Liberate the Pill

            Do you think that a medication that kills more than 3000 people in the USA should be available without a prescription, even though it has health benefits? What about another medication that has many health benefits but doesn’t increase the risk of death?

            The first drug mentioned above is aspirin and can easily be bought without a prescription. The second is “the Pill”, or Oral Contraceptive Pills (OCPs), which need a prescription now. In the past women needed a yearly Pap smear which meant a visit to a doctor (or other health care provider) with the expense and embarrassment of a pelvic exam. As the amazing safety of the pill has been recognized, laws have been changed to allow women to purchase their OCPs in some states from a pharmacist with minimal hassle–and they can keep their clothes on!

            Perhaps you noticed that the first paragraph of this essay was making an unfair comparison. The people who die from aspirin are usually older than the women taking oral contraceptives. Furthermore, the study that found no increased mortality among women who had taken OCPs, found that there was an increase in deaths from breast cancer, but that was counterbalanced by a decrease in ovarian cancer and other causes of death.

            I had the unusual experience of getting a package OCPs for an elderly nun. Our Catholic hospital had a committee to consider requests for tubal ligations–usually women undergoing repeat Cesarean sections. The sister, a member of the committee, didn’t understand that a tubal ligation could be life-saving. Apparently, she wasn’t aware that women die from pregnancy complications. I showed the nun the insert accompanying every package of OCPs, which has information about the risks of dying with various contraceptive methods, or with none. The most dangerous was not using contraception, since every pregnancy carries a small risk of death. She was convinced of the importance of tubal ligations for women who desired no more children.

            When OCPs first became available 60 years ago they were quite different. Then the level of estrogen was more than twice what it is now. Over 50 years ago my wife and I visited a college classmate in the hospital where she had been diagnosed with a blood clot from OCPs. It took years to recognize that estrogen in OCPs increases the risk of clots–the more estrogen, the higher the risk. We now know that pills with less estrogen are safer, but still effective.

            Fortunately, there are already several ways OCPs can be bought without an examination. They include Planned Parenthood, where answering a questionnaire and blood pressure check are all that’s needed. In Colorado and some other states, a pharmacist can prescribe them. Also, there are Internet sites that provide prescriptions and sell OCPs inexpensively. Why not reduce the restrictions to make it easier and less expensive to get OCPs?

            Perhaps you remember a similar situation with Emergency Contraception Pills. It took years to convince the Food and Drug Administration of their safety. ECPs can now be bought in a pharmacy or even from Amazon without restrictions. Because ECPs are most effective in preventing pregnancy if they are taken within 12 hours after unprotected sex, it is suggested that people who are at risk keep a pack “just in case”.

The “Oral Contraceptives Over-the-Counter Working Group” advocates for OCPs to be available without prescription. They have worked for years to reduce hurdles for women. They have looked at pills’ safety record in other countries, where one can purchase OCPs without a prescription. Social scientists have been developing easy-to-understand wording to go with the pills since no provider will tell the woman how to take the medication.

Well, England has beat us to it! This month Progestin-Only Pills will be available without a prescription, after a brief consultation with a pharmacist. Since POPs have no estrogen, they are safer than the usual combined OCPs and can be used by many people who should not take estrogen.

Making contraception more available is not just a matter of convenience. Studies show that access to contraception increases young women’s chances of graduation from high school. Facilitating access to safe OCPs can help change teens’ lives for the better.

© Richard Grossman MD, 2021


Refocus the Media’s Concern about Births

Teen Birth Rates

U.S. birth rates are declining. This trend is cause for concern, because an aging population puts a strain on the economy.” Kimberly Amadeo, in “The Balance”, 4/29/2021

            The CDC reported that the birth rate in the USA dropped in 2020, with much lamentation in the press. Instead, we should be applauding this decrease in births, especially among one group of people.

            The general fertility rate (the number of live births each year, per 1000 women aged 15 to 44) has been decreasing since a small peak in 2014. In 2019 it was 58.3, and in 2020 it dropped to 55.8. Not a huge decline, but newsworthy. Please note that this is the number of births, not the number of babies born. The number of babies is actually about 3% higher because of twins, triplets etc.

            Did people decide to postpone childbearing because of covid-19? Due to the timing of the births in 2020, we can figure that most of the conceptions actually happened before the pandemic. Births were down most sharply at the end of the year, however, when babies conceived at the start of the pandemic would have been born. Very preliminary information suggests that the birth rate for 2021 will show a slight rise. That figure may increase as the year goes on since September is the month when the most babies are born.

Recently, many women are waiting to start their families. I am the second and last child of my parents. My parents married in 1928 and my sister Clara was born in 1939. I was born 4 years later, when my mother was 40 years old. This was an unusual pattern of childbearing in the 1940s but is much more common now as women are entering the workforce and postpone childbearing.

The birth rate of women in the 40-to-44-year cohort has been rising 3% each year for the past 35 years. The oldest women I helped give birth was Sarah, who was 52 when she delivered her second child. Her history is unusual. She retired from a professional career and then married for the first time. Despite being postmenopausal, modern reproductive technology allowed her to bear and raise 2 healthy children.

Several countries offer financial incentives for childbearing. The USA has tax breaks to help parents with the financial expenses of raising children. However, incentives are not very effective in motivating people when it comes to family size. 

Unfortunately, the media have not focused on the good demographic news. With fewer births we can expect eventually to have less impact on our environment, including slowing of climate chaos. With smaller families, each child benefits from more time with their parents and more financial resources. The best part of the CDC’s report is the number of babies born to teens. That rate has been declining much faster than the overall births. We in Colorado can be especially proud of this decline since we have been one of the leaders in the country.

Our teen birth rate declined 76% between 1991 and 2019! Free contraception for uninsured women, paid for by a large grant starting in 2009, helped this decrease. For example, one morning I inserted 6 IUDs as a volunteer at the public health clinic; the women paid nothing. Although started by the Susan Thompson Buffett Foundation, this wonderful program was continued with private and state funds. The impact on the abortion rate was noted immediately, with a steep downturn starting in 2009. Who knows how many unplanned pregnancies were prevented, and how many young women’s lives were improved by that generosity!

 Other programs have also helped to keep the teen pregnancy rate low in Colorado. Pharmacists are allowed to prescribe birth control pills, allowing healthy young women to get started on effective contraception easily and inexpensively. Furthermore, “Obamacare”, will pay for reliable contraception for people who meet eligibility standards.

It is fortunate for many reasons that people are choosing to have fewer children. Sadly, the media stressed the short-term economic problems this downturn may cause.

© Richard Grossman MD, 2021