Fully Funded Access to Contraception Can Change an Entire Population’s Lives
February 1, 2023 7 minutes read
EXECUTIVE SUMMARY
The Colorado Family Planning Initiative greatly affected adolescents’ lives during the five-year period in which it provided an extra $27 million in funding to Title X clinics to expand contraception access.
- The program led to a population-level increase of 1.8% to 3.5% in women’s on-time bachelor’s degree attainment.
- It reduced the teen birth rate by 57% and avoided more than $66 million in public assistance costs.
- The program was associated with a 14% decrease in students dropping out of high school.
The results of Colorado’s contraception expansion experiment are in, showing a dramatic improvement in women’s lives during the period in which Title X programs were fully funded through a grant.1
The Colorado Family Planning Initiative (CFPI), operated between 2009 and 2014, profoundly affected adolescent girls and young adults, resulting in a 6% to 12% increase in women obtaining their college degrees compared to earlier cohorts that did not benefit from the expanded contraception program, according to study results.
The expanded access initiative led to a population-level increase of 1.8% to 3.5% in women’s on-time bachelor’s degree attainment.
“In many ways, it was surprising that the program had such a large impact on college completion at the population level across the state — not just among [contraception] users,” says Sara Yeatman, PhD, lead study author and a professor of health and behavioral sciences at the University of Colorado Denver. “It’s surprising because the program did not remove any of the barriers to college initiation and persistence that we know exist for more disadvantaged populations who are more likely to use Title X clinics. It also did not introduce contraception where none had been available — rather, it expanded and improved the provision of contraception for women across the state.”
Increasing funding to Title X was enough to achieve a large gain in college completion, which the findings suggest was largely due to more women initiating college, Yeatman explains.
The results of an earlier study showed expanded access to contraception in Colorado was associated with a 14% decrease in students dropping out of high school.2 Those findings also showed a surprisingly large effect, says Amanda Stevenson, PhD, study co-author and an assistant professor of sociology at the University of Colorado Boulder.
“I was expecting us not to find an effect at the population level,” Stevenson explains. “Even though there’s the folk idea that teen births cause people to drop out of high school, it would require really unlikely associations at the population level to cause a complex chain of phenomenon because not that many people get pregnant as teenagers.”
Also, not all teenagers are motivated to prevent pregnancy. While the idea that expanding access to contraception would affect high school graduation seems obvious, from a research perspective, it was surprising that a population-level impact occurred, Stevenson says.
Investigators made sure they analyzed data thoroughly and accurately. “I was very skeptical because it indicates that the people who are not able to get the kind of contraception they want are the ones whose lives could be impacted by contraception,” Stevenson explains. “It’s not just about [access to] a specific method; it impacts their entire lives.”
The Colorado Department of Public Health and Environment touts the contraceptive access program’s success, noting the initiative reduced the teen birth rate by nearly half and cut the teen abortion rate by half. It also reduced second and higher-order births to teens by 57% and cut the overall birth rate among women ages 20-24 years by 20%. The relatively affordable program also avoided more than $66 million in public assistance costs.3
Women could access Title X programs before the $27 million additional funding from the five- to six-year grant.3 But the need for services was greater than what was available. With the extra funding, women could visit a Title X clinic and receive the contraceptive method they desired on the same day.
“Any state can do that by devoting more resources to Title X,” Yeatman notes.
The expanded access program enabled patients to obtain long-acting reversible contraception (LARC) immediately. This occurred at the same time LARC was becoming a more popular contraceptive method and was approved for adolescents and young adults.
“They made sure you could get those expensive devices that most Title X clinics didn’t have [immediate] access to,” Yeatman adds. “If someone wanted an IUD [intrauterine device], the providers were trained to insert them and get them for patients on the day of the appointment, while before they had to order them.”
Because IUDs are expensive, fewer clinics could stock them for patients who asked for that method. With the extra funding, they could afford to keep IUDs and other LARC in stock.
The grant doubled federal funding for Title X. The 37 counties with 80 Title X programs reach 95% of Colorado’s population. “In general, the money we use is federal funding, and it’s about one-third of what it needs to be,” Yeatman says. Colorado’s senators have sponsored a federal bill that proposes to increase and stabilize Title X funding so it will not succumb to an annual variation that depends on whoever is in charge politically, she notes.
Since the contraception access expansion program ended, Colorado lawmakers increased Title X funding — but at a lower level than was available during the grant-funded expansion. They recognized the program’s success, but internal politics hampered a fully funded Title X.
“Support often falls along political lines,” Yeatman says. “Working through Title X programs is a good way to provide access.”
For example, Colorado already permits minors to consent to their own contraception care, but this is not true in every state. Title X programs are the one place that any person, any age, can receive such care without having to obtain guardian permission or use their family’s income to qualify for subsidized contraceptive and reproductive healthcare, Yeatman explains.
Title X programs provide cost-sharing. Many people who use their services qualify for free care or copays subject to a sliding income scale.
A program that provides affordable and widespread access to contraception affects more than just young people and teenagers, Stevenson notes. For example, a young woman with aspirations to become a physician, lawyer, or earn some other doctorate may decide it is not reasonable to invest in higher education because she is not guaranteed a chance to complete the degree program.
“When you talk with physicians, they say they could never have had a kid while they were in residency,” Stevenson says.
But when people have greater control over their reproductive health and childbearing decisions, they will make investments that provide long-lasting benefits to society as a whole.
“There’s a sense of autonomy over one’s life force that can come from knowing you have the means to control your fertility,” Stevenson says. “It’s in the same realm as when modern contraception was first introduced.”
Expanding contraception access to everyone who desires it can be a force of change in society — just as the introduction of the birth control pill brought about major societal changes.
The program may have worked through both fertility and non-fertility pathways. “Some of the impact was because the Colorado Family Planning Initiative allowed women to avert births in adolescence and young adulthood that would have made starting and finishing college by age 24 difficult,” Yeatman says.
But there likely were broader effects. “Just like the generation of women who newly had access to the oral contraceptive pill in the 1960s, women exposed to CFPI at its peak would have had greater confidence that they could start and complete college without an undesired pregnancy,” Yeatman explains.
The years when contraception was not a political wedge issue are gone. With the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, it is possible that contraceptive expansion initiatives will be hard sells in many abortion-ban states, where they could be needed the most.
“With the Dobbs decision, people now have a lower sense of security that they can control their fertility,” Stevenson says. “[This program] is a force in an opposite direction.”
Reproductive health advocates and providers should keep in mind