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Challenges accessing contraceptive care and interest in over-the-counter oral contraceptive pill use among Black, Indigenous, and people of color: An online cross-sectional survey

Open AccessPublished:January 11, 2023DOI:https://doi.org/10.1016/j.contraception.2023.109950

      Abstract

      Objective

      To examine challenges accessing contraception in the past year and their association with interest in using an over the counter (OTC) oral contraceptive pill (OCP) among Black, Indigenous, and people of color (BIPOC) in the United States.

      Study Design

      From May 2021 to March 2022, a collaborative research team conducted a cross-sectional online survey using convenience sampling to recruit people who identify as Asian American, Native Hawaiian, or Pacific Islander, Black or African American, Indigenous, or Latina/Latinx and used or wanted to use a contraceptive method in the past year. Respondents were recruited through reproductive justice and community-based organizations.

      Results

      Among 727 respondents, 45% reported experiencing at least one challenge accessing contraception in the past year of which 37% reported a logistical challenge, and 20% reported an interpersonal challenge. Sixty-seven percent of respondents said they were likely to use an OTC OCP. Respondents who reported experiencing at least one challenge accessing contraception in the past year were more likely to say they would use an OTC OCP. Fifty-seven percent of respondents who were not using a contraceptive method in the past year reported they were likely to use an OTC OCP.

      Conclusion

      Among people in this study, interest in an OTC OCP is high, particularly among those who have faced challenges accessing contraception, and among those who are not currently using a contraceptive method.

      Implications

      Availability of an OCP OTC has the potential to address challenges accessing contraceptive care among BIPOC in the United States, who are often impacted by structural inequities and racism. Findings from this study can inform future OTC implementation strategies to ensure OTC access addresses logistical and interpersonal challenges.

      Keywords

      1. Introduction

      Access to contraception is a critical component to ensuring all people have autonomy over their lives and bodies, yet barriers to accessing contraception exist. The inability to pay for a contraceptive method, the prescription requirement, inability to take time off work or school, difficulty traveling to clinics or pharmacies, and lack of clinics offering the full range of contraceptive options have all been identified as obstacles to accessing contraception in the United States [
      • Grindlay K
      • Grossman D.
      Prescription birth control access among U.S. women at risk of unintended pregnancy.
      ,
      • Kreitzer RJ
      • Smith CW
      • Kane KA
      • Saunders TM.
      Affordable but Inaccessible? Contraception deserts in the US States.
      ,
      • Dehlendorf C
      • Rodriguez MI
      • Levy K
      • Borrero S
      • Steinauer J.
      Disparities in family planning.
      ,
      • Sutton MY
      • Anachebe NF
      • Lee R
      • Skanes H.
      Racial and ethnic disparities in reproductive health services and outcomes, 2020.
      ,
      • Baum S
      • Burns B
      • Davis L
      • Yeung M
      • Scott C
      • Grindlay K
      • et al.
      Perspectives among a diverse sample of women on the possibility of obtaining oral contraceptives over the counter: a qualitative study.
      ,
      • Dennis A
      • Grossman D.
      Barriers to contraception and interest in over-the-counter access among low-income women: a qualitative study.
      ].
      These barriers are often exacerbated or intensified for Black, Indigenous, and people of color (BIPOC) in part due to systemic racism and oppression, contributing to racial and ethnic disparities in contraceptive care [

      National Asian Pacific American Women's Forum. Still fierce, still fighting a reproductive justice agenda for Asian Americans and Pacific Islanders 2017. https://www.napawf.org/our-work/content/still-fierce-still-fighting (accessed October 12, 2022).

      ,

      Black women, reproductive justice, and environmental justice 2020. http://blackrj.org/wp-content/uploads/2020/04/6217-IOOV_EnviroJustice.pdf (accessed October 12, 2022).

      , ,
      • Roberts D.
      Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. reprint.
      ,

      Native American Women's Health Education Resource Center. Native American women and the need for over-the-counter access to birth control pills. 2019.

      ]. Due to higher rates of unemployment, lower incomes, as well as, immigration statuses and policies, BIPOC are also more likely to be uninsured compared to their white counterparts [

      National Asian Pacific American Women's Forum. Still fierce, still fighting a reproductive justice agenda for Asian Americans and Pacific Islanders 2017. https://www.napawf.org/our-work/content/still-fierce-still-fighting (accessed October 12, 2022).

      ,

      Poverty Facts n.d. https://www.povertyusa.org/facts (accessed October 11, 2022).

      ] and while the Affordable Care Act has expanded insurance coverage of contraceptive care, the cost of contraceptive visits and methods continue to impede access to contraception [
      • Burke KL
      • Potter JE
      • White K.
      Unsatisfied contraceptive preferences due to cost among women in the United States.
      ] due to existing racial economic disparities in the United States [

      Racial differences in economic security: the racial wealth gap | U.S. Department of the Treasury n.d. https://home.treasury.gov/news/featured-stories/racial-differences-economic-security-racial-wealth-gap (accessed October 13, 2022).

      ]. A history of racism and historical injustice, including unethical experimental studies testing oral contraceptive pills (OCPs) on Puerto Ricans, reproductive coercion, and forced sterilization of BIPOC individuals [

      Black women, reproductive justice, and environmental justice 2020. http://blackrj.org/wp-content/uploads/2020/04/6217-IOOV_EnviroJustice.pdf (accessed October 12, 2022).

      ,

      Native American Women's Health Education Resource Center. Native American women and the need for over-the-counter access to birth control pills. 2019.

