestation in most women and was sustained for a mean of about 28 days in both groups. The risk of the primary outcome of hypoxic-ischemic encephalopathy was nonsignificantly lower in the Mg ++ group, but the overall event rate was lower than expected in both groups. Interestingly, the risk of third trimester stillbirth was lower in Mg group.[ 16 ]

In a retrospective study of medical records reported that Mg supplementation during pregnancy was associated with a reduced risk of fetal growth retardation and preeclampsia.[ 17 ]

In addition, there are many evidence that Mg supplementation during pregnancy may lead to prevent some pregnancy complications and improved many health indicators and pregnancy outcomes;[ 18 , 19 , 20 , 21 , 22 , 23 ] but as stated by others, there is not enough high-quality evidence to show that Mg supplementation during pregnancy is beneficial.[ 24 ]

Thus, according to the above mentioned, Mg supplementation during pregnancy may be able to reduce growth restriction of the fetus and preeclampsia (high blood pressure and protein in the urine during pregnancy) and increase birth weight. This study aimed to assess the effects of Mg supplementation on pregnancy outcome by randomized controlled trial with this dosage of Mg, In the previous studies, they use different dosage.

Materials and Methods

In this randomized controlled trial study, the required sample size was calculated as 60 patients in each group (totally 180 patients) using sample size formula to compare the two means’ value at 95% confidence level, the power of 80% and considering the standard deviation (SD) of serum Mg levels in the normal population which is about 1.5 mg/dl and also taking into account the significant differences between the two groups as ( d = 0.75).

To continue the study, 180 pregnant women were recruited into three randomized groups. Maternal serum Mg levels of pregnant women with gestational age 12–14 weeks were measured and those whose serum Mg levels were < 1.9 mg/dl selected. Participants were randomized to treatment or control groups through random table numbers. Participants with Mg serum levels more than 1.9 mg/dl considered as control Group A randomly. They just received one multimineral tablet once a day until the end of pregnancy ( N = 60). Participants with Mg levels < 1.9 consider as Group B and C. Participants in Group B received one multimineral tablet daily until the end of pregnancy ( N = 60). Participants in Group C received 200 mg effervescent Mg tablet from Vitafit company once daily for 1 month, and also they consumed one multimineral tablet from Alhavi Company, that contains 100 mg Mg, once a day until the end of pregnancy ( N = 60) [ Chart 1 ].

Consort flowchart

We compared the outcomes of pregnancy, including IUGR, preterm labor, maternal body mass index (BMI), neonatal weight, pregnancy-induced HTN, preeclampsia, GDM, cramps of the leg, and Apgar score between three groups.

Inclusion criteria were: have tendency to involve in this study and sign the agreement; single pregnancy; gestational age 12–14 weeks; lack of acute renal disease; hypomagnesemia in interventional group and normal Mg; lack of history chronic HTN; lack of history of overt diabetes; lack of history of severe anemia; lack of history of diagnostic heart disease; lack of anomaly in this pregnancy and previous ones; lack of use cigarette and alcohol; lack of molar pregnancy; lack of acute pancreatitis; multiparty.

Exclusion criteria were: withdrawal the study; inappropriate use of Mg; intractable vomiting.

Participants selected from the population that referred to hospital clinics. Individuals who fulfill the inclusion criteria invited to participate in this study. The trial protocol was in accordance with the Declaration of Helsinki and was approved by the Research and Ethics Committee of Isfahan University of Medical Sciences.

The trial was registered under trial registry code IRCT2015121925611N1 at the National Registry for Clinical Trials, which is a member of the World Health Organization. After providing detailed information, informed consent was signed by the participant, and oral assent from participants was obtained.

The Statistical Package for Social Sciences (SPSS) version 20.0 for Windows (SPSS, Chicago, IL, USA) was used for statistical analysis. Descriptive data were expressed as mean ± SD. Frequency tables were generated for relevant variables. Proportions were compared with the Pearson Chi-square test. A low Apgar score at 1 or 5 min was defined as a score of 7 or less. For comparisons of continuous variables in three groups, we used one-way analysis of variance (ANOVA). P < 0.05 was considered statistically significant.

The baseline characteristics of multiparous pregnant women in three groups were shown in Table 1 . As shown in Table 1 , no significant difference in all variables of the characteristics of the study population, except for a history of diabetes that was significantly different between three groups ( P = 0.006).

