Last week, Vox’s German Lopez highlighted a recent study that demonstrates how improving access to the most effective contraceptives can slash the rates of unintended pregnancies and abortions among teens. After the Colorado Family Planning Initiative (CFPI) started providing free IUDs and implants to low-income women at family planning clinics, the teen birth rate and abortion rate dropped sharply. Lopez notes that the teen birth rate has been declining nationwide, but Colorado’s has dropped more quickly: “Between 2008 and 2012, the state went from the 29th lowest teen birth rate in the nation to the 19th lowest.”
A study by Sue Ricketts, Greta Klingler, and Renee Schwalberg, published in Perspectives on Sexual and Reproductive Health’s September 2014 issue, describes the project and research findings in greater detail. In 2009, the Colorado Department of Public Health and Environment began using private money from an anonymous foundation to allow Title X family planning clinics to provide long-acting, reversible contraceptive (LARC) methods for free. (Title X centers provide cost-effective family planning and related preventive health services to low-income men and women; Kim wrote about Massachusetts Title X providers last year.) The funding supported purchase of IUDs and implants as well as training for providers and staff and technical assistance. Ricketts and her colleagues explain why in the past LARC methods have not been widely used by adolescents, despite being recommended:
LARC methods—implants and IUDs—have been shown to be effective in reducing rates of unintended pregnancy among adolescents, and their use in this population is endorsed by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the World Health Organization.[1, 2] Compared with the pill, patch and ring, LARC methods have low failure rates and a reduced likelihood of noncompliant use, which make them particularly suitable for adolescents. Increasing the use of these methods is a recommended strategy to reduce rates of unintended pregnancy. Among all users of Title X–funded family planning clinics in 2011, however, the IUD and implant were used by only 2% of clients younger than 20.
A number of barriers to LARC use among young women and others at high risk of unintended pregnancy have been described. Two barriers are the low level of awareness among consumers and providers of the availability, safety and appropriateness of LARC methods for both parous and nulliparous young women and the time required for counseling about these methods.[5, 6] In addition, high initial costs pose a substantial barrier to greater utilization. In the longitudinal Contraceptive CHOICE Project in St. Louis, 70% of women aged 14–20 chose LARC methods when cost was not a factor. Between 2008 and 2010, the researchers observed declines in the abortion rate, the proportion of abortions that were repeat procedures and the teenage birthrate in the St. Louis area. Furthermore, these rates were lower than those in comparable areas without the study program.
Under the Affordable Care Act, private insurers must cover all FDA-approved forms of contraception, including LARCs, without cost-sharing. States’ Medicaid programs must also cover contraception, but Medicaid eligibility varies substantially from state to state. Uninsured women may still find the costs of LARCs, which can total several hundred dollars, too high. As Ricketts et al note, several states have either waivers or state plan amendments that allow them to use Medicaid funds to offer family-planning services to low-income women, but Colorado does not. (The Kaiser Family Foundation summarizes state waivers and SPAs if you want to see what your state offers.)
Another issue is that young women covered by their parents’ insurance may not want to use that insurance when seeking family-planning services. Title X centers will provide confidential services on a sliding-scale fee basis, so young women can receive the services they need even if they don’t hand over an insurance card. Having such policies means that it can be hard for Title X providers to afford to stock a lot of IUDs and implants, though. Ricketts and colleagues explain that these LARC methods can cost clinics $300-$500 even with special pricing; they report, “Clinics had historically struggled to meet the demand for these two methods within their limited budgets and sliding-fee requirements, and many offered only limited numbers of LARC insertions.”
The bottom line here is that the privately funded CFPI made it possible for Colorado’s Title X providers to greatly improve their clients’ access to LARCs. Before the initiative, only 5% of Title X female clients ages 15-24 used LARC methods; by 2011, that climbed to 19%. Statewide, the birth rate for teens ages 15-19 dropped 26%. Researchers also examined abortion rates for this age group in 37 counties where Title X-funded clinics are located and those in 27 “non-CFPI” counties. They found a 34% drop in abortions among teens ages 15-19 in CFPI counties, and a drop of 29% in non-CFPI counties. Ricketts and her colleagues point out that teens living in non-CFPI counties may well cross county lines to receive family-planning services, so the initiative may have helped lower abortion rates statewide.
Lowering teen birth and abortion rates is a worthwhile public health goal on its own, but state officials with competing funding priorities will also want to know whether funding LARCs for lower-income women might let them reduce spending in other areas. The WIC infant caseload is a leading indicator of low-income births, because researchers can access WIC caseload data well before birth certificate data are finalized, Ricketts et al explain. (WIC, or the Special Supplemental Program for Women, Infants and Children, provides nutrition education and supplemental food for low-income pregnant and postpartum women and for children up to age five who are determined to be at nutritional risk.) Ricketts and her colleagues report:
Continuing a decades-long trend, the number of infants receiving WIC benefits grew steadily in the two years preceding the Colorado Family Planning Initiative, from 24,513 in January 2007 to 26,766 in December 2008 (Figure 2). In 2009, when CFPI began, the number leveled off; it ended the year at 26,862. Subsequently, the number rose to 28,978 in March 2010 and then dropped sharply; by March 2013, it had fallen to 22,407, a level well below that for any month since early 2005. The number of infants served by WIC, which had risen 18% between January 2007 and March 2010, fell 23% in the following three-year period.
Having fewer state residents with incomes low enough to qualify them for various forms of assistance translates to lower expenditures on a variety of programs. In just a few years, Colorado’s experience has demonstrated that investing in LARC accessibility can translate quickly into savings. Benefits to the women receiving LARCs may be harder to quantify, but are substantial. “This initiative has saved Colorado millions of dollars,” said Governor John Hickenlooper in a news release announcing the findings. “But more importantly, it has helped thousands of young Colorado women continue their education, pursue their professional goals and postpone pregnancy until they are ready to start a family.”
I hope these findings (and many others published over the years showing an excellent return on family-planning investments) will prompt other states to increase their investments in family planning for lower-income women. The trend in several states and at the federal level, though, has been for family-planning budgets to fall or remain stagnant despite growing demand. Some of this is likely due to overall budget-cutting pressure, and some to hostility toward women being able to control their reproductive timelines. The evidence is clear, though: improving women’s access to effective contraception pays off financially and for public health.
Updated 12/13/15 to add links to posts about the future of this successful Colorado program:
Will successful Colorado program to prevent teen pregnancies survive?
Private foundations fund another year of Colorado’s successful family planning program