Free Contraception Slashes Abortion Rates

Troy Brown

October 05, 2012

October 5, 2012 — When adolescent and adult women were offered no-cost contraception for 3 years, abortion rates fell 62% to 78% below national levels, according to a prospective cohort study of 9256 adolescent and adult women desiring reversible contraception. Teen birth rates also fell far below national rates.

Jeffrey F. Peipert, MD, PhD, the Robert J. Terry professor of obstetrics and gynecology, vice chair of clinical research, and obstetrics/gynecology residency program director at the Washington University School of Medicine in St. Louis, Missouri, and his colleagues reported their findings online October 4 in the journal Obstetrics & Gynecology .

This study is important because almost half (49%) of pregnancies in the United States from 2006 to 2008 were unintended, with a cost to taxpayers of about $11 billion annually for 1 million unintended births, the authors write in the journal.

Long-acting reversible contraceptive (LARC) methods (IUDs and implantable contraception) are more effective than other methods, but they also are more expensive initially, and many women cannot afford them.

A total of 9256 adolescents and women enrolled in the Contraceptive CHOICE Project in the St. Louis, Missouri, metropolitan area between August 2007 and September 2011. Investigators recruited 16% of them at abortion facilities.

Participants were counseled on contraceptive methods and their effectiveness, and offered the reversible contraceptive method of their choice for 3 years. They were able to switch methods during the study, if they desired.

Three-Quarters Chose LARC

At enrollment, 75% of the study group selected a LARC method (46% levonorgestrel IUD, 12% copper IUD, 17% subdermal implant). Other methods were chosen by the rest of the participants: 9% oral contraceptive pills (OCPs), 7% contraceptive vaginal ring, 7% depot medroxyprogesterone acetate, and 2% contraceptive patch.

Participants recruited from abortion facilities were more likely to choose a LARC compared with those recruited at other locations (84.5% compared with 72.9%, P < .001).

The teenage birth rate (births per 1000 females aged 15 to 19 years) within the CHOICE cohort was 6.3 per 1000. This is far below the national level of 34.3 per 1,000 reported in 2010, note the authors. They used this rate as a proxy for unintended pregnancy, which makes up as much as 80% of teen pregnancies.

Between 2008 and 2010, there was a 20.6% (P < .001) drop in the number of abortions performed at Reproductive Health Services among adolescents and women who lived in St. Louis City and County, compared with no appreciable change (0%, P = .39) in the number of abortions among adolescents and women living in the rest of Missouri.

The researchers selected the percentage of abortions that were repeat abortions as their primary outcome of interest because providers and government statistics track this information. They also hoped to have the greatest population effect by providing the contraception to those at highest risk for unintended pregnancy.

Women and adolescents who obtain abortions are at risk for unintended pregnancy and repeat abortion in the future, and may be motivated to pursue contraceptive services.

According to vital statistics data from Missouri's department of health, there was a significant difference between the proportion of repeat abortions in the St. Louis and Kansas City regions in 2009 (P = .02) and 2010 (P < .01). In addition, the proportion of repeat abortions in the St. Louis region decreased steadily from 2006 to 2010 (P = .002).

After adjusting for age and race, abortion rates among study participants ranged from 4.4 to 7.5 per 1000 women, far lower (62% to 78%) than the national rate of 19.6 abortions per 1000 women in 2008, the most recent year for which data are available.

Abortion rates for CHOICE participants were also substantially lower than those in St. Louis City and County during the same time period (P < .001), which ranged from 13.4 to 17.0 per 1000 women.

The researchers estimate that 1 abortion could be prevented for every 79 to 137 women and adolescents provided with the same intervention as the study participants.

Study Simulated IOM Recommendation

The Institute of Medicine has recommended that all contraception be provided without cost under the Patient Protection and Affordable Care Act of 2010. "The Contraceptive CHOICE Project essentially simulated this recommendation in our region for reversible contraceptive methods," the authors write.

"[B]based on our calculations…changes in contraceptive policy simulating the Contraceptive CHOICE Project would prevent as many as 41 - 71% of abortions performed annually in the United States," the authors add.

Alice Mark, MD, senior clinical advisor for Ipas, and member of the American Congress of Obstetricians and Gynecologists' Committee on Adolescent Health Care, commented on the study in a telephone interview with Medscape Medical News.

Dr. Mark explained that this study provides "more support for increasing access, especially to high-risk women and young women, to the most effective methods, which include IUDs and implants." She noted that the US has a high rate of unintended pregnancy compared with other developed countries.

"It's a great model, especially as the Affordable Care Act comes online, [that] if the cost of the devices is taken away and women are given good choices about what they can use, if they start using these methods, I think that would be something very promising to cut the rate of unintended pregnancies," Dr. Mark said.

The Contraceptive CHOICE Project is funded by the Susan Thompson Buffett Foundation.

Dr. Madden is on the Speaker's Bureau for Bayer Pharmaceuticals. The other authors and Dr. Mark have disclosed no relevant financial relationships.

Obstet Gynecol. 2012;120:1-8. Full text