Monday, October 19, 2009

Birth control pills in Chile

**DISCLAIMER: I am not a medical professional or anything close. The following are my personal opinions and should not be considered medical advice. **

While waiting at the pharmacy counter the other day, I heard the young woman next to me ask for "the cheapest birth control pills you have."

Birth control pills are available without a prescription here in Chile. This means you can simply walk into a pharmacy and ask for the pill you want -- or, in the case of my fellow customer, whichever costs less -- without having to set foot inside a doctor's office.*

I have mixed feelings about this. On the one hand, I believe contraception should be readily available to women and men who wish to use it. Selling birth control pills over the counter makes them more accessible to women without the means or the time to make a doctor's appointment. It also makes them much easier to obtain for girls and women who wish to keep their decision to go on birth control private. On a more symbolic level, there's a lot to be said for being able to take the pill without having to ask anyone's permission first.

On the other hand, I can't help but suspect that this system makes it easy for women and their partners to make important decisions about their reproductive health without being properly informed. At the risk of sounding like the condescending voiceover on a TV commercial, I'd like to remind everyone that every birth control pill is different. Different pills have different doses of hormones, different modes of use and different potiential side effects. A pill that works swimmingly for one woman may be detrimental to the health of another. That's why part of a gynecologist's job is -- or should be, in my opinion -- to help patients choose a birth control method that is right for them.

It strikes me that a woman who asks for "the cheapest birth control pills you have" is very likely not making an informed decision. Of course, she has the right to make a choice based on whatever criteria she wants. Certainly, cost is an important factor for many women, especially given the fact that Chile's public health insurance provider, FONASA, does not cover birth control pills purchased in pharmacies.** Still, I'd be willing to bet there's more than one low(er)-cost pill out there, meaning women and couples on limited budgets still have options to weigh. But it can be difficult to know what your options are when nobody tells you, especially when it comes to a specialized field like medicine.

Of course, one could make the argument that consumers have the responsibility to inform themselves. As long as information is freely and widely available and easy to understand, I would tend to agree. However, I don't think this is the case when it comes to medication. As anyone who's ever glanced at them knows, the informational pamphlets that come with medication aren't exactly easy reading for those of us without medical training. Searching for information on the internet -- which, it should be noted, not everyone is able to do -- presents its own problems. First off all, it can be difficult to separate reliable information from B.S. Plus, when you research a product on its own website, you're getting your information from a company that wants you to buy what it's selling.

This lack of access to reliable information is even more worrying to me when I consider the spotty reputation of sexual education in Chilean schools and the misinformation about reproductive health -- "But virgins can't use tampons!" -- that circulates here and in the world in general.

I'm not saying that selling birth control pills over the counter is necessarily a bad idea. Like I said before, I think it has a number of benefits. What I do think is a bad idea, however, is selling birth control pills over the counter without providing women and their partners every opportunity to make informed choices. I'm guessing that whoever sold my fellow customer her birth control pills didn't ask her about her medical history, other medications she may have been taking, or whether or not she smoked (which a lot of young Chilean women do) -- factors that, as far as I know, are generally thought to be important when a woman is considering hormonal contraception.

But what if the pharmacy employee had been required to ask her if she had any questions about the pill or how to use it? If the pharmacy had been required to have someone on hand who was qualified to give detailed answers to all these questions? If pharmacies, educational and medical facilities, government agencies and NGOs distributed accurate and user-friendly information about birth control options in multiple formats, including on the radio, the internet and TV? And what if --gasp! -- prices were low (or nonexistant) enough so that monetary considerations would never have to outweigh health-related ones? Maybe then the young woman at the pharmacy would have asked for whichever pill she considered right for her and not whichever one was cheapest.

Needless to say, this is a topic that requires more than one opinion. So please, share. What do you think of the birth control situation in Chile (or in whichever country you happen to inhabit)? Any suggestions as to how to improve things? Is there a Chilean health insurance provider that covers birth control? Obviously, I'm not going to demand that anyone share his or her personal experiences, but if you want to, please feel free to do so.

