The Case for Free Contraception
Universal access to contraception gives individuals the autonomy to make informed choices about their health and lives. It enables those who can become pregnant to plan if and when to become pregnant, leading to immediate, life-long, and intergenerational advantages. It also allows individuals to manage a broad range of conditions related to reproductive health beyond pregnancy. When individuals can access contraception, it allows them to pursue education and employment opportunities, it contributes to gender equality, it supports management of their reproductive health and it supports people to decide if and when they want to grow their families according to their own particular circumstances. Planned pregnancies also result in lower maternal and infant mortality rates as well as reduced healthcare costs associated with unplanned pregnancies and even savings to the health care system overall for every dollar invested in contraception. Better contraception access is a catalyst for healthier individuals, stronger families, and more equitablesocieties.
The ability to choose if and when to have children is a critical component of sexual and reproductive health and a fundamental human right of every person. All individuals have a right to choose the contraception that is right for them regardless of who they are, the number of children they have, their age, their disability status, or what they have in their bank account.[1] To make this right a reality, Canada must ensure that contraception is available, accessible, acceptable and of good quality, without discrimination. Universal cost coverage for contraception is one major step forward in fulfilling the right to sexual and reproductive health.
The Canadian Landscape
The Canadian Contraception Policy Atlas ranks provinces from best to worst in overall performance based on an evaluation of government policies in place to support access to contraceptive supplies and information. As last year’s contraception atlas indicated, access to contraceptives in Canada is heavily dependent on the province you live in. Canada continues to be the only country with universal healthcare coverage that does not also offer coverage for prescription drugs, including contraceptives, and this lack of coverage comes with steep costs.[2] Each province defines who is eligible for medication benefits under its respective pharmaceutical program. In addition, provinces individually define any conditions to accessing particular products, and how frequently one can access them. This leaves significant gaps in coverage across the country and the level of coverage dependent on where one lives in Canada.
Nearly half of all pregnancies in Canada are unintended and many Canadians continue to use a narrow range of contraception methods, with the three most common reported methods being among the least expensive for individuals to purchase (condoms, oral contraception and withdrawal)[3]. Fewer than 5% of individuals between 15-24 years report using a contraception method in the most highly effective tier, such as intra-uterine devices (IUDs) or contraceptive sub-dermal implants [4]. This can likely be attributed to several barriers to access, including a lack of awareness, concerns related to misinformation or ‘myths’, ability to access a prescribing healthcare practitioner and overall financial barriers. As such, socio-economically disadvantaged individuals are often faced with choosing the most affordable contraceptive options.
All contraceptives aim to prevent pregnancy to varying degrees of effectiveness, but the most effective forms of contraception are also the most expensive. The best form of contraception for each individual is determined by what works best for them, not by which is most affordable. An intrauterine device (IUD) can cost between $75 to $400, oral contraceptive pills can cost $20 per month (adding up to $240 a year), and hormone injections as much as $180 per year. These costs may force individuals to make contraceptive choices based on cost alone. Many sexual health centers fill the gaps in contraceptive care for the communities they serve by offering low or no-cost contraception programs, but these programs are often under-resourced and struggle to meet demands. These services are predominantly located in urban centers which also means patients who live far from major cities are forced to travel long distances and take time off work to accommodate appointments far from home. In practice, this means that the financial and practical cost of accessing low cost medications or inserting an IUD makes accessing the most effective forms of contraception a challenge for many. A national pharmacare program would remove the barrier of cost, and bring access to medications closer to where they live, allowing individuals to truly make their own contraceptive choices.
Developments in Contraception Coverage
Similar to last year, this update to the Contraception Atlas looks at five (5) criteria and fifteen (15) sub criteria, highlighting updates to cost coverage polices, prescriber scope, government provided information and public education available on contraception.
Recent efforts have been to improve contraception access from both the federal and provincial levels. In 2023, the British Columbia government announced free prescription contraception (oral contraceptive pill, subdermal implant and injection, copper and hormone-releasing IUD, and levonorgestrel emergency contraception, only excluding contraceptive patch and ring), becoming the first province to offer universal coverage for contraception. Since then, the provincial health authority website (HealthLinkBC) has also been updated to include information on myths about sex and pregnancy. Provincial or territorial governments’ and public health authorities’ official websites are generally people’s first point of contact for reliable information as they are considered to be trustworthy and unbiased sources. As such, they are responsible not only for providing legitimate & accurate information about contraception and contraception choices available to people, but to also debunk misleading information. This addition to British Columbia’s health page is an immensely important step in fighting the continued rise of misinformation on sexual and reproductive health.
Another province that has introduced changes to increase access to contraception is Ontario. In May 2024, the province expanded contraceptive prescribing access to include midwives under the new designated drugs and substances regulation. Enabling additional disciplines of health workers to prescribe contraception through competency-based training and enhanced scope of practice licensing authorization is an effective way of enhancing access.
Further announcements on improving access to contraceptives have also been made but as they have yet to be implemented, they have not been included in the scoring for this year’s version of the Contraception Atlas. One such announcement was the province of Manitoba announcing cost coverage for contraceptives starting in October of 2024. Once implemented, this would significantly increase Manitoba’s ranking from one of the provinces with the lowest access to contraception to one of the provinces with the best access behind British Columbia, Quebec, and Ontario. British Columbia has also announced its intention to include hormone replacement therapy under its provincial pharmacare program. While this is not tracked in the parameters of the atlas itself, it is still a significant step in increasing access to overall sexual and reproductive health.
The federal government also announced its plan to establish a national pharmacare program, starting with coverage for contraception and diabetes medication. Presented in the House of Commons on February 2024, Bill C-64: ‘An Act respecting pharmacare’ would allow the federal government to create agreements with provinces to provide cost coverage for contraception and diabetes medications included in its list of approved medications for the entirety of the population rather than under select compassionate programs, like OHIP+, as in the case of many provinces now . As of September 2024, the bill is still currently being studied by the Senate and has yet to receive royal assent. If passed, this bill would mean more Canadians will have the ability to choose their own preferred method of contraception regardless of cost. This would increase Canadian’s bodily autonomy and allow them to plan their families as they choose. It would also mean cost savings for the entire country as studies have shown that every dollar spent on access to contraception would provide nine dollars in savings over the long term[5]. It would also mean that the differences in access we see across the country currently in the atlas would be drastically decreased in future versions of the atlas and we would not see the large disparities from province to province as we see now. 75% of the country would be ranked as having very good access to contraception if this bill were to pass.
Concluding Observations
While cost coverage for contraceptives across Canada would go a long way in improving access to contraception, it is not the only barrier to access that exists. If this were the case, every province on the atlas would have the same ranking. Some barriers are highlighted in the atlas, including struggles in accessing healthcare workers who can prescribe contraception, lack of clear information around contraceptive choices, and the rise in misinformation to name a few. These barriers do not fall equally on all individuals living in Canada, and in fact disproportionately affect those who experience marginalization rooted in systemic racism, classism, ableism, and heterosexism[6].
Universal access to contraception is a huge step forward in closing the gaps in access across the country that currently exist, but this is only the first step. A comprehensive national pharmacare needs to cover the full suite of essential medication over time. A comprehensive approach to contraceptive care means strengthened sexual health education, increased access to barrier methods. A comprehensive approach to contraceptive care means strengthened sexual health education, increased access to barrier methods and better information so that everyone can make consensual and informed choices about their fertility.
[1] World Health Organization. (2014). Framework for ensuring human rights in the provision of contraceptive information and services. Geneva: World Health Organization: https://apps.who.int/iris/bitstream/handle/10665/133327/9789241507745_eng.pdf
[2] The Lancet. (2019, October 19). Canada needs universal pharmacare. The Lancet, 394(10207), 1388. Retrieved from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32324-4/fulltext
[3] Vogel, L. (2017, July). Canadian women opting for less effective birth control. Canadian Medical Association Journal, 921-922. Retrieved from https://www.cmaj.ca/content/189/27/e921
[4] Rotterman M, McKay A. Sexual behaviours, condom use and other contraceptive methods among 15- to 24-year olds in Canada. 2020. https://www150.statcan.gc.ca/n1/pub/82-003-x/2020009/article/00001-eng….
[5] Black, A. Y., Guilbert, E., Hassan, F., Chatziheofilou, I., Lowin, J., Jeddi, M., . . . Trussell, J. (2015, December). The Cost of Unintended Pregnancies in Canada: Estimating Direct Cost, Role of Imperfect Adherence, and the Potential Impact of Increased Use of Long-Acting Reversible Contraceptives. Journal of Obstetrics and Gynaecology Canada, 1086-1097.
[6] Mahabir, D.F., O’Campo, P., Lofters, A. et al. Experiences of everyday racism in Toronto’s health care system: a concept mapping study. Int J Equity Health 20, 74 (2021). https://doi.org/10.1186/s12939-021-01410-9