In conjunction with the U.S. Department of Veterans’ Affairs (VA), researchers at the University of Pittsburgh analyzed data from 24,000 women who received oral contraceptives covered by the U.S. Veterans’ Affairs insurance.
The study found that 43 per cent of women who received pills in three-month increments experience at least one gap between refills per year.
By offering a year’s supply of pills, researchers estimated that roughly 583 pregnancies could be prevented, and the switch could save the VA around US$2 million per year in prenatal, birth and newborn care costs.
Lead author Dr. Colleen Judge-Golden believes dispensing larger amounts of birth control pills at one time can promote women’s health and autonomy.
“Getting more pills up front has been shown to lead to reduced gaps in coverage, which in turn leads to reduced unintended pregnancy,” she said.
“If the goal of an individual woman is to prevent pregnancy, then this is actually an evidence-based strategy to help women achieve reproductive autonomy.”
When oral contraceptives fail
The trouble with the birth control pill is it only works at maximum efficiency if the user remembers to take it on a regular basis.
“When tell patients that the birth control pill is 99.9 per cent effective… that’s true if you’re in a clinical research trial where the nurse is calling you once a week if you’ve taken all your pills,” said Dr. Robert Reid. He’s an adjunct professor in the obstetrics and gynecology department at Queen’s University in Kingston, Ont.
“Real-world evidence suggests now that the failure rate is something like eight or nine out of every 100 women per year, which is quite alarming.”
Despite taking birth control pills, an unwanted pregnancy can occur due to several reasons.
“Some of it may be due to failure to renew the prescription, but it’s often due to missing pills at the end of a pack,” said Reid. “So, you missed the last two days of pills… and then you’re off for a full week.”
It can also happen that you take a week “off” of your birth control (taking sugar pills or no pills at all, during which time you have a period), and then it might take you a couple of days to refill your prescription.
“Nine days is long enough for ovulation and accidental pregnancy to occur,” he said.
This is not to say that the birth control pill doesn’t work for anyone. “There are lots of people who can use it highly effectively,” said Reid. “But the classic example we see is a teenager breaks up with her boyfriend, throws the pills out in the garbage and then they’re back together the next week.”
Planned Parenthood Toronto has experienced this first-hand. According to executive director Sarah Hobbs, the organization created an emergency refill program to mitigate the risk of unwanted pregnancy.
“If your prescription runs out, you can come to the clinic for one additional pack of whatever you were prescribed, and schedule an appointment within the month so that you’re able to renew it,” Hobbs said.
Gaps in coverage
Although the study looked at data from the VA, Judge-Golden said in an interview that “gaps in contraceptive use are common among women in the general U.S population as well.”
As of 2019, only 17 states and the District of Columbia have enacted legislation requiring insurers to cover the dispensing of 12-month contraceptive supplies at an initial fill. In Canada, the dispensing process is similarly limited in scope.
According to Reid, Canadian physicians have long been instructed to prescribe birth control pills for a period of one year. However, it’s common for a pharmacist to only dispense one to three month’s worth at a time.
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This could be for a number of reasons. “ get a dispensing fee,” said Reid, referring to the cost incurred each time someone fills a prescription at a pharmacy.
Ranging from $7 to $15 per prescription, the profit could be one incentive for pharmacists to prescribe lower amounts at a time.
The lower dispensing amounts could also be a policy enforced by your insurance provider. “They know that people tend to quit their pill,” said Reid.
“They take it for three months, they don’t like it because they had spotting or … meanwhile, the insurance providers paid for a whole year of medication, only to find out you took it for just three months.”
Judith Soon, an associate professor in the faculty of pharmaceutical sciences at the University of British Columbia, offers a different perspective. In addition to her role as a professor, she travels around Canada educating pharmacists about the best ways to dispense contraceptives.
“The side effects — from irregular bleeding to headaches — can be insufferable, especially in the first three months of use,” she said. “It depends on the particular ingredients in the pill, but for some people, they have to stop after two or three months of use.”
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For this reason, Soon believes the pill should initially be prescribed for a three-month “test period,” to see if the patient actually likes the product. She also recommends extended and continued use as a way for the pill to be taught to first-time users.
“Extended use is taking three or four months’ worth of pills in a row, without any stopping,” she said. “Continued use is taking the pill every single day for an undetermined amount of time.”
Both are techniques she uses to help patients ingrain the pill in their everyday lives and improve “compliance,” thus improving the efficiency of the pill as a way to prevent pregnancy.
“Both are perfectly safe,” she said.
Policy needs to catch up to science
Given the inconsistency of the birth control pill, doctors have started to recommend long-acting reversible contraceptives (LARCs) as an alternative.
The most common are intrauterine contraceptives, like copper IUDs. Similarly, U.S. products like Nexplanon — an implant placed under the skin on your arm which prevents ovulation — are growing in popularity, though none are available in Canada yet.
The beauty of a LARC is that “you put them in, you forget about them,” said Reid. “The problem is that putting in an IUD or an implant requires some skill and training… it’s a lot easier to reach in the cupboard and get the pills than try to make a referral that might take a month or two to get an IUD.”
“Having a sufficient number of able to offer rapid access” is the Canadian healthcare system’s biggest struggle right now, said Reid. “If a woman decides tomorrow that she’s going to be sexually active next week, she wants to get her IUD right away.”
There is an organization in Vancouver focused on doing exactly this. Rapid Access IUC Centres of Excellence is a database of physicians across Canada who are able to provide immediate access to an intrauterine contraception product.
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“As a physician, if you want to get your patient in for an IUD in a hurry, you can find the nearest place you can send them,” said Reid.
Ultimately, as this study shows, preventing pregnancies saves the healthcare system money.
“I think that’s why it’s something the provincial governments need to take really seriously,” said Reid. “In the long run, it’s better for the population’s health it’s better for the economics of healthcare.”
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