Last fall, researchers in Missouri caught the attention of public health experts and advocates across North America. Some 9,000 St. Louis women had been offered their choice of contraceptives for free in a study that has since been called an “Obamacare simulation.” Two years later, the teen pregnancy rate was at 6 per 1,000 instead of the US average of 34. The abortion rate was less than half the rate of other St. Louis women.
Why did they get such dramatic results? The free birth control triggered a technology shift in a microcosm. When presented with simple, accurate information and a buffet of no-cost options, a majority of the study’s participants, almost 75 percent, switched from old contraceptive technologies like the pill, condoms, and other barrier methods like cervical caps to state-of-the-art “long acting reversible contraceptives” (LARCs).
Unintended pregnancy rates in the US have been frustratingly flat for decades, hovering around half of all conceptions. Now, health advocates and community health agencies are eyeing a potential technology tipping point that could radically change the equation. What would it take to make the St. Louis results the new norm? And what might that mean for Cascadia?
If a set of things go right, Cascadia could become the St. Louis experiment writ large. But there are a number of ifs. If the Northwest states and Washington, DC, implement the Affordable Care Act’s provisions for mandatory free contraception—not exempting a patchwork of procedures or employer health plans. If better information about state-of-the-art contraception flows from experts through primary care “gatekeepers” to youth and women. If conversations about LARC methods become standard practice in adolescent medicine and maternity care. If access points in community and school-based clinics are expanded. And if state and provincial governments protect family planning services when making near-term budget cuts.
If we in Cascadia meet these conditions, and long acting contraceptives become the norm, the region’s unintended pregnancy rates among teens and adult women will plummet, budgetary pressure will ease, and more parents and children will flourish. Oh, and the abortion rate will fall, too.
Currently Washington has an unintended pregnancy rate of 48 percent, close to the national average. Oregon’s rate is almost identical. These pregnancies add to public medical costs. In 2006, Oregon spent $72 million on births from unintended pregnancies. But the public costs don’t begin or end at birth. In Washington, during fiscal 2012, Medicaid paid $700 million for prenatal, delivery, and infant care. When surveyed by the state’s Department of Health, approximately half of the women who received this care said that they would have preferred to get pregnant later or not at all.
Mostly, by the time “go-with-the-flow” babies like these arrive, their families welcome and love them. But some unintended pregnancies stack the odds against both children and parents. Maternal drinking or poor nutrition in the weeks right before and after conception may increase birth defects. Even families of healthy babies may struggle to stretch resources like time and money and space and emotional energy. When parents get too depleted, marriages can strain or break. Poor families may not be able to afford the same level of education for four kids as three or two. In many cases, families find the resources. They adjust and adapt and get help, and kids flourish. But in other cases, they don’t get help, and kids and parents alike flounder. Adding one more Jenga block to a precarious stack crashes the whole thing—and kids get neglected or rejected or abused.
During the teen years in particular, unplanned childbearing can have far reaching consequences for a mother and her children, and for their community. Each year in King County, Washington, alone, 15- to 17-year-old girls give birth to more than 300 babies. That’s enough kids, once a few years have passed, to keep several primary schools full. Those children come into the world with the odds stacked against them. Most will grow up in poverty. Fewer than half of their mothers will finish high school, and only 2 percent will get a college degree by age 30. A disproportionate number will experience learning or mental health problems, or end up as teen mothers themselves. Their struggles will contribute to the complicated web of challenges they and their communities face: strained social services, stretched public resources, crime, and an education system overwhelmed with special needs.
King County is not unique in this regard. In fact, it has one of the lower teen birth rates in Washington State, around 10 per 1,000 girls aged 15-17. The highest county rate in Washington is 55 per 1,000 girls, and the averages for Washington and Oregon are 27 and 28 respectively. (The national average is 34.)
The sheer impact of these numbers on the state budget is daunting, in large part because of the challenges faced by the children of teen mothers. Between 1991 and 2008 approximately 143,000 teens gave birth in Washington, at a taxpayer cost of $3.3 billion. The public tab includes maternal and child health, childhood welfare support and a higher than average rate of incarceration during adolescence and young adulthood.
All of this makes those numbers from St. Louis look particularly interesting at a time when Northwest families and governments are trying to do more with less. Giving women better tools to fulfill their pregnancy intentions—empowering parents so they can decide when they are ready to bring a child into the world—may offer a partial upstream solution to some of the region’s most pressing concerns: affordable health care, better educational outcomes, strong and stable families, and balanced budgets.
In subsequent parts of this series, I’ll look at the technologies that made such a difference in St. Louis and what it would take to replicate those results in the Northwest.
Valerie Tarico, Ph.D., a trustee of Sightline, is a psychologist and writer in Seattle. She is the author of Trusting Doubt and Deas and Other Imaginings and the founder of WisdomCommons.org. Her articles can be found at Awaypoint.Wordpress.com.