Baseline characteristics of study population

Table 2 shows the standard weight gain according to BMI. For each group, we calculated difference weight in early of pregnancy and weight in delivery. Then, for all category of BMI in three groups, calculate the excess weight gain. Chi-square test did not show a significance difference between three groups, although the percentage of excess weight gain had different in three groups. The Figure 1 shown the excess weight gain in three groups of the study. Type of delivery and sex of neonate have been shown in Table 3 .

Standard weight gain according to body mass index

Excess weight gain in three groups of study

Type of delivery and sex of neonate

Table 4 shows the frequency of pregnancy outcomes between groups. We compared the frequency of IUGR, preterm birth, low birth weight (LBW), preeclampsia, GDM, cramps of the leg, Apgar score, stillbirth, and premature rupture of membranes with Pearson Chi-square test between three groups. A low Apgar score at 1 or 5 min was defined as a score of 7 or less. Furthermore, the mean weight of neonate between groups was assessed by one-way ANOVA. As shown in Table 4 , in all pregnancy outcome, Group C that received effervescent Mg tablet plus multimineral tablet showed a better result than other groups and frequency of pregnancy complications as said above was fewer than the other two groups and demonstrated a significant difference.

Frequency of pregnancy outcomes between groups

The present study showed the preventive effect of oral Mg tablet in the many of pregnancies with difficulty. Moreover, because this study set a normal group without hypo Mg, we found that hypo Mg may be a risk factor for some pregnancies with complications.

The results of the present study showed that Mg supplement administered to mothers’ antenatal leads to a reduction in many bad pregnancy outcomes. Many studies have examined the therapeutic or preventive effect of Mg in pregnancy outcomes, and some of them supported our findings. Czeizel et al ., in agreement with our result, found that effect of periconceptional multivitamin on 5502 pregnant females was positive and increase fertility.[ 25 ] In addition, our results showed that IUGR was considerably reduced in oral Mg supplement groups compared with other two groups. Likewise, Roman et al . showed that maternal oral Mg supplementation reduced pregnancy-induced IUGR by 64% and suppressed cytokine/chemokine levels in the individual amniotic fluid and placentas.[ 26 ]

Today, the importance of Mg during pregnancy has been more understanding. Various studies focus on the effect of Mg on prevention or treatment of numerous pregnancy complications or pathological condition in pregnancy period.[ 24 ] Mg has an important role in homeostasis, enzyme system, and bone calcium stability.[ 27 ] As we found the beneficial effect of Mg on our oral mg supplement group such as decrease preeclampsia ( P = 0.018), lower preterm birth ( P = 0.044) as well as lower rate of LBW ( P = 0.002), in the various clinical studies which were reviewed by Duley in 2010[ 28 ] and McDonald in 2012,[ 29 ] it has also been declared that efficiency of Mg during pregnancy is noticeable, and Mg prevents many bad effects in pregnant women, and Mg component like MgSO 4 found to be efficient for preeclampsia and eclampsia.

Our evaluation demonstrated that all pregnancy outcomes such as preeclampsia ( P = 0.018), IUGR ( P < 0.001), preterm birth ( P = 0.044), LBW ( P = 0.002), GDM ( P = 0.003), cramps of leg ( P < 0.001), Apgar score (under 7) ( P = 0.006), birth weight (continuous) ( P = 0.002), and Apgar (continuous) ( P = 0.01) was significantly better in Mg received group than control and multimineral tablet used groups. In accordance with our results, Shaikh et al . in his observational study found that in many pregnancy outcomes such as toxemia of pregnancy, preterm birth, Intra Uterine Growth Restriction (IUGR), and leg cramps, and pregnant women with hypo Mg have more frequent complications than normal groups.[ 30 ] Another investigation done by Doyle et al . demonstrated that Mg intakes of 513 women toward the end of the first trimester of pregnancy (300 mg/day) was associated with optimum birth weight, length, and head circumference.[ 31 ] We used 300 mg Mg pill for our Mg received group same as Doyle et al . did[ 31 ] although in the other studies they used various doses.[ 32 ] In addition, it would be beneficial for control group to administrate low-dose Mg.[ 32 ] We believe that the standard methodological usage should be created to use worldwide as the standard pattern as it recently has been noticed and discussed comprehensively.[ 33 ]

