Preventing Unplanned Pregnancy

1/7/2018

Introduction

Silhouette of a pregnant womanWhile rates of unplanned pregnancy have declined in recent years, nearly half of all pregnancies in the U.S. States are unplanned, as described by the women themselves. In addition, despite recent progress, significant disparities in unplanned pregnancy rates remain.

Rates are highest among older teens and young women in their 20s, women living in poverty, and women of color. For example, women ages 20-to-24 experience a higher rate of unplanned pregnancy than any other age group, accounting for one-third of all unintended pregnancies. According to a 2016 report, the rate of unplanned births among women with incomes below federal poverty guidelines was nearly seven times greater than the rate among women with incomes of 200 percent of the federal poverty level or higher. The unplanned pregnancy rate among African-American women was more than double the rate among white women.  

Both individuals and states pay for the high costs associated with unplanned pregnancies. An unplanned pregnancy can disrupt educational goals, severely affecting future earning potential and family financial wellbeing.

Significant intergenerational effects also exist. Women with an unplanned pregnancy, for example, are less likely to receive prenatal care. And children born as a result of an unplanned pregnancy are more likely, on average, to have poorer health and score worse on behavioral and developmental measures, compared to children born as a result of a planned pregnancy.  

These costs extend to state coffers. A 2011 Brookings Institution report found that taxpayers spend an estimated $12 billion each year on publicly financed medical care for women and infants related to unplanned pregnancy. A 2015 report examined these and additional public medical care costs (e.g., the cost of medical care for children up to age five) associated with unplanned pregnancy. It found that in 2010, U.S. state and federal government expenditures for unplanned pregnancy-related care totaled $21 billion, with public insurance programs, such as Medicaid, financing 68 percent of unplanned births, compared to 38 percent of planned births. This number does not capture additional costs stemming from an unplanned pregnancy’s impact on educational attainment, family economics, and child health and wellbeing.

Numerous evidence-informed strategies can help prevent unplanned pregnancy and its associated costs. The Centers for Disease Control and Prevention include preventing unintended pregnancy in its 6 |18 Initiative, which targets six common and costly health conditions, such as high blood pressure and asthma, with 18 proven prevention activities.

The initiative proposes reimbursing providers for the full range of contraceptive services and removing administrative and logistical barriers to accessing long-acting reversible contraception (or LARC, such as intrauterine devices and implants) to help prevent unplanned pregnancy, among other recommendations.  

In addition, in response to the high costs for women, families and states, some state leaders have also explored a range of strategies to help women plan, space or prevent future pregnancies. These include:

  • Insurance coverage for contraception.
  • Medicaid reimbursement for post-partum long-acting reversible contraception (LARC).
  • Pharmacy access to contraception.
  • Expanding access to information for college students.

 

 

Background

The high costs of unplanned pregnancy mean that supporting women and couples in achieving their own goals with respect to pregnancy can help create economic opportunity and lead to significant benefits for states. When women are able to plan if, when and under what circumstances to become pregnant, they may be more financially prepared and better able to achieve their goals for education, career and family. Women with a planned pregnancy may also be better prepared in terms of certain health behaviors (for example, receiving prenatal care and taking folic acid) that are important for promoting a healthy pregnancy and baby.  

States have taken several different approaches, or in many cases implemented a combination of strategies, to help women act with intentionality and plan if and when to become pregnant. Strategies span a range of age groups, from teens to married women with children wishing to avoid an additional pregnancy or space their future pregnancies. Women wishing to plan their pregnancies may consider delaying sex or accessing contraception information and services.

One strategy to assist women in their planning, called the One Key Question initiative, encourages primary care providers and others to routinely ask women of childbearing age if they would like to become pregnant in the next year. Under the initiative, if the answer is no, providers can assist women with a plan to prevent an unplanned pregnancy. If the answer is yes, providers can connect women with pre-conception care to help promote a healthy pregnancy. This pregnancy intention screening tool is currently used by providers in at least 29 states and the District of Columbia. The One Key Question initiative began in Oregon, and is managed outside of Oregon by Power to Decide, a nonpartisan organization formerly called the National Campaign to Prevent Teen and Unplanned Pregnancy.  

