On December 1, 2023, the LDI Maternal and Reproductive Health Working Group submitted a public comment in response to a Request for Information (RFI) from the U.S. Departments of the Treasury, Labor, and Health and Human Services. The RFI sought input on a proposed policy which would require insurance coverage of over-the-counter (OTC) preventive items and services without a prescription by a health care provider. 

The comment highlights the obstacles that many patients, especially those from marginalized communities, face in accessing affordable birth control, and expresses the importance of and mechanisms for ensuring that OTC contraceptives are available without financial or logistical barriers.

Views expressed by the researchers are their own and do not necessarily represent those of the University of Pennsylvania Health System (Penn Medicine) or the University of Pennsylvania.

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12/1/2023
Via Electronic Submission

Office of Health Plan Standards and Compliance
Assistance, Employee Benefits Security
Administration, Room N–5653, U.S. Department
of Labor,
200 Constitution Avenue NW.
Washington, DC 20210

Attention: 1210–ZA31.

RE: Request for Information; Coverage of Over-the-Counter Preventive Services

Dear Madam or Sir:

Thank you for the opportunity to comment on access to over the counter preventive services. This comment is prepared by co-chairs Alice Abernathy, MD MSHP; Abigail Wilpers, PhD RN WHNP-BC; and the members of the University of Pennsylvania Leonard Davis Institute of Health Economics Maternal and Reproductive Health Working Group. We are practicing physicians, nurses, midwives and health services researchers who work to disseminate policy relevant recommendations to ameliorate disparities in maternal and reproductive health care.

We have limited our comments to coverage of oral contraceptives and are responding to this Request for Information because we believe, based on our experience as practitioners and on our knowledge of the literature, that requiring insurance coverage of over-the-counter contraceptives without a prescription is the most important policy the federal government can adopt to improve access to oral contraceptives.

The opinions expressed in this response do not necessarily represent those of the University of Pennsylvania Health System, the Perelman School of Medicine or the Leonard Davis Institute for Health Economics.

A. Access to and Utilization of OTC Preventive Products

How common is it for plans and issuers to provide coverage for OTC preventive products without requiring a
prescription by a health care provider?

In general, it is not common. As reported by KFF,¹ 13 states require insurance companies to cover the cost of over-the-counter methods of contraception, and in 2024, only Maryland, New Jersey, New Mexico, New York and California will require plans to cover some of these methods without a prescription. Some states have developed a statewide standing order allowing a physician of a state health department or other state agency to ensure the prescription requirement is met for all state residents.

How does a plan’s or issuer’s practice of covering OTC preventive products only when prescribed by a health care provider affect individuals’ access to OTC preventive products? What other practices (for example, reasonable medical management techniques, network restrictions, or formulary restrictions) are employed by plans and issuers that restrict access to recommended preventive products that are available OTC?

As the American College of Obstetricians and Gynecologists (ACOG) has documented, among the 68% of individuals who had ever attempted to obtain a prescription for hormonal contraception, 29% had problems obtaining the initial prescription or refills. Reported obstacles included: cost barriers or lack of insurance (14%); challenges in obtaining an appointment or getting to a clinic (13%); the health care provider requiring a clinic visit, examination, or Pap test (13%); not having a regular physician or clinic (10%); difficulty accessing a pharmacy (4%); and other reasons (4%). Requiring a prescription for insurance coverage of OTC medications reinforces barriers to access and increases healthcare costs without providing additional safety.

Quantity and dosage limits imposed by how a prescription is written also reduces rates of continuation of oral contraceptives.² States continue to restrict the quantity of oral contraceptives per prescription, despite evidence this reduces compliance.³ Many have a
preferred list of contraceptive options, or limit to generic only formula without a prior authorization. This specification can reasonably be anticipated to apply to OTC contraceptives in the future, at a detriment to those seeking it.

Moreover, though 85% of pharmacists nationally reported interest in providing hormonal contraception services, in most states, pharmacists are not able to prescribe OTC contraceptives.⁴ With convenient locations and extended hours of operation, pharmacists are the most accessible health care providers.

If the Departments were to require plans and issuers to cover OTC preventive products without cost sharing and without a prescription by a healthcare provider, what would be optimal ways to communicate these changes to help ensure that participants, beneficiaries, and enrollees are educated about any steps they need to take to access these products, including to get reimbursed for purchasing OTC preventive products without a prescription by a healthcare provider?

