Why Are Half The Pregnancies In The U.S. Unintended?

IRA FLATOW: This is Science Friday. I’m Ira Flatow. This year marks the 60th anniversary of the pill, you know, that fast and easy oral hormone that helped to not only change contraception, but also family planning and women’s health. But many of the other contraceptives we still see today were first developed way back in the 19th century. So, what are some of the contraception conversations that are happening today? Science Friday Producer Alexa Lim has more.

ALEXA LIM: The pill ushered in more effective and convenient contraceptives, like IUDs. But even with more contraceptive options, the current rate of unintended pregnancies in the US is still around 45%. This comment came in on the Science Friday VoxPop app from Valissa in Queens.

VALISSA: I think what really needs to change other than the actual the contraceptives itself is the discussion around contraceptives. Because I did not use the pill to prevent pregnancy. I used it because I had a medical issue.

ALEXA LIM: So, how is the discussion changing? We’re going to look at how contraception education and policy is evolving, and how that could affect usage and access. My guests are Linda Gordon, who is a historian and professor at New York University, and author of the book, The Moral Property of Women, A History of Birth Control Politics in America.

LINDA GORDON: Glad to be here.

ALEXA LIM: And Cynthia Harper, a professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco.

CYNTHIA HARPER: Thank you so much for having me.

ALEXA LIM: Linda, that rate of 45% of unintended pregnancy seems really high. And it’s also been 60 years since the pill was released. So, how much progress have we made since then?

LINDA GORDON: Actually, the pill did make a big change because it introduced hormones. And that, of course, allowed many, many more people to have easy access to contraception. But it also created problems. Because putting hormones in your body carries risks. If you use a diaphragm, there’s absolutely nothing you can do that would be dangerous.

The other great advantage to some people, of the pill, was that you do not use it when you’re having sex. You can do it at another time. And so, it is in some ways invisible, and it isn’t immediately associated with sex. Since then, I know, and I’m sure you’ll hear more about it, there have been many, many hormonal methods developed. But what really hasn’t happened enough is making sure that people who really want safe and healthy birth control to have access to it.

ALEXA LIM: Right. And Cynthia, you work in the area of education. How much does this play into it as well?

CYNTHIA HARPER: Well, I couldn’t agree more with Linda. And we are at a watershed moment currently in society, where we just really need to change our inequalities and to increase access for the people who historically have not had rights and access, and who today don’t have rights and access. And I believe that education has a large role to play. Because certain people are left out of knowledge and awareness, access to health care, and fewer people in our society really are able to choose when and how to have their children, and then are able to bring them up safely, with shelter and food.

ALEXA LIM: And Cynthia, you do do work in this area, where you were looking at IUDs, and you did a study providing education to health care providers. Could you talk about that study, like what did that show?

CYNTHIA HARPER: Yeah, we do a lot of work in the area of training physicians and nurses across the country in community clinics. And we have found that when nurses and physicians and their clinics are given the resources and are set up properly, then they’re able to offer quality counseling to patients who come to them, and can enlarge the range of methods that they offer them. And I think it’s a really important movement to have birth control methods available outside of clinical settings.

I worked long and hard to get the emergency contraceptive pill available in pharmacies so people could take it and time for it to be effective. And I really think it’ll be a big change in this country. What we have in California, you can now get the pill from the pharmacy. And I think that is a change that both Republicans and Democrats agree with, and would really help to increase access for people across the country who aren’t able to make it to the clinic.

That’s become a big barrier right now during the COVID pandemic. And a lot of clinics are offering telemedicine for contraception. But the IUD, for example, or the contraceptive implant require an in-clinic visit too.

ALEXA LIM: Can you talk a little bit about that, the move from emergency contraception to have it available over the counter?

CYNTHIA HARPER: OK, so that took advocacy. It took research for, oh, boy, I think it was over a decade that we conducted studies. It took the FDA evaluating all the data. And then it was really a big political process was involved too. And it took the judiciary, in the end, where I think it was the Eastern District Court of New York, where they had a lawsuit, where they decided that, yes, this would become available to all ages.

