Tuesday, October 09, 2012

Does providing free contraceptives lower the abortion rate?

Researchers at Washington University in St. Louis and the Contraceptive Choice Project have released a study which found that when women were given free contraceptives, the rates of unintended pregnancy and abortion decreased.  Here's how Time describes the women in the study:
The researchers enrolled 9,256 women from the St. Louis region into the Contraceptive Choice Project between August 2007 and September 2011. The women were aged 14 to 45, with an average age of 25, and many were poor and uninsured with low education. Nearly two-thirds had had an unintended pregnancy previously. Participants were either not using a reversible contraception method or willing to switch to a new one.
So we have women who are open to using contraceptives or at least switching which kind they use.  This is obviously a sub-group of women.

And the results:
Over the course of the study, which lasted from 2008 to 2010, women experienced far fewer unintended pregnancies than expected: there were 4.4 to 7.5 abortions per 1,000 women in the study, after adjusting for age and race — much fewer than the national rate of 19.6 abortions per 1,000 women and lower also than the rate in the St. Louis area of 13.4 to 17 abortions per 1,000 women.
But the key point of the study is here:
Researchers provided free, FDA-approved birth control to the women for three years. The women were given their choice of contraception, including oral birth control pills and long-acting reversible contraceptive (LARC) methods like implants and IUDs. The researchers specially briefed the participants on the "superior effectiveness" of LARC methods — the T-shaped IUD, or intrauterine device, has close to 100% effectiveness and can last five to 10 years, for instance — and 75% of women chose those devices over the pill, patch or ring.
So the results don't say that providing women with any kind of free contraceptives reduces unplanned pregnancies but rather that briefing women who are willing to switch contraceptives to (or rather strongly encouraging women to use) long term contraceptive methods which are more effective and getting a large percentage of women to use those methods reduces unplanned pregnancies. 

This is basically like saying implantable contraceptives have higher success rates.  Duh, that's not news.  That's something we already know.  The only novel thing about this study is the high percentage of women (75%) the researchers convinced to go on long-acting implantable contraceptives.  They accomplished this because it was the primary goal of their study ("To promote the use of long-acting reversible contraceptive (LARC) methods"). 

While they accomplished their goal, their research flies in the face of the contraception choices of most American women whose top choices for contraception have been the pill, sterilization (female and male), and condoms.  IUDs are typically chosen by less than 10% of the female population.  To get a 75% of women using contraceptives to use implantable methods, that would take every OB/GYN pushing implantables as if they were used car salespeople.

The Time article (probably based on the study's authors) attempts to act like the reason women don't typically choose to use IUD is the higher up front.
Yet American women use LARC methods at far lower rates than in other countries. In large part, that's because of cost: upfront costs to implant an IUD, which requires a doctor visit, can total $500 to $1,000, for example. Over a decade, however, birth control pills can cost just as much. American doctors also tend not to recommend long-acting birth control to women as often as they do the pill or patch, though IUDs and implants may be up to 20 times more effective.
If this is true, then why does the percentage of women using IUDs barely change based on income (table 11)?  It goes from 5.5% for women in households with incomes ranging from 0-149% of the poverty level, 5.5% for women in the 150%-299% level and 5.9% in the 300%+ group. 

As I've noted over and over again, the cost of contraceptives is not one of the top reasons why women aren't using them (or aren't using them consistently).  

There are still a large number of reasons why most women don't want to use implantable contraceptives. Cost is likely one of them but certainly not something that by itself is going to get anywhere near 75% of women on contraceptives using implantable contraceptives.  

So attempting to take this study and act like it proves Obamacare and it's provision forcing employers to cover contraceptives will dramatically lower the abortion rate simply assumes too much.  It assumes all women of child-bearing age are like the women in this study, it assumes 75% of those women will use implantable contraceptives if provided for free, and it assumes the federal subsidized abortion coverage won't increase abortion numbers. 

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