In most countries of the world, no prescription is required for birth control. Why do Canadians still need it?

Leah Morris has been using birth control since she was a teenager. She remembers that first appointment was deceptively simple.

“It was just like, ‘You’re at a time when you should be on this,'” she said.

She started taking Yasmin, a generic estrogen-based oral contraceptive. At first, getting a refill was as easy as going to her local pharmacy.

But as Morris’s work in international development and venture capital took him around the world, sometimes getting a prescription became a major struggle.

“I have to keep going to my doctor and prove that I’m not dead,” he said. “It’s just a huge waste of time.”

In Canada, oral contraceptives are far from over The most common method of birth control among women, but they are available only by prescription – the situation is very different for most other countries.

Outside Western Europe, Canada, New Zealand, Australia, and South Africa, birth control is often available without a doctor’s prescription. Even in conservative countries Like Saudi Arabia, Türkiye or Indonesia.

In the United States, where reproductive rights are often hotly debated, the issue of birth control has been available prescription-free From 2023.

So why is Canada still lagging behind? The answer is more complicated than you might think.

Common side effects

Since the 1960s, most oral birth control methods have been so-called “combined pills” – combining the hormones estrogen and progestin, which prevent the ovaries from releasing eggs.

These pills, which include common consumer products like Yasmin, come with some side effects, such as bloating and headaches, and risks such as cervical cancer or blood clots.

this risk Start small, but grow among older women. Doctors say this is one reason why constant monitoring by medical professionals is often recommended.

Dr. Wendy Norman, a family physician and sexual health researcher at the University of British Columbia, says that’s why only places with a high tolerance for medical risk — usually developing countries — allow non-prescription access to the combined pill.

Norman said, “There is no medical system in the world where malpractice would be considered (seriously) … that they would not regulate estrogen-containing drugs.”

There are better options available

But many prescription-free birth control options that have recently entered the global market no longer rely on estrogen.

Progestin-only pills – eg Opil – Work by thickening the mucus in the cervix so that sperm cannot enter to fertilize the egg. Most, but not all, women also stop producing eggs altogether, as is the case with the traditional birth control pill.

Taking these pills requires more discipline: there is less chance of error when you take the pill. But, it is safer to take them without the supervision of a doctor or pharmacist.

“There are very few contraindications to the progestin-only pill,” said Dr. Amanda Black, president of the Canadian Society of Obstetricians and Gynecologists.

Some of these pills are already available in Canada, Black said, and “potentially can be dispensed without a prescription.” But this isn’t so easy.

When registering with Health Canada, pharmaceutical companies must request that their product be made available without a prescription. So far, no company has done this – and it doesn’t seem like it’s part of their plans.

Black approved a progestin-only pill called Slind for sale in Canada in 2021, as a great potential candidate for over-the-counter sales along with generic variants like Movise.

But Duchesne Canada, the developer of Slind, said they would not request prescription-free status.

“Our business model is focused on prescription drugs,” a spokesperson said via email.

Major obstacles for businesses

This may be due to the stringent requirements for a drug to be approved for prescription-free status.

According to a spokesperson for the agency, to approve a drug for over-the-counter sale, Health Canada must be convinced “that the product is suitable for use without the involvement of a health-care practitioner.”

It sounds simple enough — but Black says it can involve expensive requirements for complex medical tests. Data from other countries, where similar products are already widely sold, are rarely accepted.

“They had to do a clinical trial in Canada and that clinical trial had to include endometrial biopsy” — an invasive procedure where a tissue sample is taken from the uterus, he said.

Under such requirements, Black says it is difficult to even find enough willing participants in Canada – let alone justify the expense.

“Companies said, we’re not going to do it, because the market isn’t there.”

Patient care, or paternalism?

Sexual health researcher Norman says there are some benefits to keeping only birth control prescriptions.

“If you have a prescription drug, the health system will pay for it,” he said.

Norman played a key role in advocating for the inclusion of free contraception in the national pharmacare scheme, which he said would expand access across the country regardless of income. She says making birth control prescription-free could jeopardize this.

“The health system (generally) does not pay for non-prescription drugs,” he said.

But despite that plan being introduced nearly two years ago, most provinces and territories Still don’t offer free contraception. And in the meantime, requiring prescriptions could do more harm than good.

Kelly Blanchard, who works with Norman on a campaign called Free the Pill aimed at improving contraceptive access, says prescription requirements present a major barrier for many women.

One recent study found that when birth control was made available over-the-counter, 31 percent of nearly 1,000 people interviewed across the United States switched to it for the first time.

Blanchard says the prescription requirement prevents about a third of women from taking the pill. “And it’s even more so when you start talking about people of color, Indigenous people, where the rates can be half or even more,” she said.

In theory, forcing women to visit a doctor or speak to a pharmacist means ensuring they are informed about potential side effects and being monitored, and offered options as they age and the risks increase.

But Black says it’s already complicated by a shortage of doctors, which is preventing many Canadians from accessing any ongoing care.

“These things may not necessarily be happening when you’re seeing someone in a walk-in clinic,” he said.

As far as Morris is concerned, she says that was never her experience anyway.

She says, even on recent visits to refill her prescription, she was never informed about the increased cancer risks, or offered an alternative to the combined pill.

“If the goal is to protect us, I don’t think the appointment of doctors in any of the countries I’ve been in has done that,” Morris said.

For that reason, Blanchard says it’s time for medical officials to understand that prescription requirements may be outdated — and based on old biases about women’s health.

“We now have 60 years of extensive research on the safety and effectiveness of these methods,” he said.

“I think what prevents our regulatory systems and our health care systems from taking that evidence into account… is patriarchy.”