One surprise of the 2014 election season was a new twist on the politics of contraception: A number of socially conservative politicians announced their support for making birth control pills available without a prescription and over-the-counter. Although that goal has considerable merit and has long been promoted by reproductive health advocates, it is critical that it be accomplished without compromising affordable access to the full range of contraceptive options and without politicizing the Food and Drug Administration’s approval process.1
The abrupt and mostly rhetorical pivot of these politicians seems to have succeeded in distracting some voters and opinion leaders from many of the same social conservatives’ longtime efforts to undermine and chip away at rights and access to family planning services. One target of these efforts has been the federal contraceptive coverage guarantee established by the Affordable Care Act (ACA), which many social conservatives have asserted could be eliminated entirely if birth control pills were available over-the-counter. Conservative politicians in recent years have also attacked the Title X national family planning program and the safety-net health centers that make quality family planning services accessible and affordable for low-income Americans.
Programs and policies that promote access to family planning services are again on the table for the 114th Congress and President Obama’s final two years in office. As Congress and the President turn their attention back to governing, new evidence from the Guttmacher Institute should inform their decisions about federal family planning policy. A Guttmacher analysis, released in October 2014 in the Milbank Quarterly, quantifies what has long been obvious to family planning providers and their clients: The nation’s public investment in family planning not only helps women and couples to avoid unintended pregnancy and abortion, but also helps them to avoid such negative health outcomes as cervical cancer, HIV and other STIs, infertility, and preterm and low-birth-weight (LBW) births.2 In addition, public investment in family planning produces billions of dollars in government savings.
Many Services, Many Benefits
It is by no means an unexplored concept that family planning services and programs have important health, social and economic benefits. Decades of research have shown that better access to contraception helps people to avoid pregnancies they do not want, and to plan and space the pregnancies they do want.3 Pregnancy planning, in turn, has well-documented health benefits for women and children, along with benefits for women’s educational and workforce achievements, family income and stability, and children’s lives.3–4
More specifically, it is well-established that the U.S. publicly funded family planning effort helps millions of women and couples each year to avoid unintended pregnancies and the unplanned births, abortions and miscarriages that would follow, in the process also saving billions of public dollars.5 Beyond these benefits, however, the contraceptive services provided at publicly supported family planning visits also help prevent poor birth outcomes. That is because many of the unplanned births prevented would have been spaced more closely than is medically recommended (an interval of less than 18 months between a birth and a subsequent pregnancy), and many would have been premature, LBW or both. A substantial body of research connects unintended pregnancy to closely spaced births, and closely spaced births to prematurity and LBW.3
Quality family planning care, however, is not only about providing contraceptive services and helping clients to achieve their childbearing goals. As the U.S. Office of Population Affairs and the Centers for Disease Control and Prevention made clear in April with their release of new clinical recommendations, a family planning visit should encompass a wide range of additional preventive care services (see "More than a Pack of Pills: The Many Components and Health Benefits of Quality Family Planning," Summer 2014).6
Among the most important of these additional services are testing for chlamydia, gonorrhea and HIV, which are conducted routinely as part of publicly funded family planning visits for female and male clients. Chlamydia and gonorrhea testing can help prevent more serious health problems, such as pelvic inflammatory disease (PID), ectopic pregnancy and infertility.3 Testing can do so directly, by detecting an infection early and facilitating treatment, and indirectly, because treating an infection prevents its spread to a client’s sexual partners and to any additional partners they may have. Similarly, HIV testing and early detection help to prevent transmission of the virus to partners, because they lead to less risky behavior after a positive test result and to reduced infectivity after entry into treatment.
Also central to the U.S. family planning effort are cervical cancer prevention services, namely Pap and human papillomavirus (HPV) testing and HPV vaccination. Pap tests—now often performed in conjunction with HPV tests—help to detect abnormal cervical cells and cases of precancer, which allows for early treatment that prevents cervical cancer cases and deaths. HPV vaccination protects clients against the viral strains most commonly linked to cervical cancer; it also provides some protection against HPV-attributable cancers of the vulva, vagina, anus and rectum, and oropharynx.
Health Benefits and Public Savings
A substantial body of research has explored the causes and incidence of poor birth outcomes and assessed the health benefits of both STI testing and cervical cancer prevention services. Yet, that work had not been comprehensively applied to the context of publicly supported family planning care. In addition, research had not accounted for the potential public savings of the broad array of preventive care services in gauging the financial impact of the U.S. family planning effort.
The new Guttmacher Institute study pulls all of these pieces together to provide a more comprehensive picture of the impact of publicly supported family planning care in 2010 (see table).2 That care includes services provided at safety-net health centers, such as health departments, federally qualified health centers, Planned Parenthood affiliates and hospital outpatient clinics, and services provided by private clinicians to Medicaid recipients. More than half of the myriad health benefits of publicly funded family planning are attributable to the services that women and men obtained from safety-net centers that receive support through the federal Title X program. Title X–supported services had a sizable impact in every state of the nation (see table).
