Reducing poverty by cutting unplanned births

Half of all pregnancies in the U.S. are unplanned. Among unmarried women under 30 the proportion is close to three-quarters. Some of these pregnancies will be terminated, but many women go on to have children that they (and their partners) are not ready to parent. The result is high rates of poverty and less social mobility among children in the U.S.

There is a solution: it’s called long-acting reversible contraception (or LARC). LARC methods include the intrauterine device (IUD) and the implant.

Efficacy And Safety

The reason for such high rates of unplanned pregnancies is some combination of nonuse and inconsistent use of birth control. If a woman is sexually active for five years, her chance of getting pregnant is 63 percent with condoms, 38 percent with oral contraception, but less than 2 percent with a LARC. LARCs are more effective because they change the default from accidentally getting pregnant unless you are a very careful and consistent user to NOT getting pregnant until you and your partner decide that you really want a child and choose to have the IUD or the implant removed.

Three questions are often raised in connection with this issue. The first is: are these pregnancies really unplanned? Data collected by the National Survey of Family Growth, covering over 20,000 individuals and asking about the intentionality of a conception at the time a women first learned of her pregnancy, show that unplanned pregnancy rates are not just high overall, but much higher for the most disadvantaged and for racial minorities. This conflicts with the commonly held belief that these women really “want” these children because of their limited options in the workforce.

Although there is often some ambivalence about these pregnancies, if the data are to be believed, unplanned pregnancies are a widespread problem among the least advantaged. To be sure, some small-scale field work in very disadvantaged communities has suggested that babies are a source of pride and validation in low-income communities. Most parents who have an unplanned birth want the best for their children, but it is not an auspicious beginning for a child to be born in such circumstances. Too often, the parents have not completed their educations, are not in a stable relationship, and have not yet found steady employment.

A second question is whether LARCs are safe. Because of earlier very serious problems with the Dalkon Shield, many women and even some doctors doubt the safety of these devices. Yet the American College of Obstetricians and Gynecologists and also the American Academy of Pediatricians have recently recommended them for all women as a means of pregnancy prevention, regardless of age or whether they have had a baby.

The third and related question is will women, especially teens or lower income women, choose a LARC if it is offered? We now have a body of evidence that they will. When patients are given a choice of contraceptive method and the effectiveness and safety of a LARC are carefully explained to them, we see high take-up rates of LARCs and a reduction in unplanned pregnancies.

Programs in St. Louis, in Colorado, and Iowa, and clinics around the country in a University of California San Francisco (UCSF) research study have all shown similar results. In the UCSF study, recently reported in the Lancet, clinics were randomly assigned to a treatment group where women received extra counselling and a control group that did not. Despite the fact that LARCs were not offered for free (as they have been in Colorado and St. Louis, for example), there was not only a high take-up rate of LARCs but the rate of unplanned pregnancies was cut in half. Other studies show that for each dollar invested the savings to Medicaid and other social programs are about 5 or 6 dollars.

Reducing Child Poverty

If we could reduce unplanned pregnancies, we would also reduce child poverty and improve social mobility. In my 2014 book, Generation Unbound, I estimate that the growth of single parent families, now driven almost entirely by unwed and unplanned childbearing, has led the child poverty rate to be 25 percent higher than it would be if we had stabilized the proportion of such families at 1970 levels. Put differently, even our largest and most expensive safety-net programs, such as Supplemental Nutrition Assistance Program (SNAP or “food stamps”) or the Earned Income Tax Credit, are swimming against a demographic tide that is pushing up the poverty rate almost as fast as these programs can reduce it.

In my view, these social programs are badly needed to help such families cope and to provide more opportunities for the less advantaged to climb the economic ladder. But this will take a commitment of resources that is not likely to be forthcoming in the near future. In the meantime, by building on the success of the efforts mentioned above, we could not only help women achieve their own desires but enhance the life prospects of their children as well.

LARCs are a winner — for women, for children, and for taxpayers.

Editor’s note: This piece originally appeared in Health Affairs Blog.