New birth-control rules may shake up behavior

In the battle over birth control, one fact often is overlooked: Women typically spend the bulk of their reproductive lives trying to avoid getting pregnant.

Out of more than three decades of fertility, the time women spend trying to conceive a baby, carrying one or in the postpartum period amounts to about five years, according to the Guttmacher Institute. As soon as women start having sex, the burden is on them to keep their bodies from making baby after baby, unless that's what they want.

The statistics paint a mixed picture. Half of all U.S. pregnancies are unintended, a rate that's unchanged since 1981, and about one in three women will have had an abortion by the time she's 45.

The focus of prevention efforts is often on teenagers, but their unintended pregnancy rate is lower than that for young single women. About seven in 10 pregnancies among unmarried women in their 20s are unplanned, according to the National Campaign to Prevent Teen and Unplanned Pregnancy, a nonprofit group in Washington.

"While teen pregnancy has gone down considerably, the unplanned pregnancy rate among their older brothers and sisters has remained stubbornly high," said Bill Albert, the campaign's chief program officer.

But that soon may change. New regulations put out this week by the U.S. government promise to make it easier for women to prevent unintended pregnancies and may even lead to wiser birth-control purchasing decisions.

Starting next year at the earliest, health plans will have to cover contraception and seven other women's preventive-care items without charging a copay, coinsurance or deductible, the Health and Human Services Department announced Monday. Newly covered will be all contraceptive methods approved by the U.S. Food and Drug Administration such as birth-control pills, patches, injections, implants, vaginal rings, condoms, sterilization, intrauterine devices (IUDs) and emergency or "morning after" pills that prevent pregnancy.

"Given that we're in a new age of fiscal austerity, this makes sense from a political and budgetary standpoint," said Adam Thomas, research director for the Center on Children and Families at the Brookings Institution in Washington. "There's a fair bit of research showing that unintended pregnancy is, among other things, enormously expensive for taxpayers."

Medicaid and the Children's Health Insurance Program, for example, spend $12 billion a year providing health care to low-income women with unintended pregnancies and for medical care during the infant's first year of life, according to a study that Thomas coauthored.

At the same time, contraception's return on investment is impressive. Every $1 spent providing subsidized birth control to people who want it ends up saving $4 to $6 down the road, Thomas said.

"Evidence-based pregnancy prevention programs pay for themselves even if you make pretty conservative assumptions about how effective they are and what kind of savings they're producing."

What's more, health and social disparities between children who were planned and those who weren't often continue through childhood, he said. "Kids whose births were intended are more likely to fare well in school, have fewer behavioral problems and are healthier on average."

The new regulations may shift the focus to what the medical community calls LARCs: long-acting reversible contraception such as IUDs and implants, Albert said. They typically come with higher price tags but may be more attractive to women than other methods because they're more convenient and less prone to failure if you forget to take a pill every day, for example.

An IUD provides maintenance-free protection until a doctor removes it, typically after years or even a decade of use. But the initial out of pocket cost often runs hundreds of dollars.

The new regulations should neutralize the potential cost barrier.

"This might have the effect of encouraging women to use more effective and long-lasting contraception," Albert said. "Nearly all young adults use contraception. Too few of them use it consistently. That's why it's really encouraging to think that these longer-acting methods hold some real promise."

Both Albert and Thomas agree that the government would be wise to follow up with a kind of 21st century sex education since many people have outdated birth-control notions.

"We need to educate people about the extraordinary number and diversity of contraceptive methods out there," Albert said. "We need to let them know they are safe and reliable when used properly."

"The fact of the matter is people have sex and if they're not planning to get pregnant or cause a pregnancy, they need to use contraception," he said.

Of course, cost is only one potential barrier to using birth control consistently and effectively. Some people underestimate their fertility, don't believe contraception works, have an exaggerated fear of side effects or have trouble remembering to keep up with their birth-control protocols.

But where cost barriers exist, the new rules will go a long way to help rebalance access, said Dr. Vanessa Cullins, vice president for medical affairs at Planned Parenthood Federation of America, based in New York.

"What this recommendation does is level the playing field between affluent women and less affluent women, the ones who have rich health benefits plans and those who have less rich benefits plans," she said.

Planned Parenthood wants to make sure vasectomy, male sterilization, is covered as well as female sterilization, she said.

As part of the health-reform law signed by President Obama in 2010, the Department of Health and Human Services asked the independent Institute of Medicine (IOM) to determine what gaps women may face in their health coverage. The IOM studied the issue and recommended that health insurers be required to offer first-dollar coverage in these preventive-care areas:

• All contraceptive methods approved by the U.S. Food and Drug Administration, and counseling about birth control.
• Screening for gestational diabetes in pregnant women.
• Human papilloma virus testing for women age 30 and older.
• Screening and counseling for HIV, the virus that causes AIDS.
• Lactation support services and breast-pump rentals. About 80 percent of breastfeeding mothers use a breast pump at some point, and 30 percent of them use a rental, according to Medela Inc., a maker of breast pumps based in McHenry, Ill.
• Domestic violence screening and counseling.
• Counseling about sexually-transmitted infections.
• Well-woman doctor visits.

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