Contraceptive use. As the Guttmacher Institute reported previously, 8.9 million U.S. women received publicly supported contraceptive services in 2010.5 Those services helped women prevent an estimated 2.2 million unintended pregnancies, which would have led to 760,000 abortions and 1.1 million unplanned births. This new analysis estimates that 288,000 of these births would have been closely spaced and 164,000 would have been preterm, LBW or both.2
STI testing. Nearly half of female family planning clients receive chlamydia and gonorrhea tests, and 19% receive an HIV test; STI testing is also common among male clients receiving publicly supported family planning care. Without access to these services, in 2010, an estimated 3.6 million women and men would have forgone chlamydia or gonorrhea testing, which would have resulted in tens of thousands of undetected and untreated STIs. By reducing transmission to partners, these testing services helped prevent an estimated 99,000 chlamydia infections, 16,000 gonorrhea infections and 410 HIV infections that year. Treating clients who tested positive for chlamydia or gonorrhea helped to avoid thousands of cases of PID and the ectopic pregnancies and infertility cases that might otherwise follow.
Cervical cancer prevention. More than one-third of female clients received cervical cancer testing during their publicly funded family planning visit in 2010, and in the absence of such services, an estimated 2.3 million women would have forgone or postponed testing. In addition, 59,000 young women were vaccinated for HPV during a visit that year. Combined, the Pap tests, HPV tests and HPV vaccines provided during family planning visits in 2010 prevented an estimated 3,700 cases of cervical cancer and 2,100 cervical cancer deaths. HPV vaccination also helped women avoid thousands of cases of abnormal cervical cells and precancer and a small number of other HPV-attributable cancers, such as anal or vulvar cancer.
Government savings. In addition to these numerous health benefits, publicly supported family planning care in 2010 resulted in substantial government savings (see table). The vast majority of those savings come from helping women and couples avoid unplanned births. Those births would otherwise lead to billions of dollars in spending on maternity care and medical care for children through Medicaid and the Children’s Health Insurance Program. In addition, contraceptive services helped prevent publicly supported care for miscarriages and ectopic pregnancies, along with abortion care (almost exclusively in the 17 states that use their own funds to pay for abortions among Medicaid enrollees). Additional savings to Medicaid and other public programs were estimated for chlamydia, gonorrhea and HIV testing, and for Pap testing, HPV testing and HPV vaccination. After subtracting out the full public costs of the U.S. family planning effort (including funding through Medicaid, Title X and other federal and state sources), the services provided in 2010 resulted in a net government savings of $13.6 billion, or $7.09 saved for every public dollar spent. Of that total savings, $7 billion was the result of Title X–supported services alone.
A Best Buy
All told, the message from this new analysis is crystal clear: The wide range of preventive services routinely offered during publicly funded family planning visits have a tremendous impact on the health of women and men, while saving the federal and state governments billions of dollars each year.
More amazing still is that the benefits estimated here are far from complete. They do not, for example, account for the unintended pregnancies averted by contraceptive services provided to male clients. They do not include the benefits from counseling and education about the importance of preconception care and early access to prenatal care, or about how to avoid STIs through the use of condoms and safe-sex practices. They do not encompass additional preventive services routinely provided at family planning visits, such as breast exams and screenings for high blood pressure, diabetes and intimate partner violence. And they do not extend to any of the numerous social and economic benefits to women and families that come from the ability to time and space their childbearing, such as greater opportunities to complete an education and participate fully in the workforce.
Notably, these findings are for the services provided in 2010, well before implementation of most elements of the ACA, most importantly the law’s expansion of Medicaid. There is every reason to believe that as more individuals gain insurance coverage, particularly through Medicaid, the number of women served by publicly funded health centers and private doctors under Medicaid will continue to increase, along with the numerous health benefits that result from access to these services.
Simply put, the U.S. investment in family planning services is a wise use of public funds. As Congress and the President set their priorities for the next two years, they cannot afford to ignore the value of family planning services to women and to society at large. That means they need to expand funding and technical support for the Title X program and its network of providers. It means protecting Medicaid and its family planning coverage, and encouraging all states to embrace the ACA’s Medicaid expansion. And it means breaking down barriers that deny many women and men access to coverage and care, such as restrictions related to immigration status. Any support from lawmakers for moving oral contraceptives over-the-counter is welcome as well, but not as a substitute for taking steps fully in their purview and power to bolster the public investment in family planning that yields such tremendous benefits for public health and the public coffers.
This article was made possible by a grant from The JPB Foundation. The conclusions and opinions expressed in this article, however, are those of the author and the Guttmacher Institute.
1. Sonfield A and Barot S, Birth control pills should be available over the counter, but that’s no substitute for contraceptive coverage, Health Affairs Blog, Sept. 10, 2014, <http://healthaffairs.org/blog/2014/09/10/birth-control-pills-should-be-available-over-the-counter-but-thats-no-substitute-for-contraceptive-coverage/>, accessed Oct. 22, 2014.
2. Frost JJ et al., Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program, The Milbank Quarterly, 2014, doi: 10.1111/1468-0009.12080, <http://onlinelibrary.wiley.com/enhanced/doi/10.1111/1468-0009.12080/>, accessed Oct. 22, 2014.
3. Kavanaugh ML and Anderson RM, Contraception and Beyond: The Health Benefits of Services Provided at Family Planning Centers, New York: Guttmacher Institute, 2013, <http://www.guttmacher.org/pubs/health-benefits.pdf>, accessed Oct. 22, 2014
4. 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 Oct. 22, 2014.
5. Frost JJ, Zolna MR and Frohwirth L, Contraceptive Needs and Services, 2010, New York: Guttmacher Institute, 2013, <http://www.guttmacher.org/pubs/win/contraceptive-needs-2010.pdf>, accessed Oct. 22, 2014.
6. Gavin L et al., Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs, MMWR, 2014, 63(RR-4):1–54, <http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf>, accessed Oct. 22, 2014.