Mg is pivotal element for preventing some diseases during whole pregnancy. Mg has been stablished to be used for avoiding some unwanted condition. It could be used by food intake among pregnant women.[ 34 , 35 , 36 ] Furthermore, Mg has various physiological benefits. Numerous studies assessed the effect of Mg supplement in preventing of preeclampsia in pregnant women. Bullarbo et al . in a clinical trial designed study concluded that Mg supplementation prevents increasing of diastolic blood pressure during the last weeks of pregnancy.[ 37 ] Rudnecki et al . in a double-blind, randomized controlled study found that using Mg chloride until the end of pregnancy has a positive effect on decreasing of blood pressure during pregnancy and delivery time.[ 38 ] In agreement with them, we also found oral mg supplement group had lower rate of preeclampsia ( P = 0.018). In addition, in a study by Dawson, the result showed that preeclampsia women had lower range of Mg compared to the nonpreeclampsia women.[ 18 ]

Our assessments revealed that Mg had a beneficial effect on preventing of LBW ( P = 0.002). Similar to our findings, in a double-blind, randomized controlled study which was done on 985 pregnant women, using of Mg aspartate was beneficial for preventing of preterm light weight children and also preterm deliveries.[ 39 ] Other investigations also proved our result in term of low-weight delivery.[ 40 ]

Mg has a pivotal role in various body homeostasis, especially pregnancy period. Undoubtedly, the functioning of Mg in many different organs has already established. According to our result and other researchers’ findings, it should be said that Mg supplement during pregnancy could decrease the probability of occurrence of many complications of pregnancies. We believe that using the right dose of Mg plays a crucial role in the treatment of unwanted pregnancy disorders as well as preventing of preterm weight, LBW, and preeclampsia.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

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Many Catholics in the U.S. and Latin America Want the Church to Allow Birth Control and to Let Women Become Priests

Most view pope francis favorably, though his ratings have dropped, table of contents.

• Views of Pope Francis
• Pope Francis as a source of change in the church
• Views on the priesthood, contraception and sexuality
• Acknowledgments
• Methodology

This Pew Research Center analysis explores views on the Catholic Church and Pope Francis among Catholics in Latin America and the United States.

All seven countries in the survey have Catholic populations that rank among the world’s 25 largest – notably including Brazil (largest), Mexico (second-largest) and the U.S. (fourth-largest) – according to the Vatican’s 2021 Statistical Yearbook of the Church . And the six Latin American countries surveyed account for roughly three-quarters of the region’s Catholics.

For non-U.S. data, this analysis draws on nationally representative surveys of 6,234 adults – including 3,655 Catholics – conducted from Jan. 22 to April 27, 2024. Surveys were conducted face-to-face in Argentina, Brazil, Chile, Colombia, Mexico and Peru.

In the U.S., we surveyed 12,693 respondents from Feb. 13 to 25, 2024, including 2,021 Catholics. Most of the survey’s respondents (10,642) – including all of the survey’s Catholic respondents – are members of the American Trends Panel (ATP), an online survey panel recruited through national random sampling of residential addresses, which gives nearly all U.S. adults a chance of selection. Read more about the  ATP’s methodology .

The remaining respondents (2,051) are members of three other panels: the Ipsos KnowledgePanel, the NORC Amerispeak Panel and the SSRS Opinion Panel. All three are national survey panels recruited through random sampling (not “opt-in” polls). We used these additional panels to ensure that the survey would have enough Jewish and Muslim respondents to be able to report on their views. (While Jewish and Muslim respondents are not discussed in this particular report that focuses on Catholic topics, they are discussed in other reports based on this survey .)

The U.S. data is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education, religious affiliation and other categories.

Here are the  questions used  for the report, along with responses, and the survey methodology .

This analysis was produced by Pew Research Center as part of the  Pew-Templeton Global Religious Futures project , which analyzes religious change and its impact on societies around the world. Funding for the Global Religious Futures project comes from The Pew Charitable Trusts and the John Templeton Foundation (grant 63095). This publication does not necessarily reflect the views of the John Templeton Foundation.

A new survey by Pew Research Center asked Catholics in six Latin American countries and the United States how they think the church should handle a variety of matters related to contraception, the priesthood and sexuality. Among the main findings:

Most Catholics in all seven countries want the church to allow Catholics to use birth control. The shares saying this range from 86% in Argentina to 63% in Brazil.