      ,

      Reproductive Coercion and Sterilization Abuse | National Women's Health Network n.d. https://nwhn.org/reproductive-coercion-and-sterilization-abuse/ (accessed October 12, 2022).

      ,

      The Bitter Pill: Harvard and the Dark History of Birth Control | Magazine | The Harvard Crimson n.d. https://www.thecrimson.com/article/2017/9/28/the-bitter-pill/ (accessed October 12, 2022).

      ] coupled with structural barriers, such as limited methods at clinics and limited locations to access contraception particularly in areas with higher populations of BIPOC [
      • Kreitzer RJ
      • Smith CW
      • Kane KA
      • Saunders TM.
      Affordable but inaccessible? Contraception deserts in the US States.
      ], has led to a decrease in contraceptive choice and autonomy, as well as, a distrust in providers and health institutions [

      Black women, reproductive justice, and environmental justice 2020. http://blackrj.org/wp-content/uploads/2020/04/6217-IOOV_EnviroJustice.pdf (accessed October 12, 2022).

      ,
      • Roberts D.
      Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. reprint.
      ,

      Native American Women's Health Education Resource Center. Native American women and the need for over-the-counter access to birth control pills. 2019.

      ,

      Reproductive Coercion and Sterilization Abuse | National Women's Health Network n.d. https://nwhn.org/reproductive-coercion-and-sterilization-abuse/ (accessed October 12, 2022).

      ,

      The Bitter Pill: Harvard and the Dark History of Birth Control | Magazine | The Harvard Crimson n.d. https://www.thecrimson.com/article/2017/9/28/the-bitter-pill/ (accessed October 12, 2022).

      ]. One study examining contraceptive preferences among women in the United States found that 22% of people at risk of an unwanted pregnancy in the study would prefer to be using a different contraceptive method [

      Frederiksen B, Ranji U, Salganicoff A, Long M. Women's sexual and reproductive health services: key findings from the 2020 KFF women's health survey 2021. https://www.kff.org/womens-health-policy/issue-brief/womens-sexual-and-reproductive-health-services-key-findings-from-the-2020-kff-womens-health-survey/.

      ]. This preference was higher among Black and Hispanic women, as well as those of other minoritized races and ethnicities compared to white women in the study.
      Lower proportions of women of color use contraception generally and OCPs specifically compared to white women [

      Daniels K, Abma JC. Current Contraceptive Status Among Women Aged 15-49: United States, 2017-2019. National Survey of Family Growth 2020. https://www.cdc.gov/nchs/products/index.htm. (accessed October 11, 2022).

      ], which is likely in part influenced by these issues of access and other structural barriers. The prescription requirement can be a barrier to accessing hormonal contraceptive methods [
      • Grindlay K
      • Grossman D.
      Prescription birth control access among U.S. women at risk of unintended pregnancy.
      ], however, there are currently no hormonal contraceptive methods, other than emergency contraception, available over the counter (OTC) in the United States. OCPs are the most common reversible hormonal method in the United States [

      Daniels K, Abma JC. Current Contraceptive Status Among Women Aged 15-49: United States, 2017-2019. National Survey of Family Growth 2020. https://www.cdc.gov/nchs/products/index.htm. (accessed October 11, 2022).

      ] and studies have demonstrated interest in an OTC OCP among women in the United States, which has ranged between 29% of teens to 37 to 39% of adults and has been highest among younger, Spanish speaking, and uninsured adults [
      • Grindlay K
      • Grossman D.
      Interest in over-the-counter access to a progestin-only pill among women in the United States.
      ,
      • Grossman D
      • Grindlay K
      • Li R
      • Potter JE
      • Trussell J
      • Blanchard K.
      Interest in over-the-counter access to oral contraceptives among women in the United States.
      ]. In 2022, a pharmaceutical company submitted an application to the Food and Drug Administration for the first OTC OCP [

      Perrigo's HRA pharma submits application to FDA for first-ever OTC birth control pill n.d. https://www.hra-pharma.com/articles/perrigos-hra-pharma-submits-application-to-fda-for-first-ever-otc-birth-control-pill-66 (accessed July 10, 2022).

      ], which has the potential to increase access and expand use for those interested in using a hormonal contraceptive method, especially for those who face additional barriers to accessing contraception in clinical settings [].
      It is important to examine the relationship between challenges accessing contraception and interest in an OTC OCP among BIPOC to better understand how implementation of OTC OCPs may meet their needs and increase contraceptive access and choice, especially given the historical legacy of contraceptive programs that have sought to control the fertility of BIPOC people [
      • Roberts D.
      Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. reprint.
      ]. Using survey data collected from a larger community-engaged research project, this paper examines how challenges in accessing contraception intersect with interest in using an OTC OCP among a sample of people who identified as Asian American, Native Hawaiian, or Pacific Islander, Black or African American, Indigenous, or Latina/Latinx in the United States. We hypothesized that those who experienced challenges accessing contraception in the past year would be more interested in using an OTC OCP than people who had not experienced recent challenges accessing contraception.