*To get the morning-after pill, however, you have to make an appointment with a doctor, get a prescription, and find a pharmacy that has the pill in stock.

**In theory, women who have public health insurance are able to get free birth control pills at their local public clinic (consultorio). However, I don't know what pills consultorios give out or how many options they offer. Also, many consultorios operate on a "first come, first served" basis when it comes to appointments, and not all women are able to get up at the break of dawn to stand in line.


Lucie said...

Very interesting. I don't know if this is true, but some friends of my fiancé were telling me that a huge problem with medications in Latin America is that many developed countries or large pharmaceutical industries use third world countries as their testing grounds for certain drugs since many lack the same strict regulations and policies we have in developed countries. They said this is true especially with birth control since it is such a huge market. Again, don't quote's just something I heard. Scary if true.

Abby said...

I totally agree with you. It's a conundrum. I agree that it's great that birth control is readily available, but I worry too about the lack of information. When my BC ran out, my friends just told me to go to the pharmacy and ask for "cualquiera" but I preferred to wait for my insurance to kick in and talk to a gyno first. Like you said, there are a lot of health risks associated with taking birth control that people should know about. Maybe pharmacists should hand out pamphlets that are easy to read and understand without all the medical lingo.

lydia said...

When I ran out of my pills from the US I just walked into a pharmacy and told them I wanted something that had the same active ingredients.

I was surprised at how easy it was.
Later, I went back to my gynecologist in the US and told her I was worried about quality control or something along the lines of what lucie said, but she said I shouldn't be too worried about that in Chile, at least not with this type of pill. Then again, perhaps it'd be a different story if I was randomly picking a pill instead of matching one with active ingredients that I already know work well for me...

I don't necessarily feel one way or another strongly on this issue, though the lack of sex ed in Chile is ridiculous. I think that's a good place to start in this problem, at least informing people that complications do exist and different methods work different ways, and they need to become active in figuring that out for themselves at least, until information is obligated or more readily presented.

Kyle said...

I had never been on BC and didn't go to a doctor before getting it over the counter. I went with Seba and we actually asked quite a few questions about which kind to get, which the pharmacist were able to answer knowledgeably. So I guess that I had a pretty good experience when it comes to that because the pill that they put me on has been good, aside from making me a little crazy emotional at the end of the month, and I'm still using it years later.

Eileen said...

and because of this dichotomy, because the pill is available over the counter, and the morning after pill is not, lots of people create their own morning after pill out of the regular pill that they can get. A friend of a guy I know recently called him on the phone in a panic from a pharmacy that would not sell her the morning after pill, and he looked on the internet to find out how to approximate the ingredients. Lucky for her, he's a good friend, and, apparently, good with math. But by profession he's a physical therapist. Is that who should be telling people how to medicate themselves? I find this astounding.

Good topic, and I'm glad you wrote it up.

Emily said...

Great post. I went to the gynecologist when I first moved here to ask what pill would be similar to what I was already taking. He was helpful, but then the particular brand he'd recommended stopped being made...his response was to "try Yazmin, a lot of people like that." My doc at home, who I e-mailed in a panic, told me that in her experience most people are either Yazmin or Ortho people and don't feel as good on the other. I did some research and found a pill that had the same active ingredients as what I was taking, but I'm smart and a self-starter and have internet access - that's not true of everyone, nor should it have to be.

I also have never been asked what medications I'm on when being prescribed something new here. No mention of possible drug interactions or the fact that some antibiotics make your birth control ineffective whatsoever. In general I've had good medical care in Chile, but I really think there's a different approach to pills in general here, and while it's nice to have easier access it doesn't seem as safe to me.

Emily said...

Oh, and I think it's insane that the morning after pill is LEGAL and yet so hard to find. I've heard this is in part because the pharmacy owners are socially conservative and don't agree with what they see as abortion, so they follow the letter of the law by having it in some pharmacies but don't follow the spirit by actually making it accessible. I don't know if there's any truth to that, but it wouldn't surprise me.

translates said...

