Most of the world doesn’t require a prescription for birth control. Why do Canadians still need one?

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

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

She started taking Yasmine, a common estrogen-based oral contraceptive. At first, getting refills was as easy as visiting her local pharmacy.

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

“I have to keep going back to my doctor and proving I haven’t died on it,” she said. “It’s just a giant time suck.”

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

Outside of Western Europe, Canada, New Zealand, Australia and South Africa, birth control is frequently available prescription-free — even in conservative countries like Saudi Arabia, Turkey or Indonesia.

In the United States, where reproductive rights are often hotly contested, birth control has been available prescription-free since 2023.

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

Common side effects

Since 1960, the majority of oral birth control methods are so-called “combined pills” — combinations of the hormones estrogen and progestin, which prevent the ovaries from releasing eggs.

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

These risks start small, but increase among older women. That’s one reason, doctors say, why ongoing monitoring by medical professionals is often recommended.

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

“There’s no medical system in the world where malpractice would be [seriously] considered … that they will not regulate medications containing estrogen,” said Norman.

Better options available

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

Progestin-only pills — like Opill — work by thickening the mucus in the cervix so that sperm cannot get through to fertilize an egg. Most, but not all, women also stop producing eggs altogether, as with a traditional birth control pill.

Taking these pills requires more discipline: the margin of error for when you take a pill is narrower. But, they are much safer to take without any monitoring from a physician or pharmacist.

“The progestin-only pill has very few contraindications,” said Dr. Amanda Black, president of the Society of Obstetricians and Gynecologists of Canada.

Some of these pills are already available in Canada, and “could probably be offered without a prescription,” said Black. But it’s not quite so simple.

Drug companies must request that their product be made available without a prescription when registering it with Health Canada. So far, no companies have done so — and it doesn’t seem like it’s part of their plan. 

Black named Slynd, a progestin-only pill approved for sale in Canada in 2021, as a great potential candidate for over-the-counter sale, alongside generic variants like Movisse.

But Duschesnay Canada, the developer of Slynd, said they wouldn’t be requesting prescription-free status.

“Our business model is centered on prescription medications,” a spokesperson said via email.

Big barriers for businesses

That may be because of stringent requirements to get a drug approved for prescription-free status.

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

That sounds easy enough — but Black says it can involve expensive requirements for complex medical trials. Data from other countries where similar products are already widely sold is rarely, if ever, accepted.

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

Under such requirements, Black says it’s hard to even find enough willing participants in Canada — much less justify the expense.

“The companies said, we’re not going to do that, because there isn’t the market.”

Patient care, or patriarchy?

Norman, the sexual health researcher, says there are some upsides to keeping birth control prescription-only.

“If you have a medication that is on prescription, then the health system will pay for it,” she said.

Norman played a key role advocating for including free contraception in the national pharmacare plan, which she says will increase access across the country, regardless of income. She says making birth control prescription-free could jeopardize that.

“The health system does not [generally] pay for non-prescription drugs,” she 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 may be doing 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 steep barrier to many women.

One recent study found that when birth control was made available over-the-counter, 31 per cent of nearly 1000 people interviewed across the United States went on it for the first time.

Blanchard says that suggests a prescription requirement prevents nearly a third of women from seeking out the pill. “And that’s even higher when you start talking about folks of colour, Indigenous folks, where the rates can be as high as half, or more than that even,” she said.

In theory, forcing women to see a doctor, or talk to a pharmacist, is to ensure that they are informed about and monitored for possible side effects, and offered alternatives as they age and risks increase.

But Black says that has already been complicated by a doctor shortage that is preventing many Canadians from accessing any continuous care.

“Those things aren’t necessarily happening when you’re seeing someone in a walk-in clinic,” she said.

As for Morris, she says it was never her experience anyway.

Even in recent trips to refill her prescription, she says, she was never informed about increased cancer risks, or offered alternatives to the combined pill.

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

For that reason, Blanchard says it’s time for medical authorities to realize prescription requirements may be outdated — and based in old prejudices about women’s health.

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

“I think what stops our regulatory systems and our health-care systems from taking that evidence as it comes … is patriarchy.”