We recommend using various messaging channels to communicate such a policy change to beneficiaries. For example, insurers could email, text and send a formal letter to their enrollees about the policy change. For patients who use an app associated with their health plan, they should receive a notification their benefits have been expanded. Explanation of benefits should be updated accordingly. Because most OTC contraceptive users are females of reproductive age with access to a smartphone, novel approaches targeted at this demographic could be useful. This includes: QR codes at pharmacies and on OTC contraceptives explaining the coverage change, the same information could be placed in social media and distributed by trusted health outlets on these platforms (a network already developed by President Biden), additionally public health departments, federally qualified health centers and Title X recipients could disseminate this change within their catchment areas. There is precedent for some of these communication strategies, including email alerts to pharmacies and notifications that contained a printable, informational flier and copy of the new policy⁶ and text messaging.⁷

B. Implementation Issues

What operational challenges may be associated with the use of telepharmacies and mail orders both within and across states or localities for OTC preventive products?

A mail order option would greatly enhance access for patients, and this is an established process already used for many over the counter and prescription items. Many patients access contraception by mail order. However, because of the foresight required and delay incurred by mail order, it is not a substitute for OTC contraception availability without a cost sharing and without a prescription in retail outlets nationwide.

If plans and issuers were required to cover OTC preventive products without cost sharing and without requiring a prescription by a health care provider, how could plans and issuers ensure that participants, beneficiaries, and enrollees who purchase OTC preventive products do not incur out-of-pocket costs at the point of sale, or are timely and correctly reimbursed, such as through post-purchase reimbursement by the plan or issuer or other mechanisms? Would utilization rates differ depending on whether the products were
covered without cost to the individual at the point of sale or were reimbursed following purchase?

The most effective approach is to ensure that consumers do not incur out of pocket costs for which they must seek reimbursement. These additional steps decrease medication uptake and disproportionately impact low-income individuals⁸; this effect has been demonstrated for contraception use.^9,10 As one participant in a focus group said: “You debate whether you get the birth control or food.… I’ll forget about the birth control if it means being able to pay my rent or buy groceries.” This is problematic for contraceptive pills use because missed doses are the primary driver of contraception failure (pregnancy occurring while using contraception).¹¹

Should plans and issuers be required to cover costs associated with shipping and/or taxes for OTC preventive products? What is the best way to eliminate out-of-pocket costs to participants, beneficiaries, and enrollees, while ensuring that they have different options to obtain such products (such as via direct mail and in person)?

Plans and insurers should be required to cover costs associated with the distribution of OTC preventative products. Studies have shown that when cost barriers are removed, effective contraception uptake increases.^12,13,14 Eliminating out of pocket costs (including for shipping and taxes) for the consumer will increase affordability and likelihood of appropriate preventative care
use. We recommend the current strategy employed for mail order medications apply to over the counter preventative medications like contraceptives.

If plans and issuers were required to cover OTC preventive products without cost sharing and without requiring a prescription by a health care provider, what types of reasonable medical management techniques related to frequency, method, treatment, or setting would plans and issuers consider implementing with respect to these products, in instances where an applicable recommendation or guideline did not specify the frequency, method, treatment, or setting for the provision of the recommended preventive service? How
would such techniques differ or compare to strategies used currently?

Currently many insurers now allow the provision of a 12 month contraception supply (dispensed 6 to 12 months at a time), after research demonstrated that shorter supply lengths cause higher rates of interruption of use of the contraceptives.¹⁵ Eighteen states have mandated insurers to cover the provision of 6 to 12 months of contraceptive supply at a time.¹⁶ We recommend that if insurers choose to implement quantity limits that these limits be maintained even in the over the counter context. Moreover, we recommend that if a patient opts to obtain a quantity less than what is mandated by coverage, they are alerted at the point of sale that a higher quantity would be covered at no cost.

If plans and issuers were required to cover OTC preventive products without cost sharing and without requiring a prescription by a health care provider, what guardrails would plans and issuers consider implementing to mitigate fraud, waste, and abuse?

As discussed above, a 12 month supply is an appropriate quantity limit.

Would plans’ and issuers’ provision of direct coverage for OTC COVID–19 diagnostic tests to participants, beneficiaries, and enrollees by providing payments to sellers directly (without requiring upfront payment by consumers and subsequent reimbursement by the plans and issuers) be a model that could be used to implement an OTC coverage requirement for preventive products? The Departments are particularly interested in the experience of consumers, plan sponsors, retailers, plans, issuers, PBMs, and other service providers related to techniques that were implemented during the COVID–19 PHE to prevent, detect, and respond to fraud, waste, and abuse related to the provision of OTC COVID–19 diagnostic tests.