In most of the countries surveyed, majorities of Catholics also say the church should allow women to become priests.

Opinion is more divided on whether the church should allow priests to get married. Roughly two-thirds of Catholics in Argentina, Chile and the U.S. are in favor, but majorities in Mexico and Peru say the church should not allow priests to marry.

Views on whether the church should recognize the marriages of gay and lesbian couples vary among Catholics in the countries surveyed. Majorities of Catholics in Argentina and Chile say the church should recognize the marriages of gay and lesbian couples, and just over half of U.S. Catholics agree. In the other four countries, fewer than half take this stance.

The survey also finds that Pope Francis, the first Latin American pope, remains broadly popular among Catholics across the region – though his favorability ratings are lower now than they were a decade ago, shortly after his papacy began in March 2013.

The decrease in favorability has been sharpest among Catholics in Argentina, his country of birth. Ten years ago , nearly all Catholics surveyed there (98%) expressed a favorable opinion of Francis, compared with 74% today.

And in the U.S., where a February 2014 survey found that 85% of Catholics viewed the pope favorably, 75% now take that view .

Most Catholics surveyed also say Francis represents a change in the Catholic Church’s direction, with more of them calling it a major change than a minor one.

These are among the key findings of a survey of 5,676 Catholics, conducted in English, Spanish and Portuguese from January through April 2024 in seven countries: Argentina, Brazil, Chile, Colombia, Mexico, Peru and the U.S.

The rest of this report explores these findings in more detail.

More than a dozen of our surveys have measured U.S. Catholics’ favorability toward Pope Francis since the start of his papacy. Find this more detailed U.S. trend in our recent report, “ Majority of U.S. Catholics Express Favorable View of Pope Francis .”

We used simple, common phrases in the survey questions about some steps that Catholics would – or would not – like to see the church take. Our goal was to make the questions easy to understand for as many respondents as possible. In some cases, the wording of the questions involved a trade-off between broad understandability and theological nuance.

For example, one question asks whether the church should “allow priests to get married.” This would not, strictly speaking, be a change in doctrine. The Catholic Church already allows married priests  under certain circumstances , such as if a man was married before being  ordained in an Eastern Catholic Church . Technically, the church considers the rule of celibacy for priests to be a  “discipline” rather than a doctrine . Nonetheless, allowing parish priests to get married and continue in their duties would represent a big change in the everyday life of the church in the United States and Latin America. 

Similarly, another question asks whether the church should allow unmarried Catholics who “are living with a romantic partner” to receive Communion. Actually, Catholicism has no rule against unmarried people living together. The church’s teaching is that  sexual activity outside of marriage   is a grave sin , and that anyone “conscious of a grave sin” should  not take Communion  unless they have been to confession.

Yet another example concerns contraception. The survey asks whether the church should allow Catholics to “use birth control.” But the church does not object to married couples using  natural methods  (i.e., abstaining from sex during fertile periods) to  “space the births of their children.”  Rather, the objection is to using methods that prevent the sexual act from resulting in conception, including  “condoms, hormonal birth control pills and sterilization.”

In every Latin American country surveyed, as well as the United States, approximately two-thirds or more Catholics express a favorable view of Pope Francis, including 88% in Colombia and 84% in Brazil.

Related: How people in Latin America and the U.S. view Pope Francis

Colombia is the only country surveyed where at least half of Catholics express a very favorable view of Francis. In the other countries, these shares range from 40% in Argentina to 23% in Chile.

Catholics who pray daily generally are more likely than those who pray less frequently to hold a very favorable view of Francis. For example, 40% of Mexican Catholics who pray daily say they view the pope very favorably, compared with 29% of other Catholics.

Most Catholics surveyed say Pope Francis represents a change in the Catholic Church’s direction. And they are more likely to say this is a major change than a minor change.

For example, in Colombia, 62% of Catholics say that he represents a major change in the church’s direction, while just 19% say he is a minor change. Another 19% of Colombian Catholics say he represents no change at all for the church.

Chilean Catholics, who tend to be less favorable toward Francis than Catholics in other surveyed countries, also stand out on this question. Nearly half say that Francis has not changed the church’s direction, and the rest are divided on whether he has been a major (21%) or minor (26%) change for the church.

