Increased contraceptive supply linked to fewer abortions

packets of oral contraceptivesHaving sex without using a method of birth control is one of many types of risk that people take—like driving over the speed limit or riding in a car without wearing a seatbelt. Giving women one cycle of oral contraceptive pills at a time is like asking people to wear a seatbelt but making them go into a clinic or pharmacy to renew their seatbelts each month. If seatbelts were given out as piecemeal as contraception, fewer people would use them. To make use of contraception as automatic as seatbelts, women need to have contraceptives on hand.

Oral contraceptive pills are the most common reversible method of contraception, used by over a quarter of contracepting American women. But there is a large gap between perfect, consistent use of oral contraceptives (3 pregnancies per 1000 users) and typical use (80 pregnancies per 1000 users). Currently, most American women get just 1 or 3 cycles at a time (Liang et al, 2006) and have to return to a clinic or pharmacy for resupply.

Five years ago, I led a study about how dispensing a one-year supply of oral contraceptives affects health care expenditures and contraceptive continuation. While we were analyzing those data, we noticed that women given just 1 or 3 packs had a lot more pregnancy tests over the course of the year than women who were given a one-year supply. And we wondered why. We were worried that they were having pregnancy scares because they had run out of medication between resupply visits.

New study of relationship between
contraceptive supply and rates of abortion

Just this week, we published a paper that examines whether a greater supply of oral contraceptives resulted in fewer unintended pregnancies. In Family PACT, the California State family planning program that gives contraceptives to low-income women and men, some family planning clinics are able to dispense a one-year supply of pills on-site. Among over 84,000 women dispensed oral contraceptives in January 2006, new Family PACT clients, new pill users, older women, Asians and non-Latinas, and women with 0 or only 1 child were more likely to get a one-year supply than other women. Because we did not randomize women to getting 1, 3, or 13 packs of pills, some women who received fewer packs may have taken fewer packs because they were planning a pregnancy in the next year. But since nobody plans abortions in advance, a reduction in abortions would be a strong indicator that a greater pill supply reduces the incidence of unintended pregnancy.

For this study, we matched contraceptive dispensing claims in Family PACT to Medi-Cal records for births and abortions. Pregnancy and abortion rates were lower in the group of women who were dispensed a one-year supply of pills, compared to women who received just 1 or 3 packs (the most common denominations). When we controlled for age, race/ethnicity, previous use of pills and Family PACT services, we found that receiving a one-year supply was associated with a 30% reduction in the odds of conceiving a pregnancy in the next year. And a one-year supply was associated with a 46% decrease in the odds of needing an abortion.

Implications of the results

There are several possible reasons for why dispensing a one-year supply may reduce unintended pregnancies. The first is obvious—convenience. Woman may be more likely to continue contraceptive use if they don’t have to return to a pharmacy or clinic for resupply. But dispensing a one-year supply may also send the message that OCPs are safe and acceptable, whereas fewer packs may suggest that the woman is likely to experience side effects and needs to reconsider use of the method at each resupply visit.

Despite this evidence-based recommendation that clinicians dispense a one-year supply of OCPs, there will be barriers to implementing a change in dispensing policy. Many health plans, including pharmacy dispensing in Medi-Cal, have a 90-day limit on medications. Yet these dispensing limits, likely designed to reduce costs, may in fact increase the incidence of unintended pregnancy and increase medical expenditures.

The biggest barrier may be the proposed cuts to the funding of Title X and Planned Parenthood’s provision of contraceptives for low-income women. Planned Parenthood and Title X clinics are among those who were able to dispense a one-year supply of pills in the Family PACT Program. If all women in our study who received oral contraceptives in Family PACT in January 2006 had gone to a Planned Parenthood or Title X clinic and received a one-year supply, almost 1,300 publicly funded pregnancies and 300 abortions might have been averted.

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