Preventing Unplanned Pregnancy

6/10/2021

Overview

Silhouette of a pregnant woman

Unplanned or unintended pregnancies include those that are unwanted, or were never desired, and those that are mistimed, or occur earlier than desired, as self-reported by women. The timing and spacing of pregnancy not only affect health, social and economic outcomes for individuals and their families, but also have broad societal implications. According to data from the Center for Disease Control and Prevention’s (CDC) Pregnancy Risk Assessment Monitoring System, states report unintended pregnancy rates ranging from about 22-45%. Rates of unintended pregnancy have declined in most states over the last few decades, yet disparities among groups persist.

Unintended pregnancy rates are highest among young women, low-income women and women of color. In particular, low-income Black and Hispanic women have much higher rates of unintended pregnancy than white women and women with higher incomes. According to a report published in 2016, women ages 20 to 24 experience the highest rate of unintended pregnancy and account for one-third of all unintended pregnancies. The rate of unintended births among women with incomes below federal poverty guidelines is more than five times greater than the rate among women with incomes of 200% of the federal poverty level or higher. The rate among Black women is more than double the rate among white women. 

Unintended pregnancies can pose certain health risks and may be associated with adverse outcomes for both mother and baby. Women with an unplanned pregnancy, for example, are less likely to receive prenatal care and may have a higher risk for postpartum depression and mental health problems later in life. Unintended pregnancies have been associated with higher rates of preterm birth and low birthweight, although some studies note the difficulty of separating confounding demographic factors from pregnancy intention. A fourth or subsequent pregnancy, for instance, is both more likely to be unintended and to have an adverse outcome. Children born as a result of an unplanned pregnancy may be more likely to fare worse in school achievement, social and emotional development, and later success in the labor market compared to children born as a result of a planned pregnancy. Unintended pregnancy may also be an important risk factor in predicting and understanding child maltreatment.

An unplanned pregnancy can also disrupt educational goals and severely affect future earning potential and family financial well-being—costs which extend to state budgets. One analysis estimated the immediate direct medical costs of unintended pregnancy to be $5.5 billion in 2018, an increase from $4.6 billion in 2011 despite declines in unintended pregnancy rates. A 2011 Brookings Institution report found that taxpayers spent between $9 and $12 billion each year on publicly financed medical care related to unplanned pregnancies, including immediate direct medical costs and infant medical care. A 2015 Guttmacher Institute report examined these and additional public medical care costs (e.g., the cost of medical care for children up to age 5) associated with unplanned pregnancy. It found that state and federal expenditures for unplanned pregnancy-related care totaled $21 billion in 2010, with public insurance programs such as Medicaid financing 68% of unplanned births compared to 38% 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 well-being.

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 includes options policymakers may consider to help prevent unplanned pregnancy, such as reimbursing providers for the full range of contraceptive services and removing administrative and logistic barriers to accessing long-acting reversible contraception (LARC), among others.

In response to the high costs of unplanned pregnancy 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 postpartum LARC insertion.
  • 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 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.

One strategy to assist women in their planning, called the One Key Question initiative, encourages primary care providers and other women’s health providers 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 30 states.

Several strategies aim to improve women’s knowledge of and access to the full range of contraceptive 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. It is estimated that only 1 in 50 women of reproductive age has 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 with limited 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 national study published in 2014 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 $7 saved for each dollar spent. These savings were primarily due to avoided medical costs from prevented unplanned pregnancies.    

Insurance Coverage for Contraception

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 study published in 2011 found that dispensing a one-year supply of birth control pills reduced the odds of an unplanned pregnancy by 30% compared to dispensing a 30- to 90-day supply of pills. The 2016 U.S. Selected Practice Recommendations for Contraceptive Use, published by the Centers for Disease Control and Prevention, also recommends dispensing up to a one-year supply of contraceptives to prevent unwanted gaps in use.

At least 21 states and the District of Columbia enacted legislation requiring insurers to increase the number of months they cover prescription contraceptives at one time. Most of these states require coverage for a one-year supply (e.g., West Virginia), while a few states cover a six-month supply (e.g., New Mexico and New Jersey). Some of these laws, including in Oregon, require a shorter, initial prescription to be dispensed first.