But it really took a lot of different sectors in society to make that happen. The reason it was so important was that because its effectiveness is time limited, and if you have to go to a doctor’s office and make a visit, and get an appointment, particularly on a weekend or a holiday, then you’ve missed the window.

ALEXA LIM: And so, is there a bigger move to get things into clinics and outside of just having them to be prescription, prescriptive?

CYNTHIA HARPER: Yes, there is a move– Free of the Pill. And this movement is strong. The research now is taking place. There is advocacy there too. There are a lot of pieces to put into place. Our health insurance system has a lot to do with what’s available and where. And in order for the pill to be a benefit in the pharmacy to people who need it, it would need to have insurance coverage. And pharmacists would also need to be remunerated for dispensing it.

Right now, we’re not set up like that across the country. We have so many vested interests in our health care system not to change. But I think now is a critical moment, where we all have to agree that our health care system isn’t working for us. We do not have the health outcomes that we really should be having in the United States, and we could be having, and I am hopeful that we can change to try to address a lot of these inequalities in care.

ALEXA LIM: I guess that’s a big question, but we do need an overhaul. But what are those individual pieces that need to be moved?

CYNTHIA HARPER: In order to make contraceptives more available to women, the Affordable Care Act went very far. And there was a mandate. And there was a lot of agreement behind it, that contraception is an essential health care for women. And I think that’s going to be hard to remove going forward. There are pieces of that are still there. Although there was this Supreme Court decision recently, that employers who are religiously affiliated may decide not to offer contraceptive coverage.

We do have more wide coverage now. However, with the increasing economic hardship from COVID, a lot of people are losing their health insurance, because we have this system where health insurance is employer-based. So, that really helps the haves, and really leaves out the have-nots. And I think our next step is to have a health insurance system that is not predicated on the fact that you have a well-paying job with benefits.

ALEXA LIM: Right. Linda, maybe this is too on the nose, but is this just like history repeating itself? Is this the same conversation we just keep having?

LINDA GORDON: Well, certainly, there have been enormous changes in the last, say, 50 years. Let me go back to a couple of earlier dates. It was not until 1965 that the last state repealed its laws against providing birth control. Then eight years later, when the Supreme Court ruled that people should have a right to abortion, at least in the early stages of pregnancy, just about everyone, all the journalists, all the experts, everyone assumed abortion rights are now on a roll. It’s no longer going to be controversial.

By the time of the Supreme Court decision there were already 18 states that had repealed their laws against abortion. What has happened since then, no one could have predicted, and that is a really massive campaign, a very well-funded campaign, not only against abortion, but as we’re seeing more recently, against providing contraception where it’s needed. There’s a little bit of a contradiction there, because I think most experts that I know of think that the best way to prevent abortions is to make contraception more easily available.

But then, politics don’t always follow that kind of logic. Anyway, I think we’re also in a period which we have to face that these issues of women’s rights to control births have been turned into a political weapon. That has done a lot to change the politics of our country. And I think that’s another thing that would have been very surprising in 1973. Because, after all, this country faces many, many serious problems and issues. And it seems strange that this very personal choice should be one of those issues that is so controversial.

ALEXA LIM: I’m going back to that 45% statistic again, which came from 2011. It seems like there, aren’t these big studies investigating this. I mean, why do you think there haven’t been more recent studies on this? Do we need more scholarship on this?

LINDA GORDON: I think when we think about the 45%, which is very upsetting, we also need to think about the fact that this country has unusually high rates of maternal mortality and infant mortality. So, we’re talking about failures in the whole system that go together.

CYNTHIA HARPER: I will add that we actually are conducting a study, and a policy study. And I’d like to offer some hope too, because we believe that there are ways that we can change our health care system, and what we make accessible to young women to improve their health. And it requires looking at large social issues too. It’s not just a health system issue.