From the perspective of clinicians who are interested in ensuring the highest level of consistent access to effective contraceptives, the federal government should use the OTC COVID-19 diagnostic test policy that required coverage without upfront payment by consumers as the model to implement OTC coverage for oral contraceptives.

What other strategies could the Departments implement to increase utilization of OTC preventive products, other than, or in addition to, requiring plans and issuers to cover such products without cost sharing and without a prescription by a healthcare provider? Should the Departments look to any specific strategies implemented by states, localities, plans, issuers, or large employers to increase utilization of OTC preventive products?

One city (Philadelphia) has adopted a local ordinance requiring pharmacies to stock Naloxone,¹⁷ and some states require emergency contraception to be stocked a certain sites¹⁸; the stocking requirement strategy might be useful in the context of oral contraception options. The federal government should include Opill as part of the contraception counseling protocol at federally funded sites (FQHCs and Title X providers).

Extending quantity limits on contraceptive drugs, devices, and supplies—also known as one-year dispensing and extended supply policies—could be a promising avenue to increase contraceptive access. Extended supply policies would require health care plans and insurers to cover a one-year supply of contraceptives.^19,20

Are there any state laws or regulations currently in place, or expected to be proposed, that could hinder utilization and access to OTC preventive products?

In the context of emergency contraceptives, seven states have laws allowing pharmacies and/or pharmacists to refuse to dispense EC pills on the basis of moral or religious objections.²¹ Neither EC pills nor oral contraceptives are abortifacients and therefore these types of objections should not be relevant. There is extensive literature on EC access problems at pharmacies.^22,23 It is critical the same missteps are not repeated for other forms of OTC hormonal contraception.

C. Health Equity

Under current standards and requirements, do certain populations face additional or disproportionately burdensome challenges to accessing OTC preventive products?

There are race and income-based disparities in access to contraceptives.²⁴ Hispanic women are the most likely to lack access to birth control, followed by younger women and impoverished women.²⁵ Uninsured and Spanish-speaking women were significantly more likely to report difficulties accessing contraception vs. privately insured and English-speaking individuals, respectively; women with a high school degree and those with some college (vs. a college degree or higher) were significantly less likely to report issues accessing contraception.²⁶ Difficulties reported included: cost barriers or lack of insurance (14%), challenges obtaining an appointment or getting to a clinic (13%), the clinician requiring a clinic visit, exam, or Pap smear (13%), or not having a regular doctor/clinic (10%).

Research has demonstrated that removing cost barriers can be a highly effective means of improving access for all women regardless of race–ethnicity and social status.²⁷

Do the current standards that require coverage of only prescribed OTC preventive products without cost sharing pose a substantial burden (for example, excess demand for appointments) on health care providers working in, or disproportionately serving, underserved communities?

We practice at clinics associated with an academic medical center in a city where one in five residents has income below the federal poverty line. These patients face significant burdens to attend routine medical care and afford the cost of prescriptions. As such, our patients are routinely prescribed medication that is available over the counter to reduce cost. Due to the safety of many of these medications, requiring a physician to see a patient and write a prescription does not improve quality of care, but does increase healthcare spending. Moreover, many patients view this as an additional hurdle to obtaining medication they can safely take without supervision of a medical professional.

If plans and issuers were required to cover OTC preventive products without cost sharing and without requiring a prescription by a health care provider, how would such a requirement improve access for these populations? For example, is there evidence that coverage of OTC contraceptive medications or devices without a prescription by a health care provider would significantly impact access in “contraceptive deserts” (areas with low access to family planning resources)? 

As stated previously, studies have shown that when cost barriers are removed, effective contraception uptake increases.²⁸ Over-the-counter contraceptives have similar continuation rates compared to prescription-only contraceptives. Improving availability of over the counter hormonal contraceptives, which are more effective than alternate over the counter options, has the potential to decrease unintended pregnancy rates.²⁹ Patients who use contraceptives are not intending to become pregnant, but may become pregnant due to imperfect contraception use. Unintended pregnancies are associated with worse maternal health outcomes relative to planned pregnancies. Moreover, patients who reside in contraception deserts often face difficulties accessing abortion and maternity care.

