Hailey Stokes- Birth Control and Adolescents

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1 Birth Control and Adolescents Birth Control and Adolescents: The Effect of Over the Counter Birth Control Access on Unwanted Pregnancy Rates in Adolescents Hailey Stokes University of Kentucky

2 Birth Control and Adolescents Abstract Birth control options are wider now than ever before. The recent FDA approval of a current birth control option, a progesterone only pill, in an over the counter format will allow for women to obtain birth control prescription free. This may have implications for women, especially those who deal with varying factors of access. Specially, adolescents may have a change in birth control usage if there is an option that is easier to access in their community. The same could potentially be said for those in contraceptive deserts than have a harder time with accessibility. However, there has been no over the counter pharmaceutical option offered before in the United States. Due to the novelty of this, research dealing with an over the counter birth control is not available in a non-hypothetical format. In an attempt to bridge this knowledge gap as the FDA approval occurs, observation of the unwanted pregnancy rate in adolescents before and after the over the counter method is introduced would provide actual data for the United States. A total of three counties will be observed, all noted to be contraceptive deserts, where high school juniors will be surveyed before and after the FDA approval. It is hypothesized that the rate of unwanted pregnancies will decrease due to the additional accessible option. The findings of this study may benefit research into better providing birth control options to adolescents and simultaneously reducing unwanted pregnancy rates.

3 Birth Control and Adolescents Birth Control and Adolescents: The Effect of Over the Counter Birth Control Access on Unwanted Pregnancy Rates in Adolescents Birth control methods have varied widely throughout the years, and the introduction to hormone-based contraception has been revolutionary. In the US, the most common form of reversible birth control are pills (Long et al. 2023). The FDA is approving a birth control pill that is progesterone only called Opill (Long et al. 2023). This contraceptive method works for users by thickening cervical mucus, preventing sperm from contact with an egg (Mayo Clinic 2023). It often prevents ovulation in about half of users (Mayo Clinic 2023). The pregnancy rate with use is as low as 1 in 100 users with perfect use, with the most being 9 out of 100 getting pregnant within the first year of use (Mayo Clinic 2023). A downside to a contraceptive pill is that it relies on users to take it at the same time every day with no gaps in usage, and this can lead to a higher rate of user error. It is essential to study the effect of higher accessibility to an over the counter birth control option on unwanted pregnancy rates as it is introduced as an option, specifically for adolescents. The rate of unwanted pregnancies is highest for this age group and further research would work to understand the effect this newly approved drug would have on the rate of unwanted pregnancies, if any. Literature Review Accessibility and Unwanted Pregnancy Rates Accessibility is related to factors such as cost, transportation, and location. For some, cost determines whether they can afford the medication itself. For others, being able to get to a healthcare facility so a prescription can be obtained is a struggle. For many people desiring contraceptives, both factors limit options and contribute to a higher unwanted pregnancy rate.

4 Birth Control and Adolescents Cost Per Birth Control Pack and its Effect on Contraceptive Use Frost et al. (2007) conducted a qualitative study where 1,978 adult women at risk of unintended pregnancy were surveyed. Sample size was collected through a random digit dial generation, allowing for a sample size that included women across the nation (Frost et al. 2007). 23% of these women surveyed had gaps in contraception use, and 5% of these women cited the expense of the birth control as the reason (Frost et al. 2007). Additionally, in a study by Grindlay and Grossman, a cross section survey was done using 2,026 women nationwide through a KnowledgePanel (2007). The goal of this panel was to determine the interest in a progestin-only pill for sexually active women ages 15-44 (Grindlay and Grossman 2007). This study found that the price adults were willing to pay for birth control out of pocket per month was $15 and teenagers reported a willingness to pay $10 (Grindlay and Grossman 2007). It is also found that 39% of adults and 29% of teens would consider using a progestin-only pill, and coverage by insurance was associated with a more willingness to use this contraceptive (Grindlay and Grossman 2007). Overall, both of these studies found that expense was a factor in contraceptive use. The second study had a wider, more accurate sample size due to the use of KnowledgePanel, but both had nation-wide coverage of the United States. This has many implications regarding an over the counter birth control that can have a higher variation in price. Low-income Accessibility in Relation to Ability to Visit Providers Most birth control options require a prescription. However, accessibility to a provider in order to obtain this prescription can be challenging. Transportation, copays, and time off of work are jut a few of the factors that affect how often patients can visit their providers. From the previously mentioned qualitative survey by Frost et al., there were also key findings that out of

5 Birth Control and Adolescents the 23% of women who reported a gap in contraceptive use, 5% reported it was related to not having the time to get a medical visit required for being prescribed a method of contraception (2007). This survey also looked at the demographics of the women who had a gap in contraceptive use and found that more women who were above 100% of the federal poverty level were more likely to have a gap in contraceptive use than those who were below (Frost et al. 2007). Additionally, in a study called the Border Contraceptive Access Study by Potter et al., convenience sampling was used to determine the rates of continuation of oral contraceptive pills for women who receive contraception over the counter in Mexico versus from family planning clinics in the United States (2013). 1,046 women participated in this survey, with the only criteria being that they must be oral contraceptive users, obtain their contraceptive from a family planning clinic in El Paso or from a pharmacy in Mexico, an El Paso resident, and ages 18-44 (Potter et al. 2013). Key results from this study include that there was more discontinuation of use associated with women who obtained their contraceptive from El Paso clinics (Potter et al. 2013). There was also an association between number of pill packs and discontinuation rates, where women who received only 1-5 pill packs from the clinic compared to those who received six or more pill packs from the clinic and those with a contraceptive obtained from Mexico (Potter et al. 2013). This study highlights that when a prescription is required, as well as frequency of doctor visits, less adherence to contraceptive use is likely. Both studies mention that it would lead to increased continuation of contraceptive use if a medical visit was not required for obtaining an oral contraceptive. Both focus on United States citizens, however the study by Frost et al. is qualitative and has a high risk of recall bias in answers. It also relied on telephone usage, so it may not include women who do not have access

6 Birth Control and Adolescents to a phone or are not around their phone often. The Border Contraceptive Access Study was quantitative and had less of a recall bias, but a smaller sample size that was limited to a town close enough to the United States-Mexico border than travel between the countries was feasible for residents. Unwanted Pregnancy Rates for Low-income Areas An important aspect to cover is unwanted pregnancy rates. Specifically, this over the counter birth control may have a larger effect in low income areas. Finer and Zolna had the goal of calculating the pregnancy rates in 2008 and 2011 and categorizing these rates based on intentions and outcomes (2016). The data used for these calculations came from the National Survey of Family Growth, National Center for Health Statistics, and other nationwide surveys on abortion, pregnancy rates, birth count, miscarriages (Finer & Zolna 2016). The results of this study relevant to unwanted pregnancy rates was that the rates of those below the federal poverty were higher, two to three times above the national average (Finer & Zolna 2016). Foster et al. (2015) also successfully predicted the effect of non-prescription oral contraceptive pills on usage, unintended pregnancy rate, and pregnancy associated costs for low income women through models. These figures have data representing the nation and predicts two scenarios estimating a high and low amount of over the counter contraceptive use (Foster et al. 2015). Importantly, this study takes into consideration the out of pocket cost and varies this to represent the likelihood women would use the contraceptive for different price ranges (Foster et al. 2015). This prediction found that the rate of unintended pregnancies could be reduced in the low model at notable rates: 11%, 15%, or 7% reduction in unintended pregnancy rates depending on if the over the counter contraceptive pill has no change in the rate of birth control failure, reduces the failure rate, or increases the failure rate, for each percentage in respectively (Foster et

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