The unintended pregnancy rate (reflecting pregnancies that are unwanted or mistimed) for women in the U.S. has hovered at around 50% for the last 35 years. Only recently has that rate dropped to 45%, but the burden continues to fall most heavily on poor, undereducated women, women from racial or ethnic minority backgrounds, and young women. Much talk has been swirling around social media (#IUD, #birthcontrol) and the news (simply Google “Trump IUD”) about women rushing out to get intrauterine devices (IUDs) post-Trump election, given the uncertainty about the future of the Affordable Care Act (ACA), Planned Parenthood, and access to abortions, in general. Google searches for “IUD” hit a historic high on November 9, the day after general election results. What we want to know is: what have women been waiting for?
IUDs and sub-dermal implants, collectively known as “LARCs” (long-acting reversible contraception methods), are the front-line recommendation for pregnancy prevention for adult women and adolescents alike. These devices, though highly effective, are significantly underutilized by American women. Less than 6% of American adult women use LARCs, with the use even lower among younger women. And this is despite a steady increase in use of LARCs nationally. LARCs have an effectiveness rate unmatched by other common methods of contraception with “typical use,” largely because they don’t depend on user compliance in the way that other popular methods do, like condoms and birth control pills. One recent analysis showed that 86% of women who relied on condoms and 61% of women who used birth control pills for pregnancy prevention would have an unintended pregnancy over a 10-year period, compared to only 1-2% of LARC users, given typical use patterns. LARCs on the market have been determined to be completely safe, with no risks for pelvic inflammatory disease, infertility, or ectopic pregnancy. The most common risk is abnormal bleeding, typically meaning that periods are lighter, although some spotting can occur, particularly in the 6 months after LARC insertion. Some women (us) rejoice over not receiving periods altogether, which is a common side effect (benefit!) of LARC use.
LARCs are a great method of birth control to be sure, so what is all the post-election fuss about? President-elect Donald Trump has threatened to repeal ACA, though now is saying that he will retain popular provisions like bans on exclusions for pre-existing conditions and allowing children to stay on parents’ insurance until age 26. Others have argued that these provisions are not possible without the insurance mandates of ACA. The fear among many women is that the covered birth control mandate of ACA will disappear, given the anti-birth control stance of the incoming administration. Here’s what we know about cost-sharing, mandates, and LARC use from Medical Care:
- Cost-sharing for LARCs significantly decreased post-ACA: 87.6% of claims examined showed no out-of-pocket expenses for IUDs in 2013 compared to 36.6% in 2010, before ACA.
- When costs are reduced, more women use LARCs: IUD initiation was less likely for those with high co-pays pre-ACA (adjusted risk ratio=0.65, 95% CI 0.64-0.67) compared to those with low co-pays pre-ACA.
- When mandates for birth control coverage by insurance exist, more women use birth control consistently: Pre-ACA, privately-insured women who lived in states with a birth control coverage mandate (about half of all states at the time of the study) were more likely to use birth control consistently (adjusted odds ratio=1.64, 95% CI 1.08-2.50).
So it’s true that if the birth control coverage mandate of ACA disappears, women are probably going to be less likely to have access to the most effective methods of birth control, possibly leading to an up-tick in unintended pregnancy rates in the United States. No doubt, poor women, racial/ethnic minority women, and young women will bear the burden of the economic, social, and health costs.
We don’t actually know yet what the fate of the birth control coverage mandate will be after the presidential inauguration. Some argue that Trump could stop defending lawsuits against the mandate or he could remove the mandate altogether. Others say that Hobby Lobby-like exemptions to the mandate could increase, and more alarmingly that funding could get cut off to Planned Parenthood and Title X clinics that absorb family planning costs. The issue of funding these clinics is expected to have far-reaching ramifications to women’s health in general, for family planning, breast and cervical cancer screening, immunizations for flu and human papillomavirus, and wellness visits. Whatever the scenario, any changes to ACA are likely to be far down the road and complicated. The worst-case scenario is that we return to pre-ACA trends where fewer people had insurance, but most insurers covered birth control anyway, given the excellent return on investment. Insurers, as it turns out are less moralists and more profit-makers.
On a population level, expanded access to LARCs, which the ACA birth control coverage mandate facilitates, could also result in lower rates of unintended pregnancy, teen pregnancy, and importantly for the incoming administration – reduced rates of abortion. In the ground-breaking St. Louis-based CHOICE study, LARCs were made available free of charge with same-day insertion (IUDs usually require at least two visits). Seventy-five percent of CHOICE participants chose a LARC method over other methods; LARC users in the study were 20 times more likely to avoid unintended pregnancy. As a result, there was a substantial reduction in abortions. In a similar regional effort, LARCs were made available for free through all Title X clinics in Colorado. Significant reductions in unintended pregnancies and abortions were found statewide – abortion rates fell by 34% for teens aged 15-19 and by 18% for young women aged 20-24 in counties that had the expanded LARC access.
As it turns out, LARCs are (still) great – for women, families, and communities, cities, and states. There are plenty of unknowns about ACA in a Trump presidency. But women shouldn’t wait around to find out. For those women and teens who are committed to preventing pregnancy, LARCs are a great choice. Providers shouldn’t wait around to find out what happens to ACA either. Rather, they should continue the push to uniformly implement recommendations that LARCs be used as a front-line defense against unintended pregnancy. And this includes obstetricians, gynecologists, family practitioners, pediatricians, and staff at local health departments that offer family planning. Policy-makers, from national to local levels, should note the benefits of the ACA birth control mandate:
- ACA increases access to birth control;
- Access to birth control results in fewer unintended pregnancies and abortions;
- Use of birth control saves communities from the real financial, emotional, societal, and health costs of unintended pregnancies.