A 2023 study including 6,561,107 women enrolled in Medicaid living in 2,157 counties across 34 states found that after the Dobbs v Jackson decision, the number of women living in counties with low contraceptive use and restricted abortion access would increase to 1,644,646 women, or 46%.³⁰ Low-income people and people of color are more likely to live in certain types of contraception deserts.³¹ While contraception deserts exist, there is typically widespread market penetration of retail pharmacies in which a patient could obtain OTC contraceptives.

D. Economic Impacts

Would utilization of OTC preventive products significantly replace utilization of non-OTC preventive products among participants, beneficiaries, and enrollees?

In our experience, we do not believe that this is likely to occur. Individuals currently using a regular method of contraception are unlikely to switch to this new pill; as most patients have preferences and preferred methods. Instead, we would expect availability of OTC oral contraceptives to be those who are not currently using contraception or draw or individuals who prefer to switch to a more effective OTC contraceptive from a different, less effective method.

To what degree would any potential increases in costs or premiums associated with a requirement for plans and issuers to cover OTC preventive products without cost sharing and without a prescription by a health care provider be offset by greater access to OTC preventive products (for example, due to improved health outcomes from greater uptake of recommended preventive products, or fewer office visits as a result of participants, beneficiaries, and enrollees no longer requiring an office visit to obtain a prescription for OTC preventive products)?

According to the most recently available CDC data more than 35% of pregnancies in the U.S. are unplanned.³² Patients using an effective, reliable form of contraception are least likely to experience unplanned pregnancy. Increasing availability of effective OTC contraceptives will reduce the rate of unplanned pregnancies. As the maternal health crisis continues, reducing unplanned pregnancies will improve birth outcomes, including lowering rates of severe maternal morbidity.³³ This will lower costs for insurers. Because Medicaid covers more than 70 percent of family planning services for low-income Americans and pays for nearly half of all U.S. births, efforts aimed at improving access to contraceptives for individuals enrolled in Medicaid offer significant opportunities for states to improve health outcomes and reduce health costs.³⁴ A 2014 study found that preventing unplanned pregnancies and their associated costs comprised the biggest share of government cost savings: $15.2 billion saved on Medicaid-covered maternity and infant care and on publicly funded medical care for 4 children aged 13 to 60 months; $409 million saved on Medicaid-covered care for miscarriages; $44 million saved for abortion care.³⁵

Identify and provide estimates related to the potential societal and economic impacts (for example, benefits, costs, and transfers) on individuals and families, as well as on health care providers, if OTC preventive products were required to be covered without cost sharing and without a prescription by a health care provider. Would these impacts vary based on region, state, socioeconomic status, race, sex, age, insured status, or other factors? For example, would there be potential reductions in unintended pregnancies or maternal deaths due to participants, beneficiaries, and enrollees no longer requiring a prescription for OTC oral contraceptives?

Contraception availability, and eliminating cost sharing through the Affordable Care Act, was associated with reduction in unintended pregnancy, reduced adolescent pregnancy rates, widespread educational attainment and achieving advanced degrees, better socioeconomic status and improved outcomes for children including reduction in childhood poverty rates and improved education attainment and healthcare system savings.

Mandated coverage of OTC contraceptives is essential to ensure these benefits extend throughout the US, and reach those who would benefit most. If OTC contraceptives are required to be covered without cost sharing and without a prescription the positive impacts would be felt most by those who experience the greatest barriers to access: Latina and Black women, low-income, and younger women. These are the same groups who disproportionately experience unplanned pregnancy and worse outcomes in pregnancy. Mandated coverage would not only reduce disparities in health outcomes by demographic characteristics, but also by region. Medicaid covers the majority of births in the US, and mandated coverage of OTC contraception without a prescription is likely to induce cost savings in non-expansion states, and those that have not expanded Medicaid postpartum. States that have not adopted these policies are also the majority of states in which there are vast contraception deserts.

There is a clear link between the provision of no cost, over the counter, effective contraception and improving women’s health before, during and after pregnancy, as well as educational and economic opportunity over their lifetime.

Thank you for the opportunity to comment on this important matter. If you have additional questions please contact Alice Abernathy (alice.abernathy@pennmedicine.upenn.edu).

