Online Access to Low-Dose Birth Control Reduces Barriers to Reproductive Health

Archived Service Delivery Innovation Profile

Online Access to Low-Dose Birth Control Reduces Barriers to Reproductive Health

Snapshot

Summary

Planned Parenthood of the Columbia/Willamette created an online service that offered Oregon and Washington women easy, 24/7 access to low-dose, hormonal contraception without requiring an office visit or a trip to the drug store. The program increased access to birth control by removing barriers to reproductive health care. The program was also a nonthreatening introduction to the importance of annual examinations and cancer screening, with 25 percent of online patients who picked up their prescription at a Planned Parenthood clinic scheduling an examination there.

Evidence Rating

Suggestive: The evidence consists primarily of data on use of the service by individuals. Although the program has likely increased access to individuals who otherwise would not have obtained birth control, there is no way to know for sure if these individuals would have accessed birth control in the absence of the program.

Use By Other Organizations

Delivery of online reproductive health care services is a highly effective way to deliver hormonal birth control to women who have access to the Internet, and it represents an entirely new model of health care service delivery that can be potentially be used by other organizations and for other services. Some organizations are already replicating various aspects of the program. For example:

  • The organization's partnership with four Washington affiliates is being replicated by other affiliates around the nation to reduce duplication of health care and/or support services and to take advantage of economies of scale.
  • They are in conversation with several other states with favorable regulatory environments for adoption of the Instant Birth Control program. Planned Parenthood Federation of America will be conducting a national analysis of regulatory and legislative environments affecting expansion, including identifying state-by-state requirements of the boards of nursing and pharmacies.

Date First Implemented

2004

Problem Addressed

To obtain hormonal birth control, women historically had to undergo a pelvic examination and Pap test at a doctor's office and obtain the prescribed birth control at a drug store. As a result, access to safe and reliable hormonal birth control has not been user-friendly for women who are anxious about a pelvic examination, live in rural areas, or lack transportation to health care providers and pharmacies. However, today's low-dose hormonal birth control methods do not require a pelvic examination or cervical and breast cancer screening before administration.

  • Approximately 21 percent of Oregon's population lives in rural, conservative communities, separated by hundreds of miles, often barricaded by coastal or inland mountainous passes that are inaccessible in winter.
  • The previously required gynecological examinations and Pap smears require burdensome visits to a clinic and drug store. The need for such examinations may reduce access to highly effective contraceptive methods and may therefore increase women's overall health risks.
  • Medical research affirms that women can adequately screen themselves for contraindications, manage side effects, and determine an appropriate initiation date, leaving little need for routine direct physician involvement.1
  • The in-office medical examination requirements unwittingly reinforce the widely held but incorrect perception that hormonal contraceptive methods are dangerous. Some women may also be reluctant to raise the issue of birth control with physicians who may not personally approve of its use.

Description of the Innovative Activity

Planned Parenthood of the Columbia/Willamette, which serves Oregon and southwest Washington, made access to low-dose hormonal birth control available online to any woman in Oregon and Washington with a credit card and access to the Internet by providing the service through a call center based in Portland. Through the program, called “Instant Birth Control,” patients requested birth control pills, transdermal patches, or vaginal rings through an online application, and then received a phone call from a Planned Parenthood registered nurse. Patients then had various options for receiving their prescriptions, including having it mailed to their home. Key elements of the program are outlined below:

  • Online application and education: The online application interface replicated what the patient's experience would be in a doctor's office. The patient completed a patient intake and medical history form that is similar to that found in a health center, then read about and selected a method of hormonal contraception.
  • Online payment: Patients had to have the resources to pay for the medication upfront by credit card. The annual costs for a year of birth control are $395 for birth control pills, $655 for transdermal patches, and $525 for vaginal rings. The program was not covered by the state Medicaid programs in Washington or Oregon. Patients could be reimbursed by private insurers if their health insurance covered the service. The organization purchased the birth control methods from pharmaceutical companies and then sold them to patients at a marginal profit.
  • Registered nurse review and followup: A registered nurse or nurse practitioner reviewed the patient's health history and followed up by phone with additional medical questions. The nurse reviewed the contraceptive information as well as other visit components.
  • Distribution of prescription: Once the patient was in contact with clinic nurses, the organization authorized the distribution of 2 months of medication, with the method of delivery left up to the patient. About half of all patients choose to have the medications mailed to them, one-fourth pick up the medication at one of 60 Planned Parenthood clinics in Washington and Oregon, and the remaining patients use a combination of mail or pickup from a clinic.
  • Followup blood pressure monitoring: The patient had to have her blood pressure measured and the reading verified by a qualified person, such as a clinic or drug store, at any point during her two initial cycles of contraceptive use. The patient could mail or fax the blood pressure report to the organization. If blood pressure was within appropriate limits, up to 11 more cycles of the medication would be prescribed.
  • Marketing the program: From 2006 to 2011, the program was marketed through a partnership with an international ad agency known as Weiden + Kennedy. This firm helped to design a marketing campaign and Web site that targets computer-savvy women. Following the launch of the campaign, Web site visits increased 34 percent, and sales through the site increased 20 percent.

Context of the Innovation

Established 40 years ago, Planned Parenthood of the Columbia/Willamette is the largest single provider of family planning health services in Oregon, serving most of Oregon and two counties in southwest Washington. Each year, more than 45,000 women, men, and teens visit its 11 health centers. Chief Executive Officer David Greenberg and staff collaborated with the heads of four other Washington and Oregon Planned Parenthood affiliates (Planned Parenthood of Western Washington, Central Washington, Mount Baker, and the Inland Northwest) to develop the program, the cornerstone of which was a common web infrastructure located in Portland. The five affiliates created a collaborative business model in which they agreed to share operating expenses and revenues, all of which would increase access of services to rural populations. In 2011 the program ceased operations due to revenue losses.

Results

Planned Parenthood of the Columbia/Willamette's Instant Birth Control pilot program increased access to hormonal birth control for Washington and Oregon women, providing easy access to women with busy work or family schedules or other challenges (e.g., lack of transportation, fear of pelvic examinations, reluctance to raise the issue with a physician) that make coming in for a visit and/or picking up a prescription difficult. The program has also served as an impetus for women to begin receiving regular women's health examinations and screenings. The program has not been as successful, however, in targeting low-income women (because the service is not covered by Medicaid) or those in rural areas, despite initial thinking that women in rural areas would be attracted to the service.

  • Enhanced access to birth control:
    • During the 6 years of program operation, 2,363 Oregon and Washington women used the program, representing 0.8 percent of all Oregon and Washington women between the ages of 13 and 44 who use the birth control pill or patch as their primary form of contraception. Use had increased significantly, with 1,141 patients using it in the year ending June 2007, up from 655 patients who used it in the year ending June 2005.
    • Most patients (75 percent) are between the ages of 20 and 29, with 7 percent being younger than 20.
    • Nearly two in three users (64 percent) had not used the organization's services previously.
    • The program appealed to a more affluent and better educated population than that of the typical program. For example, 70 percent of online patients have an income above the poverty level, compared with just 36 percent of users of other services. Nearly half (47 percent) of online users have a college degree, compared with just 18 percent of other users. In addition, 14 percent of online users are married, compared with just 9 percent of other users.
    • The Instant Birth Control program did not serve significant numbers of rural women in Washington and Oregon according to early assessments of patient zip codes, as the majority of patients came from urban centers in both states. This was counter to initial expectations for the program.
  • Impetus for changing regulations to enhance access to services: The Instant Birth Control program was the impetus behind changing regulations in Oregon and Washington that prevented online health care service delivery. This not only benefited women seeking convenient access to contraception, but it also paved the way for providers who wanted to offer other health care services online in the future.
  • Impetus for regular wellness examinations: Approximately 25 percent of women who came to Planned Parenthood clinics to pick up their prescriptions for birth control later scheduled an annual examination at Planned Parenthood because they learned the service is available and/or they may be eligible for funding. In other words, the online program helped to ease these women into an ongoing relationship with a health care provider.
  • Efficiencies that increase the program's ability to reach women: Economies of scale, including consolidated screening, drug purchasing, and sales operations across Planned Parenthood affiliates, allowed the program to reach and serve more women.

