Editorials

Contraception policies in the US are reactionary

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8069 (Published 30 November 2012) Cite this as: BMJ 2012;345:e8069
  1. Michelle J Hindin, associate professor,
  2. Michele R Decker, assistant professor,
  3. Caroline Moreau, assistant professor
  1. 1Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
  1. mhindin{at}jhsph.edu

Time to forget political posturing and focus on the evidence of gains from preventing unwanted pregnancies

Over the past decade in the United States, contraception has become a political issue rather than a public health prevention strategy, despite evidence that easier access to contraception reduces unintended pregnancy,1 thereby improving women’s and children’s health. Only 5% of unintended pregnancies occur among the two thirds of US women at risk of unintended pregnancy who practice contraception consistently and correctly.2 In 2006 alone, publicly funded contraception averted an estimated 1.94 million unintended pregnancies, which translated into about 860 000 unintended births, 810 000 abortions, and 270 000 miscarriages.3 Contraceptive services are cost effective. Every $1 (£0.62; €0.77) spent on public funding for family planning saves $3.74 in pregnancy related costs, with annual savings of $19.3bn.4 Protection against unintended pregnancy, particularly in adolescents, leads to gains in education, employment, and wealth in the longer term.5 Contraception also prevents unintended pregnancy in the 18% of women who experience sexual violence and lack control over when and with whom they have sex.6

Nevertheless, in the US, at federal and state levels, essential contraceptive services—including publicly funded clinics, insurance coverage for clinical contraceptive services and effective contraceptive methods, and over-the-counter contraceptives—have been seriously threatened. Restrictive policies, both proposed and enacted, are eroding women’s and men’s financial and physical access to contraception. The Affordable Care Act met serious resistance because of its proposed mandate for coverage of contraception by employer funded insurance. In response, the latest Health and Human Services Funding Bill for the fiscal year 2013 contains a provision ensuring “conscience protections” for organizations, which allows them to deny contraceptive coverage for their employees on moral grounds. In 2011, the Obama administration over-ruled the recommendation from the Food and Drug Administration to allow over-the counter (non-prescription) status for emergency contraception for women under the age of 17 years. The House of Representatives has repeatedly considered bills to cut all funding to Title X, a program enacted in 1970 to provide comprehensive contraceptive services and reproductive healthcare to all in need.

Such political opposition is fueled by “moral” opposition to contraception. Some equate contraception with abortion, the idea being that preventing a fertilized egg from implanting in the uterine wall is synonymous with induced abortion. Yet prevention of implantation is not the main mechanism by which most contraceptive methods work—rather, they largely prevent fertilization by changing the cervical environment, and in some cases suppress ovulation altogether. Others have argued that ready access to contraception leads to “promiscuity.” Studies dating back to the 1970s found no link between oral contraception and early premarital sex.7 More recent studies show that the availability of emergency contraception does not increase risky sexual behaviors.8 The promiscuity argument is even more dubious and suggests a dangerous double standard when considered in light of the rapid approval by the FDA and widespread availability of drugs to enhance men’s sexual performance.

Continued disregard for the advantages of contraception may have important negative consequences for health and wellbeing in the US in the long run. The US performs poorly on reproductive health outcomes compared with other economically advanced nations. Despite recent reductions, more adolescent girls become pregnant in the US annually than anywhere else in the developed world,9 with a teenage birthrate 56% higher than that of the highest western European nation (the United Kingdom).9

Globally, policies to advance family planning are being rolled out and funded. Free contraception is part of national health insurance plans in countries from the UK to South Africa. Over-the-counter access to oral contraceptives, including emergency contraception, is widespread. In sub-Saharan Africa, task shifting interventions are under way to allow trained lower cadre health workers to provide injectable contraception to women who cannot access facilities staffed by nurses and doctors.10 Task shifting enables contraceptives to be delivered outside of health facilities, greatly increasing access, particularly for women and couples who live far away from the nearest health facility. In July 2012, at the London Family Planning Summit, foundations, country governments, and organizations pledged more than $2.6bn to ensure that 120 million women have access to contraception by 2020.11 Although the US did not pledge, through the United States Agency for International Development, the US is one of the largest donors for contraception for low income and middle income countries. At the same time, the US government continues to take backward steps away from ensuring that its own people have access to affordable contraception.

The time has come for the US to respond to evidence and join the international community in realizing the social, economic, and public health gains of ensuring access to contraception. Although voters spoke and removed from office many who most vocally campaigned against contraception in the 2012 US elections, opposition remains among many elected federal and state officials. Americans must not be complacent. The United Nations Population Fund’s 2012 annual report declared that access to contraception is a fundamental human right.12 Americans must demand policies that ensure financial and physical access to contraception for all.

Notes

Cite this as: BMJ 2012;345:e8069

Footnotes

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References