Imagine the U.S.with 80% less unplanned pregnancies. The consequences of this would be myriad, but is it really possible to reduce unplanned pregnancies by 80%? It turns out that the answer is probably yes, because that is exactly the outcome of a St. Louis study of nearly 10,000 women recently, along with major reductions in the incidence of first and repeat abortions. This may be a great call to action for America as a whole, and a natural consequence of the decision to include contraception as a preventative service under the Affordable Care Act mandate to provide no-cost preventative services. With the reelection of President Obama the free access to covered preventative services is relatively assured, so this discussion is especially relevant today.
A recent report in Obstetrics and Gynecology presenting information detailing what happened in St. Louis during a 4 year program called the Contraceptive CHOICE Project between 2006-2009 gives strong evidence that providing no-cost contraception, especially the long-acting reversible contraceptive methods discussed in an earlier post Best Contraception for Young Women, leads to lower rates of unplanned pregnancy and lower rates of abortion. The consequences of an unplanned pregnancy have a high chance of having long term negative financial impact on the woman involved. If she chooses abortion there is a modest financial impact and unclear emotional and psychologic sequellae, but if she chooses to give birth and raise her child the financial cost of the unplanned pregnancies to society is unquestionably high and can be compared to the cost of providing free contraception. It turns out by my rough calculations that providing no-cost contraception is a bargain too good to turn down from a fiscal point of view.
First let’s look at some data:
- In the Contraceptive CHOICE Project in St. Louis 9256 adolescents and women were recruited into the program that led to a reduction in the incidence of abortion when compared to surrounding areas (a reduction in abortions of 20% when compared to surrounding areas where no reduction was noted)
- The program also showed a reduction in teen pregnancies to 6.3/1000 vs. a national rate of 34.3/1000 and a rate in the surrounding areas similar to the national rate. The rate of repeat abortions was significantly reduced also.
Women involved in the CHOICE program chose long acting reversible contraception at a 75% rate.
- 46% chose a lovonorgestreol IUD (Mirena)
- 12% a copper IUD (Paragard)
- 17% subdermal implant (Implanon now Nexplanon)
- 9% birth control pills
- 7% contraceptive vaginal ring ( Nuvaring)
- 7% depo medroxyprogesterone acetate (Depo-Provera)
- 2% contraceptive patch (Ortho-Evra).
This is a far higher rate of use of the “set and forget” contraceptive options than in other circumstances, and has to be credited to both the emphasis of the more effective long acting reversible contraceptive methods and the lack of a cost a barrier to their use.
If we make some assumptions about the aftermath of an unplanned pregnancy and childbirth for a teen mother we can compare the costs to the U.S. and state governments of contraception to the cost of pregnancy related medical care and public assistance including Medicaid and welfare assistance to women and children. Given the choices of contraception in the CHOICE study it is likely that the upfront cost of contraception for a woman would be high. I estimate about $600./ woman. Let’s assume that this contraception would last for about 5 years. It is estimated that it would take treatment of about 100 woman/years to prevent one pregnancy, so that is 20 women over the 5 year period. At a cost of 20 x 600 = $12,000 to prevent one pregnancy, and an estimated 50% of these women choosing abortion and 50% childbirth would be $24K to prevent one unintended birth. The cost of care and 5 years of public assistance would be about $20K for the first year and $11K for each of the next 4 years, or a total of $$64K for the 5 years. I’m sure that there are lots more costs involved, as well as other savings involved, but at a high-level glimpse it looks like by providing no-cost long acting reversible contraception to teens we could save a great deal of money and empower many of these young women to go on to more productive and likely happier lives.
President Obama has stated that providing no-cost contraceptive care to women saves money, and that seems to make sense, but this analysis would tend to support that position. Any comments?