Public health experts have long emphasized the benefits to maternal and child health of helping women and couples avoid unintended pregnancy and better time and space the pregnancies they have. Notably, numerous U.S. and international studies have found a causal link between closely spaced pregnancies and three key birth outcome measures: low birth weight, preterm birth and small size for gestational age.1 And a large body of literature highlights an association between unintended pregnancy and delayed initiation of prenatal care, as women are more likely to realize early that they are pregnant if they were trying to become pregnant.
Yet, although the preventive health benefits of unintended pregnancy prevention are clear and persuasive—and, indeed, provided the impetus for the new federal requirement that most private health plans cover contraception without copays or deductibles (see "The Case for Insurance Coverage of Contraceptive Services and Supplies Without Cost-sharing," Winter 2011)—the primary reasons American women give for why they use and value contraception are social and economic. Women know that controlling whether and when to have children has positive benefits for their lives. A pair of recent Guttmacher Institute analyses explore their motivations and the benefits they accrue from acting on them.
Asking Women Directly
In 2011, Guttmacher Institute researchers surveyed more than 2,000 women seeking contraceptive services at U.S. family planning centers to explore their motivations for contraceptive use.2 Women were asked what role contraceptive use had played in their lives and why they were seeking contraceptive services now.
A majority of women reported that, over the course of their lives, access to contraception had enabled them to take better care of themselves or their families, support themselves financially, complete their education, or get or keep a job (see chart). Women provided similar answers when asked why they were seeking contraceptive services at that moment. The most common reason women gave was not being able to afford to care for a baby at that time (65%); among women with children, nearly all cited their need to care for their current children as a reason for practicing contraception. Other frequently reported reasons included not being ready to have children (63%), feeling that contraception allows better control over life (60%) and wanting to wait to have a baby until life is more stable (60%).
Overall, women reported an average of seven different "very important" reasons for using contraceptives. Young women, women without children and unmarried women reported a particularly high number of reasons. Teenagers, on average, reported nearly nine very important reasons for their contraceptive use, compared with women 30 or older, who reported an average of five.
Reviewing the Research
A 2013 Guttmacher Institute literature review of 66 studies from the past three decades provides scientific documentation that these perceived benefits reflect reality for women and families.3 Much of this evidence comes from a series of historical analyses conducted over the past decade. These studies took advantage of a "natural experiment" arising from the fact that different states, in different years, passed laws that effectively granted legal contraceptive access without parental consent to single women aged 17 or 18, rather than 21, ages when women may be making life-altering decisions about education, career and family. By comparing trends among young women with and without legal access to contraception, researchers demonstrated that contraceptive use has contributed substantially to U.S. women’s societal advancement.
Specifically, these studies found that young women’s access to contraception was a major factor historically in the growing numbers of young women obtaining some college education and pursuing advanced professional degrees, such as in law, medicine, dentistry and business administration. In addition, contraceptive access significantly contributed to young women’s joining the paid labor force and following professional occupations. That trend was tied to advancements in women’s educational credentials and to the recognition by women and their potential employers that women could pursue a career with far less fear of it being interrupted by an unplanned pregnancy. These changes, in turn, contributed to women’s increased earning power and to a reduction in the long-standing gender gap in pay.
Education and career decisions are also tied closely to decisions about marriage, and several of these same studies found that young women’s access to family planning services helped spark a trend toward later marriage. This has given many women and men the time they need to figure out what they want out of a relationship and to identify a partner who can better fit those preferences.
A second set of studies used recent data to analyze the effects of teen and unplanned pregnancy, and family spacing and overall size, on social and economic outcomes for women and families. Some such studies were longitudinal, that is they drew on data collected from the same individuals at multiple points in time to help evaluate cause and effect. Others relied on sophisticated statistical techniques to evaluate the role of early, unintended and closely spaced births versus other competing factors.