Evidence Rating

Suggestive: The evidence consists primarily of data on use of the service by individuals. Although the program has likely increased access to individuals who otherwise would not have obtained birth control, there is no way to know for sure if these individuals would have accessed birth control in the absence of the program.

Planning and Development Process

Key steps in the planning and development process are described below:

  • Negotiating for regulatory approval: In November 2002, the organization established its Online Health Center with the launch of a Nurse Advice Line. In 2003, a decision was made to expand the organization's online offerings to include access to contraception. That same year, the organization's staff and an attorney (who donated services) began negotiating with Oregon's and Washington's boards of pharmacy and nursing for permission to screen patients and prescribe hormonal birth control through the Internet. In both states, the boards of nursing already allowed nurse practitioners to write prescriptions without face-to-face visits. (In contrast, physicians in both states are barred from writing prescriptions unless they have face-to-face visits with patients.) Obtaining approval from the state boards required negotiations about what constituted compliance with existing regulations, rather than an outright rule change. Ultimately, each licensing body approved the program, which enjoyed strong political support in both states. The online practice has withstood one challenge filed by a pharmacist and heard by Oregon's Board of Pharmacy.
  • Negotiations with affiliates: The organization negotiated with four other Planned Parenthood affiliates to offer the service to women in both states from one center. This partnership represents a unique collaboration crossing geographic boundaries. The five affiliates shared operating expenses and revenue, thus reducing duplication of health care and support services and, where appropriate, taking advantage of economies of scale.

Resources Used and Skills Needed

  • Planning and development stage: Much of the upfront planning and development was achieved through the work of existing organization's staff and donated time from an attorney, who drafted the pilot program and negotiated with state boards to start the program. Initial Web development and marketing services were donated as well.
  • Operational staff: Planned Parenthood registered nurses, operating under standing orders of nurse practitioners, review the patients' medical histories and prescribe the medications. Nurse practitioners conduct chart reviews of every patient treated by the registered nurses. During its first 2 years of operation, the Instant Birth Control program was able to rely on existing nursing and administrative staff to fulfill these functions. By 2006, the program became self-sustaining, with revenues from the sales of prescriptions exceeding program expenses (personnel and contraceptive supplies) by roughly $54,000. This surplus helped to fund the hiring of additional nurses, administrative staff, and a Web developer.

Funding Sources

As noted previously, initial planning and development for the program came from existing organization staff and donated time from an attorney, a public relations firm, and others. By 2006, the program generated a surplus each year, which was used by the organization to provide other reproductive and sexual health care services to low-income and uninsured women, men, and teens.

Additional funds are needed, however, to cover capital expenditures (including new software to upgrade the program's Web site), marketing initiatives, and technical/programming services to expand the program beyond its current market. Because these funds are not available, the program is no longer being offered.

Tools and Resources

Instant Birth Control Web site: http://www.instantbirthcontrol.com

Getting Started with This Innovation

  • Generate regional and statewide political support for the program: This program requires changes in regulations and licensing to allow for the online prescribing of birth control. Negotiations with state nursing and pharmacy licensing boards are necessary. Partnerships with Planned Parenthood Federation of America and regional Planned Parenthood affiliates may be helpful in pursuing these negotiations, depending on the scope of the service.
  • Tap into Planned Parenthood Federation of America resources: Planned Parenthood Federation of America is committed to making online access to birth control available to women all over the nation through a common, national online health center. Many affiliates have already expressed an interest in making the program available to women in their areas, and the group is exploring business models for federation-wide partnerships.
  • Use a common Internet infrastructure to facilitate collaboration: A common infrastructure housed in one location allows for collaboration that crosses geographic boundaries.

