Barriers to Contraception: or “Why Is Every Other U.S. Pregnancy Still Unplanned?

Nearly one out of every two U.S. pregnancy is unplanned, a statistic that has remained unchanged for the last 20 years.  Other ways of looking at this statistic is that approximately 5% of women aged 15-45 in the U.S. have an unplanned pregnancy in any given year.  Of these unplanned pregnancies about 20% ar unwanted, and about 30% are mistimed.  One consequence of this is that there are about 1.2 million abortions in the U.S. annually. The reasons for these depressing statistics are many.  It is easy to place the blame on this on the men and women who together generate these unplanned conceptions, but it may be more fruitful to look at institutional policies and barriers to contraception that play at least some role.  Let’s look at some of the policies, misconceptions, myths, and beliefs that together create significant barriers to adequate contraception in the U.S. today.

  • Financial Barriers:  In the U.S. large numbers of people lack affordable access to medical care.  The most effective means of contraception, the set-and-forget options including IUDs and implantable contraceptive rods, as well as birth control pills and other hormonal means of contraception require a prescription, i.e. access to medical care.  The American Congress of Obstetricians and Gynecologists (ACOG) recommended that birth control pills become available without a prescription last year.  Still no manufacturer has applied to the FDA for approval to sell the pill over-the-counter (OTC).   I recently posted about a large study showed that free and aggressively marketed contraception might reduce unplanned pregnancies by up to 80%.
  • Non-compliance with Contraceptive Use:  Most means of contraception require at least some degree of user compliance.  On the high end of user-dependent compliance are condoms, the diaphragm, and “natural family planning” (timing intercourse to the less fertile times of the women’s cycle).  All of these methods have high actual-use failure rates and lead to millions of unplanned pregnancies due to user non-compliance and to a lesser degree to method failure. Even birth control pills and their non-oral similar means like the patch and intra-vaginal ring require significant user compliance.  Actual failure rates with birth control pills are much higher than their theoretical efficacy rates, largely due to forgetting to take the pill daily, to use of antibiotics that can reduce efficacy rates, or other user related errors.  This unacceptably high failure rate has led to leading groups like ACOG recommending set-and-forget methods as the best choice for adolescent sexually active women.
  • Emotional, Religious and Family Issues:  I regularly see teens in the office who are sexually active yet who choose not to use effective contraception because they are afraid that their parents will find out that they are sexually active if they use the pill, or get a more effective set-and-forget method.  I speak with parents who feel that helping their daughters get effective contraception is giving their blessing to sexual behaviors they do not condone. I much less commonly see Catholic women who do not want to conceive but do not feel they can use contraception.  I hear young patients often who use condoms only as their contraceptive method of choice, even though they know the failure rate is high.  Part of this is a failure to clearly understand the need for condoms to reduce sexually transmitted infection risks, but the additional need for more reliable contraception to avoid unplanned and undesired pregnancy.
  • Contraceptive Failure:  Only abstinence as a means of contraception is perfect, and abstinence-only as a population based approach just does not work.  All others have failure rates that are not 0%, but some are much less perfect than others.  Many physicians and patients alike believe that birth control pills are nearly always effective, but their failure rate is about 5% annually.  The set-and-forget methods are very effective.  Failure rates of less than 1% annually can be expected with IUDs, Depo-Provera® and Nexplanon®.  Failure rates with every other non-permanent method is significantly higher.  Condoms have failure rates in actual use studies ranging from 11-16%. Diaphragm with spermicide use has a failure rate of about 15% annually.  No contraceptive use at all has an approximately 85% chance of conception annually in sexually active couples.   I have become convinced set-and-forget methods of contraception are the best option for prevention of unplanned pregnancy in teens, young single women, and others who strongly want to avoid conception. The rate of unplanned pregancy is enough higher with all of the other methods that the set-and-forget methods should be used in their situations most of the time.

So what could we as a nation do to markedly reduce unplanned pregnancies?

  • Make contraception free to all Americans.
  • Remove financial barriers and work to reduce emotional and cultural barriers to contraceptive advice and implementation.
  • Make many types of birth control that do not require provider instrumentation available without prescription. In the case of birth control pills this may require a “white-knight” type company to apply to the FDA for approval first to remove the financial disincentive the pharmaceutical industry has to losing their monopoly on prescription-only pills.  Payment for an OTC pill may be a barrier in and of itself, but I suspect providing this option would overall improve access.

Leave a comment if you have thoughts on this topic, or ideas of better ways to reduce the unacceptable rate of unplanned pregnancies in the U.S.


2 Responses to Barriers to Contraception: or “Why Is Every Other U.S. Pregnancy Still Unplanned?

  1. Shocked, It is shocking. The combination of poor access, cost barriers, compliance with user-dependent methods and contraceptive failure all added up results in high unplanned pregnancy rates. We as a nation really could do better. DrP.

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