Increasing Access to Long-acting Reversible Contraception Brings Lasting Gains for Oklahoma Women and Girls

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Choosing when and whether to have children is an important decision for Oklahoma families. When families are given more power to plan pregnancies and births, they are shown to attain more education, earn higher incomes, and develop stronger marriages.

However, unplanned pregnancies, including teen pregnancies, are more common in Oklahoma than in most other states. This can present certain challenges. Having children during high school or college is tied to lower graduation rates for both. Teen pregnancies in particular are tied to mothers earning lower wages, relying more on social services, and being more likely to become involved with the criminal justice system. These outcomes bring large costs for entire communities.

This is why access to highly effective forms of birth control is important. Long-acting reversible contraceptives (LARC) have lower failure rates than any other form of reversible birth control, leave virtually no opportunity for user error, and last for between three and ten years. For these reasons, LARC is the recommended first-line contraceptive option for adolescents, and LARC use has grown steadily across the US in recent years.

In addition, a program has shown over the last few years that LARC is a smart option for Oklahoma women and teens. The Take Control Initiative, a program promoting access to LARC in Tulsa County, has proven effective at decreasing Tulsa’s teen birth rate. Indeed, greater LARC use has been a key element in reducing unintended pregnancies throughout the US.

Unfortunately, despite some increases in recent years, LARC use is still relatively low compared to other, less-effective forms of birth control. Continued efforts are needed to expand access to LARC throughout Oklahoma.

Increasing choice of when and whether to have children has large economic and social benefits

The social and economic benefits of birth control are well-documented. Being able to decide when and whether to have children increases the likelihood that women will reach their desired level of educational attainment and employment, increase their earning potential, and maintain strong marriages¹.

These benefits extend beyond the individual woman or household to include current and future family, communities, and the state as a whole. At the state level, greater high school and college completion are directly tied to increased wages across the board. Increased employment at higher wages means less dependence on public safety net services such as SNAP and Medicaid². Planned pregnancies are also central to stable families: married and cohabitating couples are more likely to break up following an unplanned pregnancy or birth than a planned one³.

Oklahoma has a high rate of unplanned pregnancies, including teen pregnancies. Although Oklahoma’s unplanned and teen pregnancy rates have declined in the last few years, they continue to far outpace the national average. In 2010, the most recent year for which data is available, 51 percent of all pregnancies in Oklahoma were unintended, versus the US average of 45 percent⁴. In 2014, Oklahoma’s teen birth rate (38.5 births per 1,000 women ages 15-19) was second-highest in the nation, behind only Arkansas (39.5 births) and well-above the US average (24.2 births)⁵.

Unplanned pregnancies, particularly teen pregnancies, may increase the likelihood of several challenging or costly outcomes. Pregnancy, birth, and childrearing are expensive endeavors, particularly for parents with limited access to health insurance, paid leave, maternity leave, child care, and similar supports. Unplanned and teen pregnancies disproportionately occur among low-income women and can both exacerbate and perpetuate poverty.

Oklahoma’s college completion and female workforce participation rates lag behind the national average, both of which make for a less prosperous state, and wages are comparatively low⁶. High rates of unplanned and teen pregnancies likely contribute to these trends: studies have shown that teen childbearing reduces the likelihood of completing both high school and college⁷.

Teen pregnancy is also tied to greater likelihood of future involvement with both the child welfare and criminal justice systems – two areas in which Oklahoma currently struggles with overcrowded, under-resourced systems⁸.

Besides reducing education and earnings of mothers, an inability to control the timing of pregnancy also harms children. Neglect, not intentional abuse, is the most common form of child maltreatment, and neglect is often directly caused by poverty that inhibits families from providing a safe environment for their children⁹.

In addition, unplanned pregnancy can be costly to taxpayers. In 2010, Medicaid and similar public insurers paid for slightly more than 4 in 5 unplanned pregnancies in Oklahoma, the third-highest percentage in the US after Washington DC and Mississippi. From prenatal care through age 5 that year, the average cost per unplanned pregnancy and birth in Oklahoma was $16,681, for a total public cost of $331 million. Of that, $77 million was paid with state funds. The Guttmacher Institute put the potential state savings from preventing unintended pregnancies in Oklahoma at $56.7 million¹⁰. An analysis by the National Campaign to Prevent Teen and Unplanned Pregnancy estimated total state costs in 2010 of these pregnancies at $169 million, factoring in increased risk of involvement with child welfare organizations, risk of incarceration, and lost tax dollars due the likelihood of lower wages earned¹¹.