Several states have pursued additional strategies related to insurance coverage for contraception. For example, New Jersey codified the Affordable Care Act’s contraceptive method coverage provision in 2020, which requires most insurance plans to cover 18 FDA-approved categories of contraception without out-of-pocket costs for patients. At least 14 other states and the District of Columbia have enacted similar legislation and several also require coverage for additional types of contraception, such as vasectomies and over-the-counter methods. Two rules established in 2017 by the Departments of Health and Human Services, Treasury and Labor provide a federal exemption for employer-sponsored health insurance plans based on religious beliefs or moral convictions.

Medicaid Reimbursement for Postpartum LARC Insertion

Long-acting reversible contraception (LARC) methods are one of the most reliable and common 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 to be effective in preventing pregnancy. In addition, research shows that the immediate postpartum period is an ideal time to begin use of LARC to prevent a future unplanned pregnancy.

Approximately half of women with Medicaid coverage do not attend a postpartum visit. LARC insertion immediately after giving birth may be some women’s best opportunity to receive birth control services to space or prevent a subsequent pregnancy. The Centers for Medicare & Medicaid Services released an informational bulletin in 2016 detailing state Medicaid payment strategies to optimize LARC utilization.

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 postpartum birth control, at least 43 states and the District of Columbia have published guidance allowing Medicaid to reimburse providers for postpartum insertion of LARC as a separate service, according to the American College of Obstetricians and Gynecologists.  

State health officials report a variety of postpartum LARC initiatives, such as training providers or improving billing logistics. The Association of State and Territorial Health Officials (ASTHO) conducted two rounds of a learning community that convened state health agency representatives from 13 states to assist in implementing postpartum 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 postpartum LARC. In addition, ASTHO  provides resources and state examples that may be helpful for state leaders interested in increasing access to postpartum LARC.    

Pharmacy Access to Contraception

Allowing pharmacists to prescribe and dispense certain types of hormonal contraceptives without a prescription from a physician is an additional state strategy to improve access to services. 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.

Pharmacist prescribing 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. Pharmacies are often located conveniently in communities—nearly 90% of Americans live within five miles of a pharmacy—and can relieve certain barriers to accessing birth control, such as time constraints and transportation costs.

At least 14 jurisdictions allow pharmacists to prescribe some hormonal contraceptives. Some states may allow pharmacists to dispense hormonal contraceptives under a standing order or consult agreement with a licensed physician, but not to prescribe them. The types of hormonal contraception pharmacists are permitted to prescribe, as well as other aspects of the policies, vary by state. For example, laws in Colorado and Tennessee require qualifying pharmacists to enter into collaborative practice agreements with physicians. Pharmacists may also be required to complete specialized training before prescribing contraceptives, depending on the laws and regulations in the state.

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.    

Expanding Access to Information for College Students

Older teens and young adults have the highest rates of unplanned pregnancy. While rates of unplanned pregnancy have declined, 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.

Similarly, teen pregnancy rates have plummeted in recent years, but 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 younger teens, and about 75% of all teen births are to 18- and 19-year-olds.      

Unplanned pregnancy among this age group can disrupt young women’s educational and career goals, as older teens and young adults are often entering the job market or pursuing post-secondary education. Nationally, unplanned births result in nearly 1 in 10 female community college students dropping out because of unplanned motherhood. Sixty-one percent of students who have a child after enrolling in community college do not complete their degree. This dropout rate is 65% 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, as well as lack of access to effective services, can present barriers to preventing unplanned pregnancy.  

In response to these challenges, Mississippi and Arkansas enacted innovative policies in 2014 and 2015, respectively, to require community colleges and public universities to develop a plan to address unplanned pregnancy on their campuses. Louisiana passed a similar law in 2017. 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 are left up to the individual schools, and content may include information on both abstinence and contraception. The states’ action plans, guides or annual reports pursuant to these laws can be found at the Arkansas Division of Higher Education, the Women’s Foundation of Mississippi and the Louisiana Board of Regents.

Among other state efforts targeting unplanned pregnancy among teens and young adults, the Colorado Department of Public Health and Environment established the Colorado Family Planning Initiative (CFPI) in 2008 to provide low- or no-cost LARCs to low-income women throughout the state. A public outreach campaign, Beforeplay.org, provided information and encouraged young people to utilize services offered through CFPI—including presentations to and assistance with student groups at 30 of Colorado’s colleges, community colleges and universities. In the first five years, these efforts yielded reductions in unintended pregnancy rates throughout the state, including cutting the teen birth rate in half and the birth rate among women ages 20-24 by 20%. In addition, the program avoided nearly $70 million in in public assistance costs. After the initial funding mechanism expired in 2015, Colorado enacted legislation to continue funding these services through the state’s ongoing family planning program.