Several strategies aim to improve women’s knowledge of and access to the full range of contraception options. These range from natural family planning methods that teach women to recognize signs of their fertile days, to long-acting reversible contraception (LARC) such as intrauterine devices (IUDs) and implants.  Only 1-in-50 women eligible for publicly funded contraception has reasonable access to the full range of U.S. Food and Drug Administration (FDA)-approved birth control methods in the counties in which they live. That translates to more than 19 million women living in geographic regions across the country without reasonable access to the full range of birth control options, including the most effective methods, such as IUDs and implants.     

Research shows that improving access to birth control reduces unplanned pregnancies and can save public dollars. A study looking at 2010 national data found that publicly supported family planning programs, such as the Title X Family Planning program and federally qualified health center services, led to a net annual federal and state government savings of $13.6 billion, or more than seven dollars saved for each dollar spent, primarily in savings because of avoided medical costs from prevented unplanned pregnancies.    

Insurance Coverage for Contraception

United States map of States that Require Insurers Cover an Extended Supply of Prescription Contraceptives

State lawmakers have pursued policy options related to insurance coverage requirements for contraception, aiming to improve women’s access and help prevent unplanned pregnancy. Strategies include expanding the supply of contraceptives dispensed at one time, as well as ensuring coverage for a range of contraception options.   

The amount of contraception dispensed often varies by insurers, with many insurance plans covering between 30- and 90-day supplies of certain contraceptives, such as the birth control pill, at one time. Some research shows, however, that dispensing even longer supplies of contraceptives may increase ease of access and use. Women, particularly in rural or other underserved areas, may struggle to refill their prescriptions at shorter time intervals, leading to gaps in use and reduced effectiveness. For example, a 2011 study found that dispensing a one-year supply of birth control pills reduced the odds of an unplanned pregnancy by 30 percent, compared to dispensing a 30- to 90-day supply of pills. The 2016 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), published by the federal Centers for Disease Control and Prevention, also recommends dispensing up to a one-year supply of contraceptives to prevent unwanted gaps in use.

Since 2015, at least 10 states and the District of Columbia enacted legislation requiring insurers to cover a one-year supply of prescription contraceptives at one time. Some of these policies require coverage for a one-year supply for subsequent prescriptions after a shorter, initial prescription is dispensed. New York established this requirement through regulation. Maryland lawmakers enacted legislation requiring coverage for a six-month supply. As of November 2017, the New Jersey Legislature was also considering legislation requiring coverage for a one-year supply of prescription contraceptives.        

Several states have pursued additional strategies related to insurance coverage for contraception. As of October 2017, at least eight states had codified the Affordable Care Act’s contraceptive method coverage provision, which requires most insurance plans to cover 18 FDA-approved categories of contraception without out-of-pocket costs for patients. Several of these states also require coverage for additional types of contraception, such as vasectomies and over-the-counter methods. In October 2017, the U.S. Departments of Health and Human Services, Treasury and Labor issued two rules establishing a new federal exemption for employer-sponsored health insurance plans based on religious beliefs or moral convictions.     

Medicaid Reimbursement for Post-Partum Long-Acting Reversible Contraception (LARC)

United States map of States that Have Issued Guidance to Allow Medicaid to Reimburse for Immediate Post-Partum LARC

Long-acting reversible contraception methods, or LARC, are one of the most reliable pregnancy prevention strategies. LARC methods, including intrauterine devices (IUDs) and hormonal implants inserted under the skin in a woman’s arm, can last for several years, are reversible, and are demonstrated effective in preventing pregnancy. In addition, research shows that the immediate post-partum period is an ideal time to begin use of LARC to prevent a future unplanned pregnancy.   

While LARC usage more than doubled between 2008 and 2014, some access barriers remain, including reimbursement policies. For example, providers are typically given one global Medicaid payment for labor and delivery services, creating a financial disincentive for inserting LARC as an additional service immediately after a woman has given birth because of the additional expense. To improve access to post-partum birth control, 33 states and the District of Columbia now allow Medicaid to reimburse providers for post-partum insertion of LARC as a separate service, according to the American Congress of Obstetricians and Gynecologists.  

More than one-third of women with Medicaid coverage do not have a post-partum visit within three months of giving birth, meaning that immediately after giving birth may be some women’s best opportunity to receive birth control services to space or prevent a subsequent pregnancy. In addition, the federal Centers for Medicare and Medicaid Services (CMS) recommended in 2016 that state Medicaid programs provide a separate reimbursement for post-partum LARC insertion, among other recommendations to improve access to family planning services.