Great post! The conservative side in Chile is highly religious, wealthy and politically powerful so sex ed is virtually nil. Also, people tend toward self-medicating, there are pharmacies on every street corner, almost. It seems to be very culturally rooted. Pharmacists can be very helpful, though. Few people are proactive and educated enough to research medication side effects and interactions on their own. That is also true in other countries.

Leigh said...

Thanks for the insightful comments, everyone! Just goes to show how important it is to stay informed.

KeM said...

i think that the availability of BC over the counter is just the government deciding to pick the lessor of 2 evils. 1) getting on a pill that might not be the best for you v/s 2) getting pregnant and either trying to end the pregnancy via some horrible illegal measure or having a child that you don't want/know how/arent able to take care of. sure, i guess it's best to talk to a doctor before getting on BC though in my experience w/various gynos around the US they just sorta recommend whatever is the newest pill...and the whole smoking issue is totally brushed aside in the US i.e. the doctor says "you shoudln't smoke if you take BC" but still writes you the script. I mean i bet your chances of dying of a blood clot due to heavy smoking + BC are probably a lot less likely than you getting knocked up w/an unwanted pregnancy if you're NOT on i guess there too we choose the lesser of two evils. slim chance of blood clot v/s unwanted pregnancy. again maybe it's just me but i 've never had some serious physical or any serious questioning before getting BC in the fact, i think it's sorta stupid to have to go. i mean, really, you should be getting a regular pap. besdies that i dont see why you should need to go to the doc and get a script to try diff BCs. and docs aren't magicians. When i haven't liked my BC in the US, the docs simply give me a laundry list of other possible pills and a blurb about how they're supposedly differnet(which is usually a regurgitation of whatever the drug sales rep told them). and finally to respond to kyle's post, FYI when you go to a pharmacy in Chile you're not talking to a pharmacist ...those people behind the counter are sales people with zero training in pharmacy...if you want to talk to a pharmacist they're usually sitting in an office in the back and you must specifically ask for them. i just learned this recently from my husband's pharmacist cousin. i was shocked. good post. nice to think about these things. wish sex ed was better in this country AND the US...ho hum

dregonzrob said...

This is a great post and written very well! It's an important subject too, especially when considering the whole financial side of it and what that promotes (or doesn't promote) with regards to conscious and educated choices.
When I moved here I went through the trouble of finding the EXACT match of the components of my BC pill in the U.S. and it turns out to be one made by Bayer which costs over $5.000 pesos a month. It's the same price here as it was there but obviously the economic reality in Chile is quite different.

This is something that I believe the government should help regulate by making hospitals and clinics accountable for such things (i.e. as in the U.S. having to get a physical for each BC prescription.) But then again, who are we kidding? We're in Chile.

Cynthia said...

This bears repeating: The birth control pill, Yaz, has been linked to a number of adverse reactions, including strokes and lawsuits are growing over these issues. Here is some good information:

Anonymous said...

I am a practicing pharmacist in Texas, USA. Recently, I went to Chile as a business student (MBA). My group performed research on Chile while there to help start new businesses. While there, I learned that 70% of the population is Catholic, but there is also a decrease in new births in Chile. Because of this great disconnect, I decided to visit a pharmacy in Chile myself. I asked to speak to the pharmacist. When I met her, I showed my Texas license and she allowed me behind the counter. I asked to get Plan B but I don't think she understood me. Then I described the dosage for her, and still to no avail. However, she allowed me to purchase a birth control pill of my choosing without prescription.
Before the morning after pill was created, pharmacists used to use regular Ovral and double the tabs 2 in the am and 2 in the pm for 4 doses. The rest of the pills were discarded. So the so-called morning pills were always available with the right knowledge. As far as birth control pills being the same, they are definitely not! Some are biphasic, some are triphasic, so have different progestins that create different side effects in some women. Some have androgenic properties more than others. Some do not have any estrogens in them at all. So please be careful when you take them. Almost all have risks of blood clots. When you get any meds over the counter in Chile, be sure to ask to speak to the pharmacist, even if you have to wait. It's better to be safe than sorry. By the way, in the US, all pharmacists are required to do a drug utilization review on all of a patient's meds at each and every prescription fill.