Sustaining This Innovation

  • Make the interface as user-friendly as possible: Women will be more likely to use the service if the system works in an intuitive, familiar manner.
  • Develop marketing campaigns to reach target audiences: The campaign developed by the public relations firm was successful in reaching urban, computer-savvy women. The challenge going forward will be to develop a similar type of campaign to reach the target audience of rural, low-income women.

Use By Other Organizations

Delivery of online reproductive health care services is a highly effective way to deliver hormonal birth control to women who have access to the Internet, and it represents an entirely new model of health care service delivery that can be potentially be used by other organizations and for other services. Some organizations are already replicating various aspects of the program. For example:

  • The organization's partnership with four Washington affiliates is being replicated by other affiliates around the nation to reduce duplication of health care and/or support services and to take advantage of economies of scale.
  • They are in conversation with several other states with favorable regulatory environments for adoption of the Instant Birth Control program. Planned Parenthood Federation of America will be conducting a national analysis of regulatory and legislative environments affecting expansion, including identifying state-by-state requirements of the boards of nursing and pharmacies.
 

References/Related Articles

Grossman D, Ellertson C, Abuabar K, et al. Barriers to contraceptive use in product labeling and practice guidelines. Am J Public Health. 2006;96(5):791-799. [PubMed] Available at: http://www.ajph.org/cgi/content/abstract/96/5/791.

Planned Parenthood's Instant Birth Control Web site. Available at: http://www.instantbirthcontrol.com.

Scott A, Glasier AF. Are routine breast and pelvic examinations necessary for women starting combined oral contraception? Hum Reprod Update. 2004;10(5):449-52. Epub 2004 Jun 10. [PubMed] Available at: http://humupd.oxfordjournals.org/cgi/content/abstract/10/5/449.

Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs. evidence. JAMA. 2001;285(17):2232-2239. [PubMed] Available at: http://jama.jamanetwork.com/article.aspx?articleid=193803.

Footnotes

  1. Scott A, Glasier AF. Are routine breast and pelvic examinations necessary for women starting combined oral contraception? Hum Reprod Update. 2004;10(5):449-52. Epub 2004 Jun 10. [PubMed]

Funding Sources

Planned Parenthood of the Columbia/Willamette

Developers

Planned Parenthood of the Columbia/Willamette

Comments

By kristinf on
Hormonal Contraceptives available over the counter are way over due for this country. Not only does the availability to obtain BC over the counter alleviate some the unnecessary barriers women face from our current health care system, but it also allows for a more level ethical ground for society at large. HC OTC is a benefit to every member of this society, and should have been implemented long ago.

By sarautz on
While this innovation addressed with some success barriers to access hormonal birth control, computer access was required and participants had to review eligibility for the program with an R.N on the phone. Oral contraceptives are safe, effective, and women are capable of self screening for contraindications. Oral contraceptives should be available over the counter, as ACOG recommends. There remains great benefit, however, to contraception options counseling as long acting reversible contraception methods (IUDs and implants), which are inserted in a medical setting, are superior in efficacy than pills, ring, or patch.

By Marissa Patterson on
As a family nurse practitioner student with an interest in improving birth control access, I am impressed by this innovation. It helps to remove barriers to care in terms of finance, transportation, and time for the patient as well as frees up clinical staff for other needs. Additionally, it involves the patient in shared decision making and makes her an active role in her own reproductive health. I hope that similar innovations can be implemented in the future.

By mbryman on
Making contraceptive pills available without a prescription is an important public health measure which is long overdue for implementation in the United States. Planned Parenthood should be commended for being a leader in evidence-based reproductive health care.

By Sarah Gilbert on
ACOG's recent committee opinion recommending over-the-counter access to oral contraceptives and the insurance coverage mandated by the ACA will hopefully move our country toward reducing unnecessary barriers to accessing contraception, but this innovation is another avenue worth pursuing. The more ways that women can access birth control, the more likely we are to decrease the unintended pregnancy rate in this country.
Original Publication: 04/14/08

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 11/07/12

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 11/23/11

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