The view that Pope Francis represents a major change is especially strong among Catholics who say they have a very favorable view of him.

For example, 62% of Peruvian Catholics with a very favorable view of the pope also say he represents a major change in direction for the church, while 26% of Peruvian Catholics who view Francis less favorably say this. 

On balance, most Catholics in Latin America and the U.S. say the Catholic Church should allow Catholics to use birth control, allow women to become priests and allow cohabiting couples to receive Communion.

Catholic opinion in the countries surveyed is more divided on whether the church should let priests marry and whether it should recognize the marriages of same-sex couples. Catholic majorities in Argentina, Chile and the U.S. want the church to take both of these steps, while a majority of Peruvian Catholics do not want the church to take these steps.

Similarly, most Catholics in Mexico do not want the church to allow priests to get married, and a majority of Catholics in Colombia do not think the church should recognize marriages of same-sex couples.

Views by measures of religiousness

In general, Catholics who pray daily are less likely than other Catholics to say the church should take these steps. For example, 55% of Brazilian Catholics who pray daily say the church should allow Catholics to take Communion even if they are unmarried and living with a romantic partner. Meanwhile, among Catholics in Brazil who pray less often, 75% say this.

Due to small sample sizes of Catholics who say they attend church weekly or more often, we are unable to show the differences in opinions on these survey questions between frequent Mass attenders and other Catholics in all the surveyed countries.

However, in countries where the samples are large enough to allow reliable analysis, the broad pattern is similar to daily prayer: More traditionally observant Catholics are less likely to favor these ideas. In Mexico, for instance, 38% of Catholics who attend church at least weekly think the church should recognize gay and lesbian marriages, but among other Catholics, 52% say this.

Views by age

Across Latin America, younger Catholics are more likely than others to say the church should take these steps.

In Colombia, for instance, 65% of 18- to 39-year-old Catholics think the church should allow women to become priests. Among older Colombian Catholics, 49% take this position.

Views over time

We also asked several of these questions in our survey of religion in Latin America a decade ago, and in surveys of U.S. Catholics conducted around the same time.

The shares of Latin American Catholics who say the church should allow women to become priests have risen. In Argentina, these shares increased from 51% in 2013-14 to 71% in 2024, while in Mexico they increased from 31% to 47% over the same period. In the U.S., however, attitudes on this question among Catholics are in the same ballpark as they were a decade ago.

Views about the church allowing Catholics to use birth control have held fairly steady over the decade in most of the countries surveyed. The largest swings recorded in either direction were among Catholics in Peru (a 12 percentage point increase in wanting the church to take this step) and in Brazil (a 12-point decrease ).

Meanwhile, the shares of Catholics who say the church should allow priests to get married have remained relatively stable in the surveyed countries.

For more information on how attitudes on these issues have changed over time among U.S. Catholics – including the individual data points for all three surveys from 2013-15 that asked some of these questions – refer to our recent report, “ Majority of U.S. Catholics Express Favorable View of Pope Francis .”

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How people in Latin America and the U.S. view Pope Francis

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• Spanish: Muchos católicos en Latinoamérica y los EE. UU. quieren que la Iglesia permita el uso de métodos anticonceptivos y que permita que las mujeres puedan ser sacerdotes

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Birth Control

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Patient handouts, what is birth control.

Birth control, also known as contraception, is the use of medicines, devices, or surgery to prevent pregnancy. There are many different types. Some are reversible, while others are permanent. Some types can also help prevent sexually transmitted infections (STIs).

What are the different types of birth control?

There are several different types of birth control, and they work in different ways:

What are some other forms of pregnancy prevention?

There are some types of pregnancy prevention that do not involve medicines, devices, or surgery:

What is emergency contraception?

Emergency contraception is not a regular method of birth control. But it can be used to prevent pregnancy after unprotected intercourse or if a condom breaks. There are two types:

• Copper IUD, which is a small, T-shaped device that a provider inserts into the within 120 hours of unprotected intercourse.
• Emergency contraceptive pills (ECPs), which are hormonal pills which the woman takes as soon as possible after unprotected intercourse.

What else should I know about birth control?

