March 14, 2016 Liz Borkowski, MPH 0Comment

Although the US still has a long way to go in preventing unintended pregnancies, an article published earlier this month in the New England Journal of Medicine had some good news:  The proportion of US pregnancies that were unintended dropped from 51% in 2008 to 45% in 2011. Lawrence B. Finer and Mia R. Zolna of the Guttmacher institute analyzed data on pregnancy intention from the National Survey of Family Growth, and note that the rate of unintended pregnancy declined for every income and education group and all racial and ethnic groups. Disparities still persist — rates are still highest among women with incomes below the federal poverty level and black women — but have narrowed.

Finer and Zolna consider several possible explanations for this decline. They find no compelling evidence that changes in sexual behavior or population composition are behind the reduction. They note that many women surveyed in 2009 reported planning to reduce or delay childbearing due to economic hardship, and that by 2011 more women may have intended to get pregnant as economic conditions improved. However, the explanation Finer and Zolna seem to find most compelling is the switch to more-effective contraception:

A likely explanation for the decline in the rate of unintended pregnancy is a change in the frequency and type of contraceptive use over time. Evidence shows that the overall use of any method of contraception among women and girls at risk for unintended pregnancy increased slightly between 2008 and 2012. More important, the use of highly effective long-acting methods, particularly intrauterine devices, among U.S. females who used contraception increased from 4% to 12% between 2007 and 2012, and this increase occurred in almost all demographic groups.

At, Sarah Kliff reports on the increase in use of long-acting reversible contraception (LARC) methods and states, “What drove the rise of LARCs is still a bit of a mystery.” She notes that the Affordable Care Act’s contraceptive mandate, which requires insurers to make all contraceptive methods available to women without cost-sharing, wasn’t implemented until 2012, which is after the unintended-pregnancy decline reported by Finer and Zolna. She reports that Finer mentions the introductions of newer IUDs in recent years, as well as providers’ improved understanding of who is a good candidate for an IUD as potential contributors. (For instance, until fairly recently, providers tended to recommend IUDs only for women who’d already given birth.) Finer also tells Kliff that as more women use LARC methods, they tell their friends about them, which creates a snowball effect.

I can think of a few statewide initiatives that probably contributed to LARC use increasing between 2007 and 2012:

California’s Family PACT: Under a Medicaid State Plan Amendment, California extends Medicaid coverage for reproductive-health services to California residents with incomes up to 200% of the federal poverty level. All forms of contraception are free for beneficiaires. From 2008 to 2010, the California Department of Health Care Services’ Office of Family Planning educated Family PACT providers on LARC methods and offered trainings on IUD insertion. For many years, the proportion of female clients receiving IUDs had remained at 5%, but by FY 2011-2012 it was up to 10%.

Colorado Family Planning Initiative: This program, launched in 2009, gave funds to all of the state’s Title X family-planning providers to train staff, expand clinic hours and service, and purchase IUDs and contraceptive implants. The providers’ low-income clients could then receive LARC methods at no cost. As I’ve written before, the initiative’s launch was followed by sharp drops in both the teen pregnancy and abortion rates, and by a decline in preterm births.

Iowa Initiative to Reduce Unintended Pregnancies: Launched in 2007, this program provided funding to Title X family-planning providers to train them on LARC use and allow them to purchase IUDs and contraceptive implants. A public marketing component spread the “Until You’re Ready, Avoid the Stork” message.  At the same time, the state was expanding Medicaid coverage for family-planning services. In 2006, the state began offering this coverage to residents with incomes of up to 200% of the federal poverty level, and in 2010, that limit rose to 300% FPL. (For more details, check out the November 2012 webinar from the HHS Office of Population Affairs.)

In addition to these statewide initiatives, the Contraceptive CHOICE project brought free LARC methods to thousands of women in the St. Louis area starting in 2007. I hope we’ll see more states investing in removing barriers to LARC use, and a continued decline in the percentage of pregnancies that are unintended.

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