Economic inequality in the United States starts at conception. Of the country’s 6 million pregnancies each year, almost half are unintended, and these are more likely to occur among single and less-educated women. After giving birth, mothers of unintended children therefore tend to have less-generous maternity leave, if any, and have less time and financial resources to support their children. Such differences set the children of low- and high-income families on very different life trajectories, amplifying the already large economic inequalities.
For decades, researchers have asked why women don’t use better contraception to prevent these unintended pregnancies. One explanation favoured by economists for many years is that, although not planned, not all these pregnancies are really unintended. Recent sociological research confirms that many unintended births result from deep ambivalence about getting pregnant. If some women don’t use contraception because they have conflicting feelings, the role for public policy is limited. This line of thought stresses that falling rates of unintended pregnancy might be closely linked to other factors, such as the economy or culture.
Another explanation is that many women who want to avoid pregnancy are not given adequate information or counselling about contraception by healthcare providers. This information gap disproportionately affects women of colour, who are more likely to articulate concerns that long-acting methods of contraception, such as intra-uterine devices (IUDs), could cause them harm or infertility.
To help address this issue, five US states have spent tens of millions of dollars to hire a non-profit organization called Upstream, based in Oakland, California, to train healthcare providers. A recent evaluation of these expensive efforts in Delaware, however, found limited evidence of success in reducing unintended births.
But evidence for a third explanation is mounting. In most high-income countries, the government makes contraceptives free or inexpensive. In the United States, however, the out-of-pocket costs for contraception are closely linked to health insurance. Before the Affordable Care Act (ACA) was passed in 2010, insurers often required people to pay all, or a large part of, the cost of birth control. Women with health insurance could be charged more than US$1,000 to use an IUD, which was bound to discourage take-up. Consistent with price being a barrier, the ACA’s requirement that private health insurance covers contraception led to increased use of the most expensive and effective methods of contraception.
But the ACA did not reduce prices for the millions of US women who do not have private insurance and who used publicly funded reproductive-health services. For this group, the price of contraception has tended to increase over the past decade. Political initiatives that link access to contraception to the highly charged issue of abortion have led many state legislatures to reduce the amount of public spending on reproductive health and limit the organizations that are eligible to receive it. In 2019, President Trump’s administration also revised federal guidelines to defund reproductive-healthcare providers such as Planned Parenthood, a nationwide non-profit body that until then had served more than 40% of people who received publicly funded services. Within five months, about 1,000 provider sites closed down and 20% fewer low-income people received reproductive-health services than in 2018.
Research aimed at evaluating the effects of these policy changes are ongoing, but studies of other periods are informative. Opening federally funded family-planning programmes in the 1960s and 1970s reduced birth rates among the most disadvantaged women by around 25%. When Medicaid expanded the eligibility for family- planning services in the 2000s, the use of contraception increased and the number of unplanned births fell. In the states that expanded Medicaid eligibility after the ACA was passed, the use of the most expensive (and effective) contraceptive methods increased. After Colorado made long-acting contraception free for all women in 2009, the number of teens giving birth fell by 5% in four years. Observational studies such as the Contraceptive CHOICE Project in St Louis, Missouri, and HER Salt Lake in Utah, also suggest that free access to contraception increases take-up and reduces pregnancy rates, although neither included control groups.
The current trend to reduce access to, and raise the prices of, birth control is therefore likely to further depress use — especially of the more expensive and effective methods — and also increase the number of unintended pregnancies in women who are already economically disadvantaged.
As income inequality in the United States soars to its highest levels in a century, the stakes have never been higher. As the fortunate enjoy better schools and neighbourhoods, better healthcare and more parenting resources, the less fortunate fall further behind.
Increasing access to contraception for low-income women will help to level the playing field at birth, empowering parents to give their children the best opportunities for success. Research shows that children born in areas where their mothers had access to subsidized family-planning programmes are better off economically and are less likely to live in poverty or in households receiving public assistance. These children complete more education, earn higher wages and have higher family incomes decades later.
Empowering women to plan their pregnancies is about more than reproductive justice. It is about expanding opportunities for the next generation.
Nature 588, S177 (2020)
Updates & Corrections
Correction 18 December 2020: An earlier version of this Outlook article overstated the proportion of US pregnancies that are unintended.