      2. Methods

      We conducted a cross-sectional survey with BIPOC people, specifically those who identified with at least one of the following racial or ethnic groups: Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American, Indigenous, and Latina/Latinx. The study was designed and implemented by a collaborative research team (CRT) consisting of six organizations with research and advocacy expertise, five of which are led by and represent communities included in this study. We designed recruitment to be completed by community-based organizations and therefore did not aim for our sample to be representative of these groups across the country. Eleven community-based organizations participated in recruitment using online invitations and some in-person targeted outreach. Recruitment was focused in, but not limited to, California, Georgia, Illinois, and New Mexico due to the location of the community-based organizations.
      People were eligible to participate in the study if they lived in the United States; were aged 13 to 50; identified as American Indian or Alaskan Native, Asian, Black or African American, Hispanic, Latina, Latinx, or Spanish origin (referred to throughout as “Latina/Latinx”), and/or Native Hawaiian or Pacific Islander; identified as a woman, transgender, or non-binary, regardless of sex assigned at birth
      Eligibility criteria for gender was determined based on likelihood to interface with the healthcare system for contraception or to face challenges or stigma obtaining a method. Based on our criteria, cis-gender men were not eligible to participate.
      ; had used or wanted to use a contraceptive method for any reason in the past year; and had a functioning email address. We offered the survey in four languages chosen by the CRT to ensure participation in regions they serve: English, Spanish, Vietnamese, and Urdu. Using convenience sampling, participating organizations and 2 data collectors recruited respondents between May 2021 and March 2022. Due to a high volume of fraudulent surveys and online bots, we developed a multi-step process to review each survey (Appendix A).
      We followed The Checklist for Reporting Results of Internet Surveys (CHERRIES) framework [
      • Eysenbach G.
      Improving the Quality of Web Surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES).
      ] (Appendix B). This study was approved by the Allendale Investigational Review Board.

      2.1 Measures

      To document challenges accessing contraception, respondents who had used a method of contraception in the past year selected challenges they had faced accessing contraception in the past year and those who had not used a method of contraception in the past year reported reasons why. Response options were presented in a similar pre-populated list of possible challenges, which we used to create variables indicating whether the participant had faced any access challenges and the types of challenges faced including, logistical challenges, such as those related to cost and transportation and interpersonal challenges, including those related to privacy and interactions with people within and outside the healthcare system (See Table 2 for lists of specific challenges in each category). Open ended “other” responses were reviewed and coded into the appropriate type of challenge where applicable.
      We documented likelihood to use an OTC OCP if it were available based on a survey item that included an OTC OCP description and then asked how likely respondents would be to buy and use it if it were available (Appendix C). We considered respondents likely to use an OTC OCP if they selected somewhat likely or very likely (versus somewhat unlikely, very unlikely, or not sure). Respondents who indicated they were likely to use an OTC OCP selected situations or for what reasons they would consider purchasing an OTC OCP. We asked those who were not likely to use an OTC OCP why they would not buy or use an OTC OCP.
      We included measures of respondent race/ethnicity, age, education, insurance status, nativity, employment status, student status, gender identity, interest in using a contraceptive method the respondent was not currently using, contraceptive method use in the past year, as well as whether the respondent had ever given birth. Respondents selected their race/ethnicity from the following options: American Indian or Alaskan Native; Asian; Black or African American; Latina/Latinx; Native Hawaiian, or Other Pacific Islander (combined with Asian to create AANHPI variable in analysis); white
      Given the eligibility criteria, all respondents who selected “white” also selected another provided race/ethnicity option. Respondents who exclusively identified as white were not eligible to participate in the study.
      ; and another race, ethnicity, or origin (please specify). Respondents could select more than one response option.
      Respondents reported all contraceptive methods they had used in the past year (Appendix D), which we categorized for analysis (Appendix E).

      2.2 Analysis

      We conducted univariate and bivariate descriptive analyses to describe interest in OTC OCP use and challenges faced in accessing contraception in the past year. We conducted χ2 tests of independence and Fisher's exact tests to test the associations between demographic variables and both experience of at least one challenge accessing contraception as well as likelihood of OTC OCP use. Statistical tests assumed a significant relationship between variables at p < 0.05. We excluded missing data and “prefer not to answer” responses from tables and analyses as no variable had greater than 10 (1%) missing values.
      We examined whether challenges experienced accessing contraceptive methods were associated with likelihood of OTC OCP use using a multivariable logistic model to control for potential factors that might jointly influence challenges to accessing contraception and interest in OTC OCP use. We controlled for the sample characteristics, except gender identity and interest in using a contraceptive method the respondent was not currently using, as well as a subset of contraceptive methods in the past year (OCP use and any method in the past year), included in Table 1. All variables were binary except age, which was measured and analyzed continuously, and insurance status, which was analyzed as a categorical variable. Racial ethnic groups were not mutually exclusive, so that anyone who identified as multiracial or mixed race were included in more than one category. Due to our analysis aims and the limited data available to interpret and contextualize any differences, the CRT decided to examine our outcomes among the entire sample and not explore differences between racial/ethnic groups.
      Table 1Sample characteristics among respondents in the United States from May 2021 to March 2022
      Full sample (N=727)% who experienced at least one challenge accessing contraception^,§ (N=715)p-value% likely to use an OTC OCP*,^,§ (N=722)p-value
      n (%)n (%)n (%)
      Total727 (100)321 (45)-485 (67)-
      Race/ethnicity⁎⁎
      American Indian or Alaskan Native92 (13)43 (48)0.5662 (68)0.84
      Asian American, Native Hawaiian, and/or Pacific Islander208 (29)107 (52)0.02146 (70)0.27
      Black or African American245 (34)98 (41)0.14143 (59)0.001
      Hispanic, Latina, Latinx, or Spanish origin228 (31)96 (43)0.42165 (73)0.03
      White/other^^70 (10)34 (49)0.5248 (70)0.66
      Age (years)<0.0010.004
      Under 1813 (2)7 (58)10 (77)
      18-24326 (45)175 (54)238 (74)
      25-34300 (41)115 (39)189 (63)
      35-4468 (9)20 (30)38 (56)
      Over 4520 (3)4 (20)10 (50)
      Education0.0010.24
      Incomplete high school16 (2)8 (57)11 (69)
      High school graduate250 (34)126 (52)172 (69)
      College graduate340 (47)152 (45)232 (69)
      Professional or advanced degree118 (16)34 (29)68 (58)
      Insurance status0.0050.78
      Private453 (63)75 (51)309 (68)
      Public150 (21)182 (40)100 (67)
      None116 (16)61 (56)74 (65)
      Born in United States0.700.41
      Yes580 (80)253 (44)382 (66)
      No144 (20)65 (46)100 (70)
      Working0.030.96
      Yes508 (70)212 (42)339 (67)
      No216 (30)109 (51)145 (67)
      Student0.0010.003
      Yes329 (45)168 (52)239 (73)
      No395 (55)153 (39)245 (63)
      Gender identity⁎⁎0.930.15
      Ciswoman or woman685 (94)302 (45)463 (68)
      Gender expansive23 (3)11 (48)13 (57)
      Selected more than one19 (3)8 (42)9 (50)
      Ever given birth0.0010.001
      Yes160 (22)53 (34)90 (56)
      No566 (78)268 (48)395 (70)
      Method of contraception in the past year**,††
      Oral contraceptive pills307 (42)149 (49)0.07234 (77)<0.001
      Prescription-based methods275 (38)107 (39)0.04169 (62)0.04
      Non-prescription based methods407 (56)204 (51)<0.001279 (69)0.17
      Permanent method14 (2)3 (21)0.087 (50)0.25
      No method in past 12 months73 (10)40 (57)0.0352 (71)0.44
      Want to use method other than one currently using<0.001<0.001
      Yes266 (37)152 (58)207 (78)
      No455 (63)165 (37)276 (61)
      *Respondents were considered likely to use an OTC OCP if they reported being very likely or somewhat likely (vs. somewhat unlikely, very unlikely, not sure) Respondents who selected "Prefer not to answer" were considered missing.
      ^Columns may not sum to 100 as missing values were not reported. No variable had more than 10 (1%) missing values.
      By Chi-square and Fisher's Exact Tests, which excluded ``Missing'' and ``Prefer not to answer''. Bolded p-values indicate significance of p<0.05.
      §Row percentages.
      ⁎⁎Respondents could select more than one response option.
      ^^Eleven respondents who wrote in “another race or ethnicity” were reviewed and coded into racial ethnic groups as appropriate. Six respondents who wrote in “Middle Eastern” and “Palestinian” were included in the white/other group with people who selected “white”.
      ††Methods included in each group: prescription-based methods including copper intrauterine device (IUD), hormonal IUD, implant, patch, ring, shots or injections, and female/internal condoms

      Kempner M. Female condoms, used by women and men for HIV prevention, will now be prescription only 2017. https://www.thebody.com/content/80020/female-condoms-used-by-women-and-men-for-hiv-preve.html (accessed May 23, 2022).

      non-prescription based methods, including male/ external condoms, withdrawal, fertility awareness methods, and emergency contraception (although we recognize that some emergency contraception is prescription based); and permanent methods including tubal ligation and partner's vasectomy.
      Table 2Types of challenges experienced in the past year when accessing contraception, by interest in use of an over-the-counter (OTC) oral contraceptive pill (OCP)
      Respondents who did not answer any challenge-related questions were considered missing and not reported.
      More than one response possible.
      among respondents in the United States from May 2021 to March 2022
      Total% likely to use an OTC OCP
      Respondents were considered likely to use an OTC OCP if they reported being very likely or somewhat likely (vs somewhat unlikely, very unlikely, not sure). Respondents who selected “Prefer not to answer” were considered missing and not reported.
      Row percentages.
      (N = 711)
      p-value
      By Chi-square and Fisher's Exact Tests, which excluded “Missing” and “Prefer not to answer” to test relationship between experiencing any logistical challenge (yes/no) or interpersonal challenge (yes/no) and interest in an OTC OCP. Bolded p-values indicate significance of p < 0.05.
      n (%)n (%)
      Total715 (100)476 (67)
      Experienced a challenge accessing a contraceptive method in the past year321 (45)240 (76)<0.001
      No challenge accessing contraception394 (55)236 (60)
      Challenge related to logistics261 (37)192 (74)0.002
      Challenges making an appointment (limited time slots, inconvenient times)125 (18)95 (76)
      Too expensive and/or don't have insurance100 (14)77 (77)
      Don't have a regular doctor or clinic91 (13)73 (81)
      Challenges with transportation or getting to an appointment66 (9)56 (86)
      Other logistics-related challenges
      Recoded from “Other (please specify)” response option.
      9 (1)7 (78)
      Citizenship or documentation status
      We recognize that “Citizenship or documentation status” could also be categorized as a challenge related to interpersonal experience, but based on open text responses for these respondents, we categorized this response option as a challenge related to logistics.
      2 (0)1 (50)
      Challenge related to interpersonal experiences140 (20)111 (81)<0.001
      Feared being judged65 (9)48 (75)
      Privacy concerns47 (6)38 (82)
      Treated unfairly by a staff person at the doctor's office, clinic or pharm28 (4)20 (77)
      Did not feel comfortable or safe getting my method27 (4)23 (89)
      Partner won't let me or doesn't want me to12 (2)11 (92)
      Unable able to use my preferred language when talking to a provider3 (0)3 (100)
      Other interpersonal related challenges
      Recoded from “Other (please specify)” response option.
      3 (0)3 (100)
      Other18 (3)15 (83)-
      low asterisk Respondents were considered likely to use an OTC OCP if they reported being very likely or somewhat likely (vs somewhat unlikely, very unlikely, not sure). Respondents who selected “Prefer not to answer” were considered missing and not reported.
      ^ Respondents who did not answer any challenge-related questions were considered missing and not reported.
      By Chi-square and Fisher's Exact Tests, which excluded “Missing” and “Prefer not to answer” to test relationship between experiencing any logistical challenge (yes/no) or interpersonal challenge (yes/no) and interest in an OTC OCP. Bolded p-values indicate significance of p < 0.05.
      § Row percentages.
      †† More than one response possible.
      low asterisklow asterisk Recoded from “Other (please specify)” response option.
      ^^ We recognize that “Citizenship or documentation status” could also be categorized as a challenge related to interpersonal experience, but based on open text responses for these respondents, we categorized this response option as a challenge related to logistics.
      We conducted data analyses using Stata version 15 SE.

      3. Results

      In total, we received 24,086 completed screening forms, of which 13,499 were eligible based on their responses to the screening form, and 12,772 completed the full survey. After removing fraudulent responses through a multi-step review process (Appendix A), our final sample included 727 people (Fig. 1).
      Figure 1
      Figure 1Study sample and removal of fraudulent responses among Qualtrics respondents from May 2021 to March 2022.
      A majority of respondents (86%) were between the ages of 18 to 34 with an average age of 26.5 years (Table 1). Thirty-four percent of respondents identified as Black or African American, 31% identified as Latina/Latinx, 29% identified as AANHPI, and 13% identified as American Indian or Alaskan Native. Fourteen percent of respondents selected more than one race/ethnicity.

      3.1 Challenges accessing contraceptive methods in the past year

      Forty-five percent of respondents reported they had experienced at least one challenge accessing contraception in the past year. Respondents who identified as AANHPI, younger respondents, those with lower levels of education, those with no insurance, respondents not working, students, and those who had never given birth were more likely to have experienced a challenge accessing contraception (Table 1). Fifty-seven percent of those who had not used a method in the past year reported challenges accessing a method, compared to 44% who had used a method in the past year.

      3.2 Likelihood of OTC OCP use

      Overall, 67% of respondents were likely to use an OTC OCP (36% were very likely and 31% somewhat likely to use). In bivariate analyses, respondents who were Latina/Latinx, younger, students, and had never given birth were more likely to indicate they would use an OTC OCP. Respondents who had used OCPs and those who indicated there was a contraceptive method they would like to use but were not currently using were also more likely to report they would use an OTC OCP (Table 1). Respondents who identified as Black or African American and those who had used non-OCP prescription-based methods in the past year were less likely to indicate they would use an OTC OCP. Most frequently, respondents reported wanting to use an OTC OCP to save time and not have to visit a doctor or nurse (65%) (Table 3). The main reasons respondents would not use an OTC OCP were that they were not interested in any kind of OCP (46%) and wanted a clinician to make sure an OCP was right for them (45%) (Table 3).
      Table 3Reasons why respondents would and would not consider using an over-the-counter (OTC) oral contraceptive pill (OCP)
      Respondents were considered likely to use an OTC OCP if they reported being very likely or somewhat likely (vs. somewhat unlikely, very unlikely, not sure). Respondents who selected "Prefer not to answer" were considered missing and not reported.
      among all respondents in the United States from May 2021 to March 2022
      Total
      n (%)
      Reasons would consider using an OTC OCP (among those likely to use an OTC OCP (n = 485))
      More than one response possible.
      To save time to not have to visit a doctor or nurse316 (65)
      I could easily and quickly start a pill when I need it309 (64)
      When I run out of my birth control method264 (54)
      To save money to not have to visit a doctor or nurse257 (53)
      I could send someone else to get my birth control method when I needed it181 (37)
      I wouldn't need to get a physical or pelvic exam156 (32)
      I could get it without telling my parents120 (25)
      I could get it without telling my partner40 (8)
      Other3 (1)
      Reasons would not consider using an OTC OCP (among those unlikely to use an OTC OCP (n = 237))
      More than one response possible.
      I am not interested in any kind of OCP84 (46)
      I would want a doctor or nurse to make sure the pill is right for me83 (45)
      I am satisfied with what I am using now62 (34)
      I need more information39 (21)
      Insurance might not cover the OTC pills35 (19)
      The cost of this OTC pill may be higher than the prescription-only pill24 (13)
      I might not use the pill correctly if I don't talk to a doctor or nurse23 (13)
      Other2 (1)
      a Respondents were considered likely to use an OTC OCP if they reported being very likely or somewhat likely (vs. somewhat unlikely, very unlikely, not sure). Respondents who selected "Prefer not to answer" were considered missing and not reported.
      b More than one response possible.
      Experiencing at least one challenge accessing contraception in the past year was associated with higher likelihood of OTC OCP use. In the multivariable model, experiencing at least one challenge accessing a method in the past year was associated with 69% higher odds of interest in OTC OCP use (OR: 1.69, 95% CI: 1.19–2.40; Table 4).
      Table 4Association between experiencing challenges accessing contraception and interest in over-the-counter (OTC) oral contraceptive pill (OCP) use among respondents in the United States from May 2021 to March 2022 (n = 698)
      Results from a multivariable logistic regression controlling for age, student status, working full or part time, ever given birth, born in United States., identified as Black or African American, identified as Latina/Latinx, identified as American Indian or Alaskan Native, identified as AANHPI, identified as white/other, use of contraceptive method in past year, use of OCPs in past year, and insurance status. * p < 0.05, ** p < 0.01 ***p < 0.001.
      aOR (95% CI)
      Experienced a challenge accessing a contraceptive method in the past year1.69** (1.19–2.40)
      Age (continuous)0.97 (0.94–1.01)
      Student1.35 (0.90–2.04)
      Ever given birth0.83 (0.50–1.36)
      Born in US0.75 (0.47–1.20)
      Race/ethnicity
      American Indian or Alaskan Native1.20 (0.57–2.54)
      Asian American, Native Hawaiian, and/or Pacific Islander0.92 (0.43–1.97)
      Black or African American0.66 (0.32–1.34)
      Hispanic, Latina, Latinx, or Spanish origin1.40 (0.70–2.80)
      White/other0.92 (0.51–1.65)
      Contraceptive use in past 12 months0.71 (0.39–1.27)
      Used OCPs in past year2.38*** (1.64–3.45)
      Insurance
      Private insurance[Ref]
      Public insurance1.00 (0.65–1.55)
      None0.89 (0.55–1.45)
      Working full or part time1.37 (0.90–2.08)
      Results from a multivariable logistic regression controlling for age, student status, working full or part time, ever given birth, born in United States., identified as Black or African American, identified as Latina/Latinx, identified as American Indian or Alaskan Native, identified as AANHPI, identified as white/other, use of contraceptive method in past year, use of OCPs in past year, and insurance status.* p < 0.05, ** p < 0.01 ***p < 0.001.

      4. Discussion

      Our findings highlight an association between experiencing challenges in accessing contraception and the likelihood of using an OTC OCP among our convenience sample of Black, Indigenous, and people of color recruited by reproductive justice and community-based organizations in the United States. The results support that obtaining OCPs without a prescription may be attractive to people who experience barriers such as getting to a clinic appointment and negative interactions with providers [
      • Dehlendorf C
      • Rodriguez MI
      • Levy K
      • Borrero S
      • Steinauer J.
      Disparities in family planning.
      ,
      • Thompson TAM
      • Young YY
      • Bass TM
      • Baker S
      • Njoku O
      • Norwood J
      • et al.
      Racism runs through it: examining the sexual and reproductive health experience of Black women in the South.
      ]. The needs of these communities should be centered in the implementation of an OTC OCP should it be approved by the FDA and to avoid perpetuating systemic inequities, oppression, and harm emphasized in other previous work [
      • Dehlendorf C
      • Perritt J.
      Statewide contraceptive access initiatives: a critical perspective.
      ,
      • Moniz MH
      • Spector-Bagdady K
      • Perritt JB
      • Heisler M
      • Loder CM
      • Wetmore MK
      • et al.
      Balancing enhanced contraceptive access with risk of reproductive injustice: a United States comparative case study.
      ].
      Close to half of the respondents in this study reported experiencing at least one challenge accessing contraception in the past year. Given the data collection occurred during the COVID-19 pandemic, we can hypothesize that the types and intensity of challenges were impacted by the pandemic [
      • Maier M
      • Samari G
      • Ostrowski J
      • Bencomo C
      • Mcgovern T.
      Scrambling to figure out what to do”: a mixed method analysis of COVID-19’s impact on sexual and reproductive health and rights in the United States.
      ,
      • Kavanaugh ML
      • Pleasure ZH
      • Pliskin E
      • Zolna M
      • MacFarlane K.
      Financial instability and delays in access to sexual and reproductive health care due to COVID-19.
      ], and perhaps somewhat mitigated by telehealth and online service delivery [
      • Lindberg LD
      • Mueller J
      • Haas M
      • Jones RK.
      Telehealth for contraceptive care during the COVID-19 pandemic: results of a 2021 National Survey.
      ]. Research conducted both during and pre-pandemic has demonstrated how access-related challenges reflect the existing and intersecting systems of structural racism, economic injustice, and a history of reproductive coercion that continues to negatively impact the experiences of BIPOC accessing contraception in the United States [
      • Dehlendorf C
      • Rodriguez MI
      • Levy K
      • Borrero S
      • Steinauer J.
      Disparities in family planning.
      ,
      • Sutton MY
      • Anachebe NF
      • Lee R
      • Skanes H.
      Racial and ethnic disparities in reproductive health services and outcomes, 2020.
      ,
      • Roberts D.
      Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. reprint.
      ,
      • Thompson TAM
      • Young YY
      • Bass TM
      • Baker S
      • Njoku O
      • Norwood J
      • et al.
      Racism runs through it: examining the sexual and reproductive health experience of Black women in the South.
      ,
      • Diamond-Smith N
      • Logan R
      • Marshall C
      • Corbetta-Rastelli C
      • Gutierrez S
      • Adler A
      • et al.
      COVID-19’s impact on contraception experiences: exacerbation of structural inequities in women's health.
      ]. For those interested in using a hormonal contraceptive method, the advantages to an OTC OCP, like other OTC methods, are convenience and increased privacy. These factors could help people overcome some access challenges [
      • Baum S
      • Burns B
      • Davis L
      • Yeung M
      • Scott C
      • Grindlay K
      • et al.
      Perspectives among a diverse sample of women on the possibility of obtaining oral contraceptives over the counter: a qualitative study.
      ]. To further address interpersonal challenges raised in this study, all contraceptive services, including OTC provision, should be assessed and improved based on quality and person-centered care measures including respect, confidentiality, lack of judgment, and adequate information, among others [
      • Jain AK
      • Hardee K.
      Revising the FP quality of care framework in the context of rights-based family planning.
      ,
      • Dehlendorf C
      • Henderson JT
      • Vittinghoff E
      • Steinauer J
      • Hessler D.
      Development of a patient-reported measure of the interpersonal quality of family planning care.
      ].
      Our study also helps identify particular groups of people who may be interested in an OTC OCP. Similar to previous research [
      • Grindlay K
      • Grossman D.
      Interest in over-the-counter access to a progestin-only pill among women in the United States.
      ,
      • Grossman D
      • Grindlay K
      • Li R
      • Potter JE
      • Trussell J
      • Blanchard K.
      Interest in over-the-counter access to oral contraceptives among women in the United States.
      ], young people in our study are among groups most interested in using an OTC OCP and among groups most likely to report challenges accessing care. Such findings underscore the need for an OTC OCP to be available without an age restriction and to center young BIPOC in advocacy efforts to implement equitable access without a prescription. Our study also indicates high interest in OTC OCP use among people who identify as Latina/Latinx—corroborating findings in a 2010 study of Latinas in El Paso, Texas [
      • Grossman D
      • Fernández L
      • Hopkins K
      • Amastae J
      • Potter JE.
      Perceptions of the safety of oral contraceptives among a predominantly Latina population in Texas.
      ]. Given interest in an OTC OCP among people in our sample who want to use a contraceptive method but are not currently using a method (71%), an OTC OCP may help meet the needs of people not currently using contraception but who want to be doing so [
      • Grossman D
      • Grindlay K
      • Li R
      • Potter JE
      • Trussell J
      • Blanchard K.
      Interest in over-the-counter access to oral contraceptives among women in the United States.
      ]. Conversely, our results indicate lower interest in OTC OCP use among those who identified as Black or African American in our sample, although additional research is needed to better contextualize this finding. Those who were unlikely to use an OTC OCP commonly said that they would want a clinician to ensure an OCP was right for them, which would still be an option for people regardless of the availability of OCPs OTC. This finding indicates, however, a need for more widespread information about contraindications and potential side effects to help potential users determine if an OCP is right, especially as research has indicated that people, including young people, can accurately self-screen for contraindications to OCP use [
      • Grossman D
      • Fernandez L
      • Hopkins K
      • Amastae J
      • Garcia SG
      • Potter JE.
      Accuracy of self-screening for contraindications to combined oral contraceptive use.
      ,
      • White K
      • Potter JE
      • Hopkins K
      • Fernández L
      • Amastae J
      • Grossman D.
      Contraindications to progestin-only oral contraceptive pills among reproductive-aged women.
      ,
      • Shotorbani S
      • Miller L
      • Blough DK
      • Gardner J.
      Agreement between women's and providers’ assessment of hormonal contraceptive risk factors.
      ].
      This study has several limitations. Given this is a convenience sample with people connected to community-based organizations, it is not generalizable nor representative of racial/ethnic groups across the country. Some experiences may be context specific and may vary by location/region in the United States. Additionally, we lack information on previous contraceptive methods used, beyond those used in the past year. Those who ever used an OCP may have unique perspectives on OTC OCP use that we were not able to capture. While our multivariable analysis controlled for factors we hypothesized could jointly affect challenges in accessing contraception and interest in OTC OCP use, this analysis should not be interpreted causally. Additionally, we experienced a high volume of fraudulent responses to the survey. Multiple studies have had challenges with high volumes of fraudulent activity when using online recruitment methods, but employing rigorous, multistep review systems mitigates the impact on the quality of data [
      • Glazer J.v.
      • MacDonnell K
      • Frederick C
      • Ingersoll K
      • Ritterband LM.
      Liar! Liar! Identifying eligibility fraud by applicants in digital health research.
      ,

      Simone M. How to battle the bots wrecking your online study 2019. https://behavioralscientist.org/how-to-battle-the-bots-wrecking-your-online-study/(accessed December 19, 2022).

      ,
      • Salinas MR.
      Are your participants real? Dealing with Fraud in recruiting older adults online.
      ,
      • Ballard AM
      • Cardwell T
      • Young AM.
      Fraud detection protocol for web-based research among men who have sex with men: development and descriptive evaluation.
      ,
      • Teitcher JEF
      • Bockting WO
      • Bauermeister JA
      • Hoefer CJ
      • Miner MH
      • Klitzman RL.
      Detecting, preventing, and responding to “Fraudsters” in Internet research: ethics and tradeoffs.
      ].
      Interest in potentially using an OTC OCP is high and may address challenges faced by Black, Indigenous, and people of color in accessing hormonal contraceptive methods, particularly OCPs. Future implementation of an OTC OCP should center the perspectives and needs of populations that face inequities due to systemic oppression to ensure implementation overcomes and addresses the challenges identified in this study.

      Disclosures and funding

      Declaration of Competing Interest: Ibis Reproductive Health, where some study authors have an affiliation, has a partnership with HRA Pharma in which Ibis provided financial support for some of the research that will be part of an over-the-counter switch application for the United States Food and Drug Administration for a progestin-only pill. Ibis receives no monetary compensation nor ownership of any rights to the product. Ibis raised the funding for this partnership from a private foundation and selected HRA Pharma as its partner through an open process overseen by the Oral Contraceptives Over-the-Counter Working Group steering committee in an effort to incentivize a pharmaceutical company to complete the work to make a birth control pill available over the counter.
      Funding: This study was supported by Arnold Ventures, the Collaborative for Gender and Reproductive Equity, and the David and Lucile Packard Foundation. These funders had no role in the study's design, analysis or interpretation of the data, or the writing of the manuscript.

      Acknowledgments

      We would like to thank Jasmine Berry for her support in data collection and Kate Grindlay and Victoria Nichols for their review of the manuscript. We would also like to thank all the organizations who supported with recruitment.

      Appendix A. Process for identifying fraudulent responses

      First, we identified entries with duplicate IP addresses and emails. We included the first surveys and removed subsequent surveys with duplicate IP addresses (with the exception of those with university- or school-based email addresses) or emails. Second, we removed all surveys with a location outside the United States. Third, we reviewed open-ended responses and removed all incomprehensible responses or those that appeared copied and pasted from the internet. Fourth, we flagged suspicious open-ended responses and removed surveys that failed any one of the following additional checks: 1) consistency of responses to age-related items on the eligibility form and survey; 2) a “test” question that asked the participant not to select a response; and 3) short surveys which took less than 15 minutes to complete. All open-ended responses were reviewed by two research team members. The research team identified and removed 12,045 fraudulent surveys (Fig. 1).

      Appendix B. CHERRIES framework

      Potential respondents were directed to a study website for additional information about the survey. All interested respondents completed an eligibility screening form. Eligible respondents received a one-time use, personal link to the self-administered survey on Qualtrics, an online survey platform. Research staff were available to answer questions and to support with survey administration in each study language as necessary. Respondents gave written informed consent (adults) or assent (minors) electronically prior to starting the survey. Minors did not need parental consent. Respondents were emailed a $25 gift card after participating. Participant emails were stored separately from survey responses on password-protected devices. Four eligible respondents piloted the survey in each language.
      There were 78 questions in the core survey with an additional 15 questions specific to OCPs for respondents who indicated they had used an OCP in the past year. Respondents saw an average of two questions per screen and surveys had an average of forty-four pages. Respondents could not review or change previous responses in the survey and all respondents received questions in the same order. To prevent multiple submissions from the same respondent, Qualtrics placed cookies on each browser at the start of the survey and the study team reviewed individual responses to identify and remove additional fraudulent responses. Because we recruited online, we have no measure of how many people interacted with or viewed the study invitation, making it impossible to calculate a response rate.
      Surveys took a median duration of 22.5 minutes (IQR 16–34) to complete after removing respondents who took more than one day to complete the survey.

      Appendix C. Survey question to determine likelihood of OTC OCP use

      Right now, you need a prescription to get birth control pills. But it could be possible someday soon for people to get birth control pills “over the counter” without a prescription. With “over-the-counter” (OTC) access, birth control pills would be available on the shelf at a pharmacy or grocery store just like cough medicine or some allergy pills. You would not need a prescription from a doctor or nurse. You would not need to talk to anyone about buying birth control pills (not a doctor, pharmacist, or parent) unless you wanted to.
      Based on the description of an over-the-counter birth control pill, how likely are you to buy and use it if it were available? If you are currently using a different method, think about how likely you would be to buy and use this over-the-counter birth control pill the next time you need to change your method.
      Appendix DContraceptive methods used in the past year
      Total
      n (%)
      727 (100)
      Male condoms or external condoms322 (44.3)
      Oral contraceptive pills307 (42.2)
      Withdrawal (pulling out)219 (30.1)
      Emergency contraception128 (17.6)
      Hormonal IUD (Mirena, Skyla, Liletta, Kyleena)115 (15.8)
      No method in past 12 months73 (10.0)
      Implant (Implanon/Nexplanon)67 (9.2)
      Fertility awareness methods (rhythm method, cycle beads, periodic abstinence)53 (7.3)
      Cooper IUD (Paragard)49 (6.7)
      Shots or injections (Depo-Provera or Depo)31 (4.3)
      Vaginal ring (NuvaRing, Annovera)16 (2.2)
      Female condoms, F2C, internal condoms16 (2.2)
      Patch (OrthoEvra patch, Xulane)12 (1.7)
      Tubal ligation11 (1.5)
      Partner's vasectomy3 (0.4)
      Appendix EContraceptive method categories
      Oral contraceptive Pills
      Given our interest in analyzing interest in an OTC OCP, we kept OCPs as its own category.
      Prescription-based methods

      Hormonal IUD (Mirena, Skyla, Liletta, Kyleena)

      Implant (Implanon/Nexplanon)

      Cooper IUD (Paragard)

      Shots or injections (Depo-Provera or Depo)

      Vaginal ring (NuvaRing, Annovera)

      Female condoms, F2C, internal condoms

      Patch (OrthoEvra patch, Xulane)
      Non-prescription based methods

      Male condoms or external condoms

      Withdrawal (pulling out)

      Emergency contraception
      We recognize that some emergency contraception is prescription-based, however, we categorize emergency contraception as a non-prescription method due to availability of some brands without a prescription. Results hold if emergency contraception is categorized as prescription based.


      Fertility awareness methods (rhythm method, cycle beads,

      periodic abstinence)
      Permanent methods

      Tubal ligation

      Partner's vasectomy
      No method in past 12 months
      We categorized those who had not used a method in the past year and those who had never used a contraceptive method as “No method in the past year”.
      low asterisk Given our interest in analyzing interest in an OTC OCP, we kept OCPs as its own category.
      We categorized those who had not used a method in the past year and those who had never used a contraceptive method as “No method in the past year”.
      1 We recognize that some emergency contraception is prescription-based, however, we categorize emergency contraception as a non-prescription method due to availability of some brands without a prescription. Results hold if emergency contraception is categorized as prescription based.

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