Preventing unplanned pregnancy: Lessons from the states

In the context of a looming debate about women’s reproductive health, this paper reviews what we have learned about strategies for reducing unplanned pregnancies and births, especially at the state level. Our primary findings and conclusions are:

• Unintended pregnancies are at an all-time low in the U.S. but still represent about 45 percent of all pregnancies. (Unintended pregnancies include those that women themselves say they did not want or that occurred earlier than they desired. We use “unintended” and “unplanned” interchangeably in this paper.)

• About 40 percent of unplanned pregnancies end in abortion, while the other 60 percent result in a birth. The result is that about one-third of all births are unplanned.
• Unintended pregnancies and births are most common among young unmarried women, especially teens and the most disadvantaged. However, these groups have also seen the largest declines in unintended pregnancy rates in recent years.
• The reasons behind these declines remain somewhat obscure, but two potential reasons stand out. The first has to do with changes in social norms around women’s roles. More women are expected to work, to get some postsecondary education, and to support their families, which make unplanned childbearing more costly and the benefits of delay much greater. The second reason is greater access to and increased use of the most effective forms of contraception, such as long-acting reversible contraceptives. Other factors that could have played a role include the Great Recession and a decline in sexual activity.

• Low-income women tend to have the least access to contraception through employer-sponsored health insurance, and many rely on publicly subsidized family planning services. Two key federal programs that provide contraceptive coverage for low-income women include Title X family planning grants and Medicaid. The Affordable Care Act (ACA) also increased access to contraception. Efforts to curtail those services are now underway, fueled mainly by religious or moral beliefs.
• State initiatives, often in collaboration with philanthropic funding, have played a positive role in preventing unplanned pregnancies by expanding access to family planning services. Studies of programs in Missouri, Colorado, Iowa, Delaware, and Utah suggest that such efforts have had some success. They have involved some combination of training providers, making the most effective forms of contraception more available or affordable, screening for pregnancy intentions in health visits, or educating potential users via the internet, TV, or social marketing campaigns.
• These state initiatives have not only led to declines in unplanned pregnancies but have also contributed to declining abortion rates and lower government costs for health care and social assistance.
• Efforts to provide women with affordable reproductive health care remain contentious on both the right and the left. Some conservatives are concerned about casual sex outside of marriage and often have religious reasons for opposing birth control, as well as abortion. Some liberals worry about discrimination against poor women or women of color and emphasize the need for opportunity-enhancing policies that would give less advantaged women a reason to delay. States are dealing with these issues in pragmatic ways and showing what can be accomplished in the process.
• While the controversies persist, most people agree that empowering women to have only the children they want has positive benefits for everyone in the form of better pregnancy outcomes, improved child well-being, more opportunities for women and their partners, reductions in costs to governments, and lower abortion rates.