State health officials report a variety of post-partum LARC initiatives, such as training providers or improving billing logistics, according to the Association of State and Territorial Health Officials (ASTHO). ASTHO conducted two rounds of a learning community that convened state health agency representatives from 13 states to assist in implementing post-partum LARC initiatives, which then expanded to a larger state learning community on increasing access to contraception. ASTHO provides several reports with information on state activity in this area, as well as summary findings from these meetings. For example, participants identified provider training as an essential activity for increasing access to post-partum LARC. ASTHO also provides resources and state examples that may be helpful for state leaders interested in increasing access to post-partum LARC.    

Pharmacy Access to Contraception

United States map of States that Allow Pharmacists to Prescribe Some Hormonal Contraceptives

Allowing pharmacists to prescribe and dispense certain types of hormonal contraceptives without a prescription from a physician provides an additional state strategy to improve access to services and prevent costly unplanned pregnancies. After meeting with patients, pharmacists who have undergone appropriate training may prescribe certain hormonal contraceptive methods, such as the birth control pill, patch, ring or shot, or refer patients to a physician for follow-up care.

This may be particularly effective in improving access for women living in rural or other underserved areas with limited access to health care providers, or for women without health insurance to cover the cost of a doctor’s visit. Time constraints and transportation costs can also act as barriers to accessing birth control. A recent Pew article illustrates that pharmacies can help improve contraceptive access, as they are often located conveniently in communities and 93 percent of Americans live within five miles of a pharmacy. 

While proponents of pharmacy access policies point to increased ease of access, others express concerns around how to handle reimbursement for pharmacists, whether such access provides sufficient opportunity for private patient counseling, and whether adequate safeguards exist for certain women for whom physician involvement is important. Some advocate for providing certain hormonal birth control methods over-the-counter, in lieu of pharmacy access policies.    

As of November 2017, at least six states had enacted legislation to allow pharmacists to prescribe and dispense some hormonal contraceptives. The New Mexico Board of Pharmacy adopted a regulation in 2017 that also allows pharmacists to prescribe and dispense hormonal contraceptives. At least eight additional states considered similar legislation during the 2017 legislative session. The types of hormonal contraception pharmacists are permitted to prescribe, as well as other aspects of the policies, vary by state. For example, Colorado and Tennessee’s laws require qualifying pharmacists to enter into collaborative practice agreements with physicians.      

Expanding Access to Information for College Students 

United States map of Older Teen Birth Rates, 2015

Older teens and young adults have the highest rates of unplanned pregnancy among all age groups. While rates of unplanned pregnancy have declined across the board in recent years, older teens and women in their 20s are still more likely than other women of reproductive age to experience an unplanned pregnancy. In fact, women ages 20-to-24 account for one-third of all unintended pregnancies.

Despite declining rates, approximately 1-in-12 women ages 20-to-24 experiences an unplanned pregnancy each year. Similarly, while teen pregnancy rates have plummeted in recent years, the older teen birth rate (ages 18-to-19) is declining at a slower rate than the younger teen birth rate (ages 15-to-17). Older teens are more than four times as likely to become parents as are younger teens, and about 70 percent of all teen births are to 18- and 19-year-olds.      

Unplanned pregnancy among this age group can disrupt young peoples’ educational and career goals, as older teens and young adults are often entering the job market or pursuing postsecondary education. Nationally, unplanned births result in nearly 1-in-10 dropouts by women from community college. Sixty-one percent of students who have a child after enrolling in community college fail to complete their degree. This dropout rate is 65 percent higher than for those who do not have children during community college.   

Several states have targeted unplanned pregnancy prevention efforts to this population by providing information and services at community colleges and universities. Lack of relevant knowledge about how to prevent pregnancy, as well as lack of access to effective prevention services, can present barriers to preventing unplanned pregnancy.  

In response to these challenges, Mississippi and Arkansas recently enacted innovative policies to require community colleges and public universities to develop a plan to address unplanned pregnancy on their campuses. The plans must address eight different areas, such as incorporating information on unplanned pregnancy into student orientation and courses, conducting public awareness campaigns and increasing student access to health services. Most of the details of how to address these areas are left up to the individual schools, and content may include information on both abstinence and contraception. Louisiana passed a similar law in 2017.