When deciding which birth control type is right for you, there are many different factors to consider:

• Do you want to have children someday? How soon?
• Do you have any health conditions?
• How often do you have sex?
• How many sex partners do you have?
• Do you also need protection from HIV and other STIs?
• How well does the birth control method work?
• Are there any side effects?
• Will you be able to use it correctly every time?
• How much does it cost?

Your provider can answer your questions about birth control to help you select the best type for you.

NIH: National Institute of Child Health and Human Development

• Birth Control (Food and Drug Administration)
• Birth Control Methods (Department of Health and Human Services, Office on Women's Health) Also in Spanish
• Birth Control Options: Things to Consider (Mayo Foundation for Medical Education and Research) Also in Spanish
• Contraception (Centers for Disease Control and Prevention)

• Douching (Department of Health and Human Services, Office on Women's Health) Also in Spanish
• Noncontraceptive Benefits of Birth Control Pills (American Society for Reproductive Medicine)
• Are Condoms 100% Effective? (Nemours Foundation)
• Barrier Methods of Birth Control: Spermicide, Condom, Sponge, Diaphragm, and Cervical Cap (American College of Obstetricians and Gynecologists)
• Birth Control: How to Use Your Diaphragm (American Academy of Family Physicians) Also in Spanish
• Birth Control: Implantable Contraception (Nemours Foundation) Also in Spanish
• Combined Hormonal Birth Control: Pill, Patch, and Ring (American College of Obstetricians and Gynecologists)
• Depo-Provera: An Injectable Contraceptive (American Academy of Family Physicians) Also in Spanish
• Emergency Contraception (American College of Obstetricians and Gynecologists)
• Essure Permanent Birth Control (Food and Drug Administration)
• Fertility Awareness-Based Methods of Family Planning (American College of Obstetricians and Gynecologists)
• Know Your Rights: Reproductive Health Care (Department of Health and Human Services) Also in Spanish
• Long-Acting Reversible Contraception (LARC): Intrauterine Device (IUD) and Implant (American College of Obstetricians and Gynecologists)
• Morning-After Pill (Mayo Foundation for Medical Education and Research) Also in Spanish
• Postpartum Birth Control (American College of Obstetricians and Gynecologists)
• Progestin-Only Hormonal Birth Control: Pill and Injection (American College of Obstetricians and Gynecologists)
• Sterilization for Women and Men (American College of Obstetricians and Gynecologists)
• Withdrawal Method (Coitus Interruptus) (Mayo Foundation for Medical Education and Research) Also in Spanish
• Barrier methods of birth control - series (Medical Encyclopedia) Also in Spanish
• Birth control pill - series -- Normal female anatomy (Medical Encyclopedia) Also in Spanish
• Condom application - series -- Procedure, part 1 (Medical Encyclopedia) Also in Spanish
• Test Your Knowledge About Birth Control (Medical Encyclopedia) Also in Spanish
• FastStats: Contraceptive Use (National Center for Health Statistics)
• Key Statistics from the National Survey of Family Growth: Vasectomy (National Center for Health Statistics)

Journal Articles References and abstracts from MEDLINE/PubMed (National Library of Medicine)

• Article: Men's involvement in family planning programs: an exploratory study from Karachi,...
• Article: Patient-centered pregnancy planning in multiple sclerosis: evidence for a new era.
• Article: Exposure to family planning messages on social media and its association...
• Birth Control -- see more articles
• Department of Health and Human Services, Office on Women's Health Also in Spanish
• How to Find Find an Ob-Gyn (American College of Obstetricians and Gynecologists)
• Abstinence (Nemours Foundation) Also in Spanish
• Birth Control Patch (Nemours Foundation) Also in Spanish
• Birth Control Pill (Nemours Foundation) Also in Spanish
• Birth Control Ring (Nemours Foundation) Also in Spanish
• Birth Control Shot (Nemours Foundation) Also in Spanish
• Condoms (Nemours Foundation) Also in Spanish
• Could I Get Pregnant if I Have Sex During My Period? (Nemours Foundation)
• Diaphragm (Nemours Foundation) Also in Spanish
• Emergency Contraception (Nemours Foundation)
• IUD (Intrauterine Device) (Nemours Foundation) Also in Spanish
• Withdrawal (Nemours Foundation) Also in Spanish
• Birth control - slow release methods (Medical Encyclopedia) Also in Spanish
• Birth control and family planning (Medical Encyclopedia) Also in Spanish
• Birth control pills (Medical Encyclopedia) Also in Spanish
• Birth control pills - combination (Medical Encyclopedia) Also in Spanish
• Birth control pills - progestin only (Medical Encyclopedia) Also in Spanish
• Condoms - male (Medical Encyclopedia) Also in Spanish
• Deciding about an IUD (Medical Encyclopedia) Also in Spanish
• Female condoms (Medical Encyclopedia) Also in Spanish
• Intrauterine devices (IUD) (Medical Encyclopedia) Also in Spanish