Arina Chesnokova MD MPH
Heather H. Burris, MD, MPH
Holly Harner, PhD, MPH, MBA, WHNP-BC, FAAN
Jennifer D. Cohn, MD
Sammy S. Dhaliwal, PhD, MSc
Courtney A. Schreiber MD, MPH
Sindhu K. Srinivas, MD, MScE
Ellen C. Caniglia, ScD
Mario DeMarco, MD MPH

Members, Penn LDI Maternal and Reproductive Health Working Group

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References

1. Long, Michelle, et al. “Over-the-Counter Oral Contraceptive Pills.” KFF, 14 Sept. 2023, https://www.kff.org/womens-health-policy/issue-brief/over-the-counter-oral-contraceptive-pills/.
2. White KO, Westhoff C. The effect of pack supply on oral contraceptive pill continuation: a randomized controlled trial. Obstet Gynecol 2011;118:615–22
3. Ranji, Usha, et al. “Medicaid Coverage of Family Planning Benefits: Findings from a 2021 State Survey – Report – 9882.” KFF, 17 Feb. 2022, https://www.kff.org/report-section/medicaid-coverage-of-family-planning-benefits-findings-from-a-2021-state-survey-report/.
4. Landau S, Besinque K, Chung F, Dries-Daffner I, Maderas NM, McGhee BT, et al. Pharmacist interest in and attitudes toward direct pharmacy access to hormonal contraception in the United States. J Am Pharm Assoc (2003) 2009;49:43–50.
5. Mitchell, Madeline, et al. “Opposition to Pharmacist Contraception Services: Evidence for Rebuttal.” Pharmacy (Basel, Switzerland), vol. 8, no. 4, Sept. 2020, p. 176. PubMed, https://doi.org/10.3390/pharmacy8040176.
6. Jones K. “Advancing Contraception Access in States Through One-Year Dispensing and Extended Supply Policies.” Center for American Progress, 9 Jan. 2023, https://www.americanprogress.org/article/advancing-contraception-access-in-states-through-one-year-dispensing-and-extended-supply-policies/
7. Stewart, M. “States Can Use Text Messaging to Communicate Effectively With Medicaid and SNAP Enrollees.” Center on Budget and Policy Priorities, 9 Aug. 2022, https://www.cbpp.org/blog/states-can-use-text-messaging-to-communicate-effectively-with-medicaid-and-snap-enrollees#:~:text=With%20the%20majority%20of%20adults,such%20as%20Medicaid%20and%20SNAP
8. Ibid
9. Dennis, Amanda, and Daniel Grossman. “Barriers to Contraception and Interest In Over‐the‐Counter Access Among Low‐Income Women: A Qualitative Study.” Perspectives on Sexual and Reproductive Health, vol. 44, no. 2, June 2012, pp. 84–91. DOI.org (Crossref), https://doi.org/10.1363/4408412.
10. Doherty, Meredith, et al. “Administrative Burden Associated with Cost-Related Delays in Care in U.S. Cancer Patients.” Cancer Epidemiology, Biomarkers & Prevention: A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology, vol. 32, no. 11, Nov. 2023, pp. 1583–90. PubMed, https://doi.org/10.1158/1055-9965.EPI-23-0119.
11. Ibid
12. Krashin, Jamie W., et al. “Contraception Insurance Coverage and Receipt of Long-Acting Reversible Contraception or Depot Medroxyprogesterone Acetate on the Day of Abortion.” Obstetrics & Gynecology, vol. 130, no. 1, July 2017, p. 109. journals.lww.com, https://doi.org/10.1097/AOG.0000000000002070.
13. McNicholas, Colleen, et al. “The Contraceptive CHOICE Project Round Up: What We Did and What We Learned.” Clinical Obstetrics and Gynecology, vol. 57, no. 4, Dec. 2014, p. 635. journals.lww.com, https://doi.org/10.1097/GRF.0000000000000070
14. Goyal, Vinita, et al. “Postabortion Contraceptive Use and Continuation When Long-Acting Reversible Contraception Is Free.” Obstetrics and Gynecology, vol. 129, no. 4, Apr. 2017, pp. 655–62. PubMed Central, https://doi.org/10.1097/AOG.0000000000001926
15. White, Katharine O’Connell, and Carolyn Westhoff. “The Effect of Pack Supply on Oral Contraceptive Pill Continuation: A Randomized Controlled Trial.” Obstetrics & Gynecology, vol. 118, no. 3, Sept. 2011, p. journals.lww.com, https://doi.org/10.1097/AOG.0b013e3182289eab.
16. Ibid
17. Department of Public Health City of Philadelphia. City Council Bill No. 180695. https://www.phila.gov/media/20210429093114/7_NaloxoneAvailabilityOrdinanceFAQ.pdf