These studies find, for example, that teen mothers are less likely than their peers without children to attend or graduate college, or even to complete high school. This appears to translate into immediate and long-term decreases in income, and in an increased likelihood of relying on public assistance for a time. More generally, the findings suggest that delaying the birth of a first child into one’s late 20s or 30s can help working mothers mitigate the lower pay they still typically experience in comparison to working women without children. Perhaps not surprisingly, highly educated women appear to benefit the most economically from delaying when they have children; they are also most likely to receive and benefit from family-friendly workplace policies, such as flexible hours and paid maternity leave.
These studies also provide evidence that family planning has an impact well beyond education and the workforce. They find that unplanned pregnancy is linked to more conflict and less satisfaction in a relationship, and is associated ultimately with greater odds that a relationship will fail. In addition, there is some evidence that women whose pregnancies are unplanned are more likely to experience physical and sexual abuse. Moreover, women and men who experience an unplanned pregnancy are particularly likely to experience depression, anxiety and a decreased perception of happiness; early childbearing is linked to decreased happiness as well.
Finally, research indicates that pregnancy planning has implications for the well-being of the next generation. Women and men are less likely to see themselves as prepared for parenthood and to develop a positive relationship with their children if they become a parent as a teenager or if the birth of a child is unplanned. The economic and emotional investments made by parents in each child can be constrained by close birth spacing and larger family size. And these types of pregnancy planning outcomes, in turn, appear to be tied to children’s mental and behavioral development and to their educational achievement.
It needs to be acknowledged that there is ongoing debate in the research community about the true driving factors behind the negative life consequences commonly linked to unplanned births and especially teen births. Some researchers theorize that these results do not stem from teen motherhood itself, but instead that it is preexisting disadvantage that leads to both teen motherhood and negative outcomes later in life. Most of the evidence, however, gives credence to the influence of disadvantage, but also suggests an independent impact of teen motherhood, and delayed motherhood, on women’s social and economic outcomes and those of their families. Moreover, the research suggests a "virtuous circle" involving effective pregnancy planning and adults’ positive educational, professional and relationship outcomes. Indeed, the relationship may extend across generations, because all of these factors benefit children’s well-being, too.
In sum, the systematic evidence confirms what women themselves assert: Access to effective contraception is a catalyst of opportunity, and its increasing availability and use over time has helped reshape women’s expectations about their educational and career opportunities, and their roles in the home and workplace. It has helped transform societal expectations of women, as well as their opportunities.
Yet, even five decades after the advent of the pill, access to and consistent use of the most effective contraceptive methods are not enjoyed equally by all U.S. women. Disparities in contraceptive use are a major reason why half of U.S. pregnancies—3.2 million each year—are unplanned.4 Included in that count are the vast majority of the roughly 750,000 teen pregnancies annually. These unplanned and teen pregnancies occur disproportionately to poor women (those with incomes below the federal poverty level), whose unplanned pregnancy rate is five times that of higher income women (above 200% of poverty; see chart). Disparities in reproductive health access and outcomes have contributed to the continuing challenges faced by economically disadvantaged women in American society. Compared with their higher income counterparts, they have fewer opportunities for educational and economic achievement, for a stable marriage and for helping their children succeed.
The United States has for decades attempted to address these interconnected disparities through a wide range of civil rights policies and antipoverty programs. For example, federal and state laws prohibit discrimination in education and employment on the basis of sex, pregnancy and parenthood, and require businesses to provide unpaid parental leave to many employees. In addition, numerous family and child welfare programs provide financial support, nutrition assistance, child care and education, and government policies aim to prevent and address family violence and abuse.
Notably, some teen pregnancy prevention programs have explicitly linked attempts to improve reproductive health outcomes and other social and economic outcomes, by teaching the skills and knowledge that adolescents and adults need to thrive on all of these fronts. Grantees under the federal Personal Responsibility Education Program, for example, must teach adolescents about a variety of subjects to prepare them for adulthood, including healthy relationships and positive self-esteem; life skills such as goal setting, decision making, negotiation and communication; and career skills, such as for employment preparation, job seeking, workplace productivity and financial self-sufficiency.