The information on this site should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

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• Talking with Your Healthcare Provider
• Birth Defects Statistics
• Birth Defects Resources
• Birth Defects Awareness Month
• Living with Down Syndrome
• Conversation Tips
• Growth Charts for Down Syndrome
• Accessing NBDPS and BD-STEPS Data
• Birth Defects Awareness Month Social Media Resources

Related Topics:

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• About Alcohol Use During Pregnancy

Data and Statistics on Birth Defects

What to know.

• The United States does not have a national birth defects tracking system.
• Most states have birth defects tracking systems that monitor selected birth defects.
• Data from these state systems have been used to estimate how often birth defects occur in the United States.
• These tables show the current national estimates of certain major birth defects in the United States.

Brain/spine defects

Specific defects

How often do they occur?

How many babies are affected each year?

Anencephaly

1 in 5,246 births

Encephalocele

1 in 10,365 births

Spina bifida without anencephaly

1 in 2,875 births

Eye defects

Anophthalmia/ microphthalmia

1 in 5,078 births

Heart defects

Atrioventricular septal defect (Endocardial cushion defect)

1 in 1,712 births

Coarctation of the aorta

Common truncus (truncus arteriosus or TA)

1 in 15,984 births

Double outlet right ventricle (DORV)

1 in 4,237 births

Ebstein anomaly

1 in 12,916 births

Hypoplastic left heart syndrome

1 in 3,955 births

Interrupted aortic arch (IAA)

1 in 10,058 births

Pulmonary valve atresia and stenosis

1 in 972 births

Pulmonary valve atresia

1 in 6,708 births

Single Ventricle

1 in 15,356 births

Tetralogy of Fallot (TOF)

1 in 2,077 births

Total anomalous pulmonary venous connection (TAPVC)

1 in 7,552 births

Transposition of the great arteries (TGA)

1 in 3,348 births

Dextro-transposition of great arteries(d-TGA)

1 in 3,957 births

Tricuspid valve atresia and stenosis

1 in 5,527 births

Tricuspid valve atresia

1 in 11,309 births

Mouth/face defects

Cleft lip with and without cleft palate

1 in 1,032 births

Cleft lip with cleft palate

1 in 1,583 births

Cleft lip alone

1 in 2,963 births

Cleft palate alone

Muscle/bone defects

1 in 536 births

Diaphragmatic hernia

1 in 3,214 births

Gastroschisis

1 in 2,439 births

Limb deficiencies (reduction defects)

1 in 2,064 births

Omphalocele

1 in 4,021 births

Stomach/intestine defects

Esophageal atresia/tracheoesophageal fistula

1 in 4,167 births

Rectal and large intestinal atresia/stenosis

1 in 2,220 births

Chromosome (gene) malformations

1 in 6,967 births

1 in 3,336 births

Trisomy 21 (Down syndrome)

1 in 643 births

• Stallings, E. B., Isenburg, J. L., Rutkowski, R. E., Kirby, R. S., Nembhard, W.N., Sandidge, T., Villavicencio, S., Nguyen, H. H., McMahon, D. M., Nestoridi, E., Pabst, L. J. National population-based estimates for major birth defects, 2016–2020. Birth Defects Research. 2024 Jan;116(1), e2301.

Birth Defects

About one in every 33 babies is born with a birth defect. Although not all birth defects can be prevented, people can increase their chances of having a healthy baby by managing health conditions and adopting healthy behaviors before becoming pregnant.

For Everyone

Health care providers, public health.

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Find a Study on Contraception and Birth Control

Select one of the following links to get ClinicalTrials.gov search results for studies on contraception and birth control:

• All NICHD clinical trials on contraception and birth control
• All ClinicalTrials.gov trials on contraception and birth control