18. “Emergency Contraception.” KFF, 4 Aug. 2022, https://www.kff.org/womens-health-policy/fact-sheet/emergency-contraception/#:~:text=Pharmacies%20are%20not%20required%20to,high%20cost%20of%20the%20product
19. “Advancing Contraception Access in States Through One-Year Dispensing and Extended Supply Policies.” Center for American Progress, 9 Jan. 2023, https://www.americanprogress.org/article/advancing-contraception-access-in-states-through-one-year-dispensing-and-extended-supply-policies/.
20. York, Ashley Dao, PharmD Candidate 2024 St John’s University College of Pharmacy and Health Sciences Queens, New York Tina Caliendo, PharmD, BCGP, BCACP Assistant Professor St John’s University College of Pharmacy and Health Sciences Queens, New. Addressing Barriers to Emergency-Contraceptive Access. https://www.uspharmacist.com/article/addressing-barriers-to-emergencycontraceptive-access. Accessed 20 Nov. 2023.
21. Ibid
22. Ensuring That Individuals Are Able to Obtain Contraceptives at Pharmacies. https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/18/13/39/ensuring-that-individuals-are-able-to-obtain-contraceptives-at-pharmacies. Accessed 20 Nov. 2023.
23. Goldschein, S. Religious Refusals and Reproductive Rights: Accessing Birth Control at the Pharmacy. American Civil Liberties Union Foundation, 2007. https://www.aclu.org/sites/default/files/images/asset_upload_file576_29402.pdf
24. Sutton, Madeline Y., et al. “Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020.” Obstetrics and Gynecology, vol. 137, no. 2, Feb. 2021, pp. 225–33. PubMed Central, https://doi.org/10.1097/AOG.0000000000004224.
25. Hammond, A. “Disparities in Access to Contraception in the United States: an Intersectional Analysis.” Claremont Colleges. 2019 https://scholarship.claremont.edu/cgi/viewcontent.cgi?article=2435&context=scripps_theses
26. Grindlay, Kate, and Daniel Grossman. “Prescription Birth Control Access Among U.S. Women at Risk of Unintended Pregnancy.” Journal of Women’s Health (2002), vol. 25, no. 3, Mar. 2016, pp. 249–54. PubMed, https://doi.org/10.1089/jwh.2015.5312.
27. Sutton, Madeline Y., et al. “Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020.” Obstetrics and Gynecology, vol. 137, no. 2, Feb. 2021, pp. 225–33. PubMed Central, https://doi.org/10.1097/AOG.0000000000004224.
28. Krashin (2017), McNicholas (2014), Goyal (2017)
29. Over-the-Counter Access to Hormonal Contraception. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/10/over-the-counter-access-to-hormonal-contraception.
30. Rodriguez, Maria I., et al. “Predicted Changes in Travel Distance for Abortion among Counties with Low Rates of Effective Contraceptive Use Following Dobbs v Jackson.” American Journal of Obstetrics and Gynecology, vol. 228, no. 6, June 2023, pp. 752–53. ScienceDirect, https://doi.org/10.1016/j.ajog.2023.01.032.
31. Kreitzer, Rebecca J., et al. “Affordable but Inaccessible? Contraception Deserts in the US States.” Journal of Health Politics, Policy and Law, vol. 46, no. 2, Apr. 2021, pp. 277–304. PubMed, https://doi.org/10.1215/03616878-8802186.
32. U.S. Pregnancy Rates Drop During Last Decade. 10 Apr. 2023, https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2023/20230412.htm.
33. Hall, Jennifer A., et al. “Pregnancy Intention and Pregnancy Outcome: Systematic Review and Meta-Analysis.” Maternal and Child Health Journal, vol. 21, no. 3, Mar. 2017, pp. 670–704. Springer Link, https://doi.org/10.1007/s10995-016-2237-0.
34. “Increasing Access to Contraception Learning Community”.Bulletin of the Karaganda University. Pedagogy Series, vol. 104, no. 4, Dec. 2021, pp. 101–07. DOI.org (Crossref), https://doi.org/10.31489/2021Ped4/101-107.
35. Frost, et al., (2014). Retrieved from https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/MQFrost_1468-0009.12080.pdf