And we are conducting a study, comparing young women who are in community colleges in California with young women in community colleges in Texas. And our intervention is to improve their access to contraception and care. And we also work with a network of community clinics around where these young women live in order to train the clinics to open their doors and have quality care.

We will see how the policies in California, including the recent COVID policies that are covering very innovative contraceptive care practices, such as the delivery. there is a new formulation of Depo Provera that can be administered at home. It can be self-administered. Or right now some clinics have drive-by supplies for SDI testing and for contraceptives.

California is also covering, as I mentioned, pharmacy access to contraceptives. They have a lot of coverage in place that helps people to be able to choose a wide variety of methods, and also to choose methods in this time of telemedicine.

In Texas, reproductive health care is more restrictive. People have a harder time affording the method that they may want. And this really gets to reproductive– those questions of reproductive autonomy, and what they’re able to choose when, and when they want a child, the conditions in which they have the child.

So, we are following these women far out, for five years, to look at their reproductive health outcomes, and also to see how they fare in their larger lives. Because all of these things are closely tied together. And we’re looking at their educational pathways, also their entry into the labor market. And we’re very hopeful that the kind of safety net that California provides, which is more similar to what you might see in a European country, will result in better outcomes, overall better life outcomes for these young women, in addition to better access to reproductive health.

The big question will be, moving forward, I believe this data will be very useful if we have a change in the administration. But it also can be useful on the state level for states that are considering whether to cover certain things and whether to pay attention to certain things, such as contraceptive access for young people and maternal mortality, which is a burning issue in our country right now.

ALEXA LIM: I’m Alexa Lim, and this is Science Friday from WNYC Studios. And I know it’s probably different state by state, but do we have overall guidelines about this? Or do we need overall guidelines?

CYNTHIA HARPER: We do not have overall guidelines. I don’t know if overall guidelines are needed. I do know that it takes– it will take all of us and all sectors of society to try to make essential health care available to our population at large.

ALEXA LIM: Right, OK. And I know this has been a wide ranging conversation, but what are your general thoughts on the future of contraceptives and family planning. Like I said, it’s been 60 years. Maybe we don’t have to look exactly 60 years out, but what are the key issues?

LINDA GORDON: I think what is fundamental here is that people absolutely need the ability to control reproduction. Part of the evidence for that is then every society in the past, people have tried to do that. They’re not always successful. But it’s just too important. It’s very important economically. It’s very important in terms of the kind of family you want to have.

It’s been increasingly important as more, and more, and more families and children depend on women’s employment and their wages. Over time, the closest correlation, that I’ve read anyway, and I’m talking over a century of time, over time, the strongest correlation with use of birth control is women’s employment. Because this is something that just makes it really impossible to do a good job as a mother if you cannot control how many kids you want to have.

Because of that, I’m actually fairly optimistic. Because I think so many people need and want this that they can’t do without it for long. And we see that in the polls, which are that the public opinion, even in the so-called red states, is much more favorable for making contraception, and even abortion, accessible than the politicians respond to.

But ultimately, I think it’s just one of the most fundamental things that you do in life, that you have to be able to make these decisions and have a way to make the decisions that work for you.

ALEXA LIM: Cynthia, what are your thoughts?

CYNTHIA HARPER: I absolutely agree. And I also am hopeful. I envision our society where all young people are able to choose in this very important area of their lives, and are able to enter the labor force if that’s what they want to do, are able to have the children they want to have, and are able to have safe and healthy lives.

ALEXA LIM: Thanks so much for taking the time to talk today.

CYNTHIA HARPER: Yeah, thank you so much for having us.

LINDA GORDON: Thanks.

ALEXA LIM: Linda Gordon is a historian and professor at New York University, and author of the book, The Moral Property of Women A History of Birth Control Politics in America. And Cynthia Harper is a professor in the Departments of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco. For Science Friday, I’m Alexa Lim.

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