The government’s primary attempt to address these disparities through a reproductive health lens, however, has been through its substantial public investment in family planning services for young and lower-income women, and in a network of safety-net health centers to provide these services. Over the years, that investment has paid considerable dividends in terms of helping women access contraception and avoid unplanned pregnancies. Unfortunately, public funding has never been enough to fully meet women’s needs. Moreover, that inadequate level of funding has suffered recently under budget cuts and political attacks on contraception (related article, page 13).
Health Reform’s Potential
The 2010 Affordable Care Act (ACA) could do much to address the unmet need for affordable family planning services. If fully implemented and protected from political pressures, the health reform law could extend comprehensive health coverage—including coverage for contraceptive methods and counseling—to more than 30 million individuals who would otherwise be uninsured. It would accomplish this through expanded eligibility for Medicaid and federal subsidies to purchase private insurance on new health insurance "exchanges." Moreover, most women’s insurance, whether Medicaid or private coverage, will cover contraception without out-of-pocket costs. Combined, these measures should eliminate the financial barriers millions of women have faced to choosing a method they can use consistently and effectively.
The potential of the ACA is by no means assured, however. The U.S. Supreme Court, in its 2012 decision upholding the law overall, ruled that the federal government could not enforce the requirement that all states expand Medicaid to cover Americans with incomes up to 138% of poverty. This requirement was expected to account for about half of the gains in U.S. insurance coverage under the law. States have numerous strong reasons to take up the expansion, from protecting public health to bolstering the finances of safety-net hospitals to the billions of federal dollars they could bring to their economy. But, some states are balking on political grounds, which would leave millions of their most disadvantaged residents without affordable insurance options (see "Affordable Care Act Survives Supreme Court Test, but Medicaid Expansion Placed in Peril," Summer 2012) and expand the nation’s already sizable inequities in access to coverage and care.
Also uncertain is the fate of the ACA’s requirement for most private health plans to cover contraception without patient out-of-pocket costs. Social conservatives in Congress and in the states have made repeated attempts to undermine the requirement, and as of the end of February, more than 45 lawsuits had been filed by employers challenging it as a violation of their religious freedom.5 In the meantime, the administration is developing an "accommodation" to distance many such employers from the requirement, while still ensuring seamless coverage of contraception for employees (related article, page 31). It is almost certain that the U.S. Supreme Court will take up the issue eventually.
The uncertainty around key components of the ACA is in sharp contrast to the clarity of the evidence about the benefits of contraception. If U.S. policymakers were to heed this evidence, their decisions would be simple. They would halt the archaic and harmful attacks on family planning and on the programs and providers that make these services accessible and affordable for all Americans, especially those most disadvantaged. They would embrace the opportunity provided by the ACA to reduce inequality in health coverage. And they would make every effort to help women and couples, regardless of their background, make their own choices about whether and when to have children—choices that can, in turn, help them achieve the American dream.
1. Guttmacher Institute, Testimony of Guttmacher Institute, submitted to the Committee on Preventive Services for Women, Institute of Medicine, 2011, <http://www.guttmacher.org/pubs/CPSW-testimony.pdf>, accessed Feb. 13, 2013.
2. Frost JJ and Lindberg LD, Reasons for using contraception: perspectives of U.S. women seeking care at specialized family planning clinics, 2012, Contraception, <http://www.guttmacher.org/pubs/journals/j.contraception.2012.08.012.pdf>, accessed Feb. 13, 2013.
3. Sonfield A et al., The Social and Economic Benefits of Women’s Ability to Determine Whether and When to Have Children, New York: Guttmacher Institute, 2013, <www.guttmacher.org/pubs/social-economic-benefits.pdf>, accessed Mar. 21, 2013.
4. Finer LB and Zolna MR, Unintended pregnancy in the United States: incidence and disparities, 2006, Contraception, 2011, 84(5):478–485, <http://www.guttmacher.org/pubs/journals/j.contraception.2011.07.13.pdf>, accessed Feb. 13, 2013.
5. American Civil Liberties Union, Challenges to the federal contraceptive coverage rule, Feb. 27, 2013, <http://www.aclu.org/reproductive-freedom/challenges-federal-contraceptive-coverage-rule>, accessed Feb. 27, 2013.