Long-acting, reversible birth control is critical to building prosperous futures

Family planning – especially access to birth control – has substantial social and economic benefits for women, their families, and their communities, as well as for taxpayers. However, not all birth control is equally effective – and some birth control methods’ effectiveness declines steeply when not used perfectly. For example, the birth control pill, the most common form of contraceptive in the US, has a failure rate of less than 0.5 percent when used perfectly – but a failure rate of 9 percent when used typically. Similarly, the male condom has a 2 percent failure rate with perfect use, but an 18 percent failure rate with typical use¹². Birth control is also less likely to be used correctly by younger women: adolescent women are more than twice as likely as women aged 30 or older to experience a pill failure, for example¹³.

This is why long-acting reversible contraceptives are important, particularly for teens and young women. Long-acting reversible contraceptives, including intrauterine devices (IUDs) and hormonal implants, are birth control methods that are effective for an extended period without requiring user action. Depending on the device, LARC is effective for between three and ten years, unless the user chooses to have the device removed¹⁴. Because of LARCs’ “set it and forget it” nature, there’s very little gap in LARCs effectiveness rate for perfect use versus typical use. Hormonal implants have no difference in effectiveness for perfect use versus typical use (just a 0.5 percent failure rate for both), and while an effectiveness gap for IUDs exists, it’s vanishingly small¹⁵.

[pullquote]”The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists say that LARC should be considered the first-line contraceptive choice for adolescents.”[/pullquote]

LARC also sidesteps many of the issues women and girls report that prevent them from acquiring and using birth control correctly. LARC insertion requires two appointments at most, which can be on the same day – and then no effort or action on the part of the user, meaning that user error is nearly impossible. For the same reasons, LARC is also discreet. It is for these reasons, and others, that the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists say that LARC should be considered the first-line contraceptive choice for adolescents¹⁶.

The good news is that after years of low usage rates, LARC use is finally on the rise – particularly among teens and young women. LARC usage among teens 15-19 grew from less than 1 percent in 2002 to 4.5 percent in 2009 and has likely increased further since then. Among all women of childbearing age, more than 1 in 10 use LARC¹⁷.

We’re already seeing gains in teen pregnancy prevention thanks to rising LARC usage. In places where LARC has been made readily available with accompanying education, teen pregnancies decreased markedly over the last decade, even accounting for the US’s overall decline in teen pregnancy at the same time. A study in St. Louis providing no-cost birth control to women between 2007 and 2013 found that three-quarters of teens participating chose LARC¹⁸. The study’s teenagers subsequently had much lower rates of birth and abortion than their counterparts nationwide. Similarly, provision of no-cost LARC in Colorado is broadly credited with playing a significant role in reducing teen pregnancy in that state. The Guttmacher Institute credits increased use of LARC for the US’s steep drop in the abortion rate over the last decade¹⁹. In short, LARC works.

Local effort, local success

The Take Control Initiative (TCI) has shown that better access to LARC can make a difference in Oklahoma. The Take Control Initiative grew out of the George Kaiser Family Foundation’s effort to decrease intergenerational poverty by reducing teen and unintended pregnancy. TCI promotes access to LARC through education, outreach, and free clinical services in Tulsa County. The program works with over 15 safety net clinics as the payer of last resort for several forms of LARC. Since the initiative began in 2010, nearly 13,000 women have received LARC through TCI partner clinics. In addition, TCI provides comprehensive education on all forms of contraception, working with more than 100 outreach partners to increase awareness and access.

Analysis by OK Policy found that since TCI began, Tulsa County’s teen birth rate dropped 27 percent more than demographically-similar counties without a TCI-style program. Using updated cost data provided by the National Campaign to Prevent Teen and Unplanned Pregnancy, we found that the decrease produced an estimated combined savings to taxpayers of more than $300,000 between 2011 and 2014 and a 15-year savings of nearly $5 million²⁰. It should be safe to assume that increasing use of the most effective forms of birth control would reduce both the teen and unplanned pregnancy rate and realize a similar level of cost savings, although it’s not possible to simulate the effect of such an intervention on the state level.

Just as LARC has effectively reduced Tulsa’s teen pregnancy rate, it’s also reasonable to assume that it’s reduced the abortion rate. Recent restrictions on abortion access in Texas and Arkansas could be resulting in more women from those states seeking abortions in Oklahoma, but the abortion rate in Tulsa County, home to one of Oklahoma’s very few abortion care providers, has nonetheless decreased significantly. Nationwide, the overall US abortion rate has declined notably since its peak in 1999, but the percentage of unplanned pregnancies ending in abortion has not. Instead, the abortion decline is driven by a falling unplanned pregnancy rate²¹.

It is important to note that the teen birth data analyzed here does not capture the full picture of TCI’s effect on Tulsa County’s unplanned pregnancy rate. Teen birth data is much more closely monitored than unplanned pregnancy data, making it easier to study, but it captures only a very narrow segment of unplanned pregnancies in Tulsa County. While most teen pregnancies are unplanned, most unplanned pregnancies are not teen pregnancies. Since multiple studies have found that efforts to increase LARC usage are consistently successful at preventing unplanned pregnancy, we expect similar success in Tulsa even if we currently cannot measure it. It should also be noted that because 17 percent of unplanned pregnancies in Oklahoma in 2010 resulted in abortions, TCI has almost certainly contributed to Tulsa County’s decreasing abortion rate, although we may not currently be able to capture the precise magnitude of that effect with data²².

Conclusion

Family planning is key to assisting women and girls to lay the educational and financial groundwork for prosperous, successful futures for themselves and their families – and LARC is the most effective family planning method available. By increasing education about and access to LARC in Tulsa County, the Take Control Initiative has helped thousands of women plan for better futures, while decreasing the teen birth rate and saving taxpayer dollars. Expansion of similar efforts statewide would benefit Oklahoma families, communities, and the state as a whole.

Note on methods

In order to assess TCI’s effect on Tulsa County, we needed to be able to compare it to a control group without a similar intervention. Some studies have looked at LARC’s effects by comparing the actual birth rates in intervention areas with a projected teen birth rate created by drawing a trend line using several years of data prior to the intervention. However, this fails to take into account that teen birth rates across the US in areas with and without birth control interventions have plummeted over the last few years, interfering with our ability to make accurate projections based on years prior to the decline. LARC programs in Oklahoma County meant that it could not be used as a control group for comparisons, and because the Tulsa and Oklahoma City metropolitan areas are such a large part of Oklahoma’s overall teen birth data, the state as a whole was also unsuitable for comparison. Ultimately, we selected 18 Oklahoma counties with similar income and high school graduation rates to Tulsa County’s that bordered neither Tulsa County nor Oklahoma County and so were unlikely to have been part a LARC program (Alfalfa, Beckham, Blaine, Carter, Comanche, Custer, Garfield, Grady, Love, McClain, Mayes, Murray, Noble, Pontotoc, Stephens, Texas, Washita, and Woodward). Tulsa County’s teen birth data was compared to the average teen birth data of this control group. As TCI began in 2010 and any change to teen birth rates would take nine months to take effect at minimum, only teen birth data from 2011 onward was used for comparison.

Acknowledgements

This report was prepared with the generous support of the George Kaiser Family Foundation.

In addition, we express our gratitutde to the individuals and organizations who have contributed their time and expertise to this report. They include:

• Laura Bellis, Gaby Ortega, and Tara Jackson of the Take Control Intitiative
• Kimberly Butler of the George Kaiser Family Foundation
• Alison Ng of The Campaign to Prevent Teen and Unplanned Pregnancy
• Emily Shipley and Dr. Garth Splinter of the Oklahoma Health Care Authority
• Kiran Duggirala and Sandra Braun of the Tulsa County Health Department

References

1. Guttmacher Institute. March 2013. “The Social and Economic Benefits of Women’s Ability To Determine Whether and When to Have Children.” https://www.guttmacher.org/report/social-and-economic-benefits-womens-ability-determine-whether-and-when-have-children
2. Oklahoma Policy Institute. May 2016. “This part of the budget deal may be the greatest threat to Oklahoma’s economy.” https://okpolicy.org/part-budget-deal-may-greatest-threat-oklahomas-economy/
3. Guttmacher Institute. March 2013. “The Social and Economic Benefits of Women’s Ability To Determine Whether and When to Have Children.” https://www.guttmacher.org/report/social-and-economic-benefits-womens-ability-determine-whether-and-when-have-children
4. Guttmacher Institute. April 2016. “State Facts About Unintended Pregnancy: Oklahoma.” https://www.guttmacher.org/fact-sheet/state-facts-about-unintended-pregnancy-oklahoma
5. Kaiser Family Foundation. “Teen Birth Rate per 1,000 Population Ages 15-19.” http://kaiserf.am/2d1iErL
6. Oklahoma Watch. September 2015. “Oklahoma Universities Struggle To Graduate Students.” http://oklahomawatch.org/2015/09/29/oklahoma-universities-struggle-to-graduate-students/. Status of Women in the States. August 2015. “The Status of Women in Oklahoma, 2015: Highlights.” http://statusofwomendata.org/app/uploads/2015/08/Oklahoma-Fact-Sheet.pdf. Kaiser Family Foundation. “Median Annual Household Income.” http://kaiserf.am/2cGXpsA.
7. The National Campaign to Prevent Teen and Unplanned Pregnancy. June 2012. “Teen Pregnancy and High School Dropout: What Communities Can Do to Address These Issues—Full Report.” https://thenationalcampaign.org/resource/teen-pregnancy-and-high-school-dropout. American Association of Community Colleges. 2012. “Make It Personal: How Pregnancy Planning and Prevention Help Students Complete College.” http://www.aacc.nche.edu/Resources/aaccprograms/horizons/Documents/mipcc_dec2012.pdf. Guttmacher Institute. March 2013. “The Social and Economic Benefits of Women’s Ability To Determine Whether and When to Have Children.” https://www.guttmacher.org/report/social-and-economic-benefits-womens-ability-determine-whether-and-when-have-children
8. The National Campaign to Prevent Teen and Unplanned Pregnancy. 2013. “Counting It Up: The Public Costs of Teen Childbearing.” https://thenationalcampaign.org/why-it-matters/public-cost
9. Southern California Academic Center of Excellence on Youth Violence Prevention, University of California, Riverside. 2010. “Child Maltreatment.” http://stopyouthviolence.ucr.edu/factsheets/FACTSHEET%20ChildMaltreatmentSpring2010.pdf. The National Bureau of Economic Research. “Poverty and Mistreatment of Children go Hand in Hand.” http://www.nber.org/digest/jan00/w7343.html
10. Guttmacher Institute. February 2015. “Public Costs from Unintended Pregnancies and the Role of Public Insurance Programs in Paying for Pregnancy-Related Care.” https://www.guttmacher.org/sites/default/files/report_pdf/public-costs-of-up-2010.pdf
11. The National Campaign to Prevent Teen and Unplanned Pregnancy. April 2014. “Counting It Up: The Public Costs of Teen Childbearing in Oklahoma in 2010.” https://thenationalcampaign.org/sites/default/files/resource-primary-download/fact-sheet-oklahoma.pdf
12. Guttmacher Institute. September 2016. “Contraceptive Use in the United States.” https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states
13. Guttmacher Institute. December 2013. “Leveling the Playing Field: The Promise of Long-Acting Reversible Contraceptives for Adolescents.” https://www.guttmacher.org/about/gpr/2013/12/leveling-playing-field-promise-long-acting-reversible-contraceptives-adolescents
14. The American Congress of Obstetricians and Gynecologists. May 2016. “Long-Acting Reversible Contraception (LARC): IUD and Implant.” http://www.acog.org/Patients/FAQs/Long-Acting-Reversible-Contraception-LARC-IUD-and-Implant Guttmacher Institute. September 2016. “Contraceptive Use in the United States.” https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states.
15. Guttmacher Institute. September 2016. “Contraceptive Use in the United States.” https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states
16. American Academy of Pediatrics. September 2016. “Policy Statement: Contraception for Adolescents.” http://pediatrics.aappublications.org/content/pediatrics/early/2014/09/24/peds.2014-2299.full.pdf. The American College of Obstetricians and Gynecologists. October 2012. “Committee Opinion / Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices.” http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Adolescents-and-Long-Acting-Reversible-Contraception
17. Guttmacher Institute. October 2014. “Contraception Drives Decline in Teen Pregnancy—and Expanded Access to LARC Methods Could Accelerate this Trend.” https://www.guttmacher.org/article/2014/10/contraception-drives-decline-teen-pregnancy-and-expanded-access-larc-methods-could. Centers for Disease Control and Prevention. November 2015. “National Health Statistics Reports: Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15-44: United States, 2011-2013.” http://www.cdc.gov/nchs/data/nhsr/nhsr086.pdf
18. Vox. October 2014. “This researcher gave 10,000 women free birth control. Here’s what she found.” http://www.vox.com/2014/10/6/6916587/free-birth-control-st-louis-iud-contraception
19. Guttmacher Institute. March 2016. “New Clarity for the U.S. Abortion Debate: A Steep Drop in Unintended Pregnancy Is Driving Recent Abortion Declines.” https://www.guttmacher.org/about/gpr/2016/03/new-clarity-us-abortion-debate-steep-drop-unintended-pregnancy-driving-recent
20. The National Campaign to Prevent Teen and Unplanned Pregnancy has assigned a taxpayer cost of $1,703 per teen birth per year for 15 years.
21. Guttmacher Institute. March 2016. “New Clarity for the U.S. Abortion Debate: A Steep Drop in Unintended Pregnancy Is Driving Recent Abortion Declines.” https://www.guttmacher.org/about/gpr/2016/03/new-clarity-us-abortion-debate-steep-drop-unintended-pregnancy-driving-recent
22. Guttmacher Institute. April 2016. “State Facts About Unintended Pregnancy: Oklahoma.” https://www.guttmacher.org/fact-sheet/state-facts-about-unintended-pregnancy-oklahoma