Although the rate is declining, each year 600,000 American teenagers
become pregnant; 30% will become pregnant at least once before the age of 20.
According to the National Campaign to Prevent Teen and Unplanned Pregnancy, in 2010, births by teenage mothers cost the country $9.4 billion in
health care, public assistance and lost income due to reduced
educational attainment, to say nothing of the long-term public health and social costs to teenage mothers and their children.
Dr. Gina Secura and her colleagues at
the Contraceptive CHOICE Project in St. Louis have published a case study of the effects of offering free long-term contraceptives to
teenage girls. The participants were 1404 adolescents between 14 and
19 who were enrolled in the program between 2007 and 2011. They were
recruited via referral from clinics, community flyers and word of
mouth. To participate in the study, they had to be sexually active
or say they were planning to be, and not want to become pregnant.
All participants received a
standard counseling session in which the risks and benefits of
alternative contraceptive methods were reviewed and questions
answered. After making a choice, participants were provided with
their chosen contraceptive option free of charge. Followup
interviews were conducted by telephone at three months, six months
and every six months thereafter for the next two or three years
(depending on when they enrolled). They received a $10 gift card for
each completed survey. The one, two and three year followup rates
were 92%, 82% and 75%. Rates of pregnancy, birth and abortion were
compared both to their age cohort in the general population and their
sexually active age cohort (since enrollment was limited to those who
were or planned to be sexually active). Here are the data, reported
as the number of pregnancies, births and abortions per 1000 in the
population.
CHOICE Project
|
U. S. Population
|
Sexually Active Teens
|
|
| Pregnancy |
34.0
|
57.4
|
158.5
|
| Birth |
19.4
|
34.4
|
94.0
|
| Abortion |
9.7
|
14.7
|
41.5
|
Comparing the CHOICE participants to
sexually active teens in the general population—the more
appropriate comparison group—shows that they became pregnant and
gave birth at 21% the national average, and had abortions at 23% the
national rate. The CHOICE Project reduced unwanted pregnancy more for older (18-19) than younger (14-17) girls, and more for
African-American than White participants.
The project was effective primarily
because the majority of participants—68.4% of the older and 77.5%
of the younger girls—chose long-acting reversible contraceptive
(LARC) methods, either the hormonal or non-hormonal IUD or the
etonogestral implant, rather than birth control pills, rings, patches
or injections. These methods don't require participants to remember to reuse them and have a close to zero failure rate. But fewer than 5%
of teenagers in the general population use LARCs. The researchers
report that most of their participants had never even heard of them.
The study doesn't separate the effects
of counseling, the contraceptive method, or the fact
that the contraceptives were free, and it's likely that all these factors played a
role. Other limitations of the study include its less than 100%
response rate, its reliance on self-report data about pregnancies, the
possibility that the followups reminded some participants to use
their contraceptives, and the requirement of parental consent for the
14 to 17-year-olds, who may have been at lower risk of pregnancy than
those whose parents did not consent. These drawbacks may be balanced
by the high percentage of African-American (60%) and poor teenagers
in the CHOICE Project, who are at greater risk of unintended
pregnancy than the general population.
Rarely do we have a chance to report a
study that is so effective in solving an important social problem,
and that provides such a vivid reminder of the superiority of prevention over remediation. The cost of these birth control methods
varied, with the LARCs being more expensive—$400 to $1000
depending on the method and the individual. To this must be added
the costs of recruitment, counseling and followup. All of
this is a pittance compared to the medical and social costs of
unwanted pregnancy. We have the technology; what we lack is the
political will.
In theory, the Affordable Care Act
requires insurance companies to cover all forms of contraception with
no co-pay, but there is no reason for insurance companies to publicize this option. And there are other problems:
- Doctors probably don't follow as good a script as the CHOICE Project counselors, and are not as aggressive in recruitment and followup. In general, doctors get paid less for time spent talking to patients than other activities.
- Teenagers, who are usually covered by their parents' insurance, may not seek contraceptives because the visit will show up on their parents' statements.
- According to the National Health Interview Survey, 18.4% of Americans aged 18-64 were uninsured during the first three months of 2014. Girls from uninsured families are probably at greater risk of unwanted pregnancy than those whose families are insured.
The Secura study argues strongly for a
single-payer health care system, not only to guarantee that everyone
is covered, but also because government can prescribe a uniform set of
procedures to be followed by doctors when discussing birth control
with teenagers.
Newspaper articles about the Secura study mention anticipated resistance from conservatives who believe that providing teenagers with contraceptives encourages sexual activity. But these
articles fail to mention that research doesn't support the claim
that education about contraceptives encourages teenagers to have sex. (That would be rude.) In
fact, the reverse is true. Comprehensive sex education is associated
with delayed or reduced sexual activity.
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