Eligibility barriers. Some health care programs or providers require women to meet certain requirements for OCs that have no medical basis. Eligibility criteria related to age and parity, for example, have no medical basis but nevertheless are widespread (81, 200, 222). For example, in a 1992 survey in Pakistan 3 of every 10 family planning providers said that a woman had to be at least 25 years old to use the pill, while 4 of every 10 said women over 35 years could not use the pill (160). In fact, age in itself is not relevant to pill safety.

Eligibility criteria and their interpretation need to be broad enough to ensure that women who cannot use the pill safely do not use it but also specific enough that they do not exclude women who can safely use the pill (222). For example, a screening checklist that includes “headache” as a condition that rules out pill use could improperly keep women who have ordinary tension headaches from using the pill (198, 210). Only 1) women who have true migraine headaches with focal neurologic symptoms (aura) and 2) women who have true migraines without aura and are age 35 or older are the focus of concern (245).

Unnecessary eligibility barriers have hampered OCs in particular, perhaps because they were the first hormonal contraceptive method. At first, many researchers and practitioners were cautious about providing the pill, concerned that OC use might be bad for women's health or worsen existing medical conditions. Eligibility criteria established many years ago, when hormone levels in the pill were much higher and less was known about effects of the pill, have persisted today in many places, even though subsequent research and experience have proved these limitations to be unnecessary (16). For example, in the US many providers did not prescribe OCs to any woman who is diabetic (198). Research, however, has found no adverse clinical effects among diabetic OC users who have no circulatory system complications (25, 66, 154).

JHU/MMC

Making it easy to obtain and use oral contraceptives can help women take a pill every day and thus avoid the risk of unintended pregnancies.

For example, required pelvic exams and laboratory tests for women who choose OCs are a burden to all women seeking OCs and a particular barrier to women who have never before had a pelvic exam or who are afraid of needles (222). In Jamaica a 1993 survey of over 350 private practitioners found that one-quarter performed blood and urine tests on women seeking the pill, even though Jamaican service delivery guidelines make no mention of either test as a prerequisite for pill use (80). In Senegal providers required Pap smears and urine, blood, and sexually transmitted infection tests—all medically unnecessary to safe pill use—before giving clients the pill. In fact, they often did not allow clients to use the pill unless they were in apparently perfect health (81). In Ghana a 1993 Situation Analysis found that 55% of providers required blood hemoglobin tests for prospective OC users, even though such tests are not medically necessary for safe pill use (161).

When these unnecessary tests are required, facilities ill-equipped to do such tests cannot provide pills, thus limiting women's access to OCs. While some tests or procedures, such as a pelvic exam, are good preventive health practices that benefit women's overall reproductive health, they nonetheless are not relevant to safe OC use (70, 224). No condition that a pelvic exam might detect rules out OC use (245).

Menstrual requirement. Probably the most common process barrier is to deny OCs to new clients unless they are menstruating when they see the provider (2, 60, 209). In Jamaica nearly one-half of private practitioners interviewed would send women home without pills if they were not menstruating. In another Jamaican survey 92% of providers and clinic supervisors said they required menstruation or a negative pregnancy test before they would give women any contraception. In 12 clinics surveyed in Kenya, every provider said that clients are often sent home to await menses. At the same time, over half of the clients visiting 19 Kenyan family planning sites were not menstruating at the time of their clinic visit (209).

If women are not actually sent away because they are not menstruating, they may be forced to choose a nonhormonal method instead of the pill. In Cameroon a study of 10 clinics found that only 33% of clients who were not menstruating were given a hormonal method, while 82% of menstruating women left with a hormonal method. Of 21 service providers, only 2 said that they did not require their clients to be menstruating before they would provide OCs (209).

The menstrual requirement is meant to ensure that a woman is not pregnant when she starts OCs, for fear that hormones may harm the fetus. This is also why some programs even require a negative pregnancy test before giving OCs. There is no evidence, however, that combined or progestin-only contraceptives harm a fetus (57, 67, 236). WHO medical eligibility criteria were recently changed to make clear that current pregnancy is not a condition relevant to decisions about providing hormonal contraceptives (245).

Women who want to start using OCs do not have to do so when they are menstruating: Women can begin using the pill at any time during their menstrual cycle if it is reasonably certain that they are not pregnant (84, 85, 220) (see side-bar, When Can a Woman Start the Pill?). By asking a series of questions, a provider can be reasonably sure that a woman is not pregnant even though she is not menstruating (208, 221). If a woman's answers to these questions cannot affirm that she is not pregnant, a provider can still give her OCs with instructions to start the first packet when menstruation begins and can also provide condoms or spermicides to use until then.

Legal and regulatory barriers. In some countries only doctors can legally provide OCs, a requirement that can seriously limit access to the pill, particularly where doctors are few. Such restrictions have no sound medical basis. Not only physicians but also many other personnel, including midwives, nurses, community-based health workers, traditional birth attendants, pharmacists, social marketing vendors, and pharmacy clerks, are safely providing OCs around the world. OCs are made available through door-to-door delivery to people's homes, at community centers, and in shops, markets, and grocery stores (183, 199, 222) (see Chapter 6.2).

Unnecessary prescription requirements. In some countries, notably the United Kingdom and the US, OCs are available to women only by prescription. Given the proven safety of low-dose OCs, the widespread demand for the pill, and safe use of OCs among women obtaining them without a prescription throughout the world, some experts argue that OCs should become available without prescription everywhere (30, 69, 167, 224).

Making OCs available only by prescription requires women to overcome a series of hurdles to start the pill and to keep using it. First, they must see a physician or other specified health care provider, often endure a pelvic exam, and obtain a prescription for the pill. Then they must go to a pharmacy to have the prescription filled, often for only one pack of pills at a time. Women must continue to return to a pharmacy every month to get another pill pack and return to the doctor every year to have the prescription renewed.

Researchers debate the impact that availability of OCs without prescription might have on access, safety, effectiveness, cost, and preventive reproductive health care (28, 39, 69, 70, 79, 92, 167, 187, 189, 224, 249). Eliminating a visit to the doctor—and consequently, the pelvic exam—could increase access to the pill for women who are intimidated by a pelvic exam, cannot afford a provider visit, or are embarrassed to be seen entering a family planning clinic (69, 213, 224). Not seeing a provider for a prescription, however, could also mean that fewer women receive preventive health care screenings such as yearly Pap smears, breast exams, and screening for reproductive tract infections (79).

Some are concerned that, without a required visit to a doctor to obtain OCs, women will not heed warnings about health conditions that rule out pill use, such as migraines with aura, high blood pressure, and other circulatory system disorders, and, for women age 35 or older, smoking. They argue that lack of provider intervention would compromise pill users' health, since women who should not use the pill may begin using it if a provider is not there to disallow OC use (79, 213, 249). Studies have shown, however, that giving women accurate information about health conditions and risks helps them correctly assess their own health risks and decide for themselves which methods are most appropriate. In fact, often they can do so as well or better than providers (29, 167, 250). Thus, others argue, women are fully capable of making the right decisions about their health risks.

What would offering the pill without a prescription mean for the pill's effectiveness? Some argue that a doctor's or nurse's instructions help women use the pill more effectively (79, 213, 249). Others contend that, given the current gap in pregnancy rates between perfect use and typical use of the pill, clients apparently get too little information from providers as it is. Thus, they reason, using other ways to inform women about how to use the pill may be more effective than continuing current practices (69, 167, 224).

In June 2000 the US Food and Drug Administration discussed with scientists, professional groups, and consumers the possibility of changing oral contraceptives from prescription status to being available without a prescription (30, 230).