Giving More Women the Choice Not to Get Pregnant

We're not making the use we should of forms of contraception that can dramatically reduce unplanned pregnancies and infant mortality.

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Mattie Quinn, Governing's health and human services reporter, wrote recently about how in just two years a rural region of Louisiana cut its infant-mortality rate in half, from 9 deaths for every thousand live births to just 4.7. The rate for the United States as a whole is 6 per thousand, so this region went from having 50 percent more infant deaths per thousand live births to a number about 22 percent lower than that of the country as a whole. Among the factors leading to this dramatic reduction was the promotion by Region 6 of the Louisiana Office of Public Health of long-acting reversible contraceptives (LARCs), such as intrauterine devices and arm implants.

In Generation Unbound: Drifting into Sex and Parenthood without Marriage, Isabel V. Sawhill, a senior fellow at the Brookings Institution, wrote in 2014 that "LARCs have been found, in practice, to be about forty times more effective than condoms and twenty times more effective than the pill at reducing the incidence of unplanned pregnancies." The key words here are "in practice." To be effective, the pill and condoms require nearly perfect planning, and human beings are far from perfect. The result, Sawhill writes, is that is that about half of all pregnancies in the United States are unintended, and among young, single women, 60 percent of births are unplanned.

Wider use of LARCs would seem to be a sensible, powerful approach to getting that number down, but only 5.3 percent of women who practice contraception in the United States use them, according to 2012 data cited by Sawhill. That compares with 8 percent in the Netherlands, 10 percent in the United Kingdom, 22.7 percent in France and 23.3 percent in Norway. Those countries have much lower infant-mortality rates than the U.S., according to data for 2017 published by the Organisation for Economic Co-operation and Development: 3.5 per thousand live births in the Netherlands, 3.8 in the U.K., 3.7 in France and 2.2 in Norway.

I am not arguing that there is a direct relationship between the two sets of data, but the vastly superior effectiveness of LARCs, given the vagaries of normal human behavior, means that women who employ this method of contraception are able to "set it and forget it," making not getting pregnant the default option.

There are at least three reasons why LARC use is lower in the U.S., and they need to be considered and addressed. First, as Quinn points out, among low-income populations there is "the impression of coercion, which harkens back to a history of involuntary sterilization in the early and mid-20th century." Sawhill notes that "there is a suspicion in some circles that family planning advocates are simply trying to reduce childbearing among the poor and minorities," while in fact most of those women "say they do not want to become pregnant as frequently as they do now."

Second, IUDs continue to have a bad rap because of serious problems, including infections, miscarriages and loss of fertility, associated with an early version called the Dalkon Shield, which Sawhill says "scared generations of women." But the research is clear: Today's LARCs are as safe as they are effective.

A third barrier to LARC use is their cost -- $500 to $1,000 or even higher -- relative to other forms of contraception, even though spread over the useful life of the device they are actually cheaper. But there's a strong case to be made that the initial costs are worth it. The state of Colorado, which makes LARCs available to all women based on a sliding scale ranging from no cost to full price, depending on income, experienced a drop in both birth and abortion rates between 2009 and 2014 of nearly 50 percent for teens aged 15-19 and 20 percent among women aged 20-24. The associated reduction in public spending across four entitlement programs was more than $54 million.

And consider this: For every unplanned pregnancy that does not occur, there are huge benefits in terms of a young woman's life chances. Since at least the 1970s, abortion has been one of the most contested issues in American life. Maybe those who favor, as I do, women's empowerment, ought to pay more attention to the prevention side. Surely a woman's right to choose should include her right to choose not to get pregnant until she feels fully ready to care for a child.

Former publisher of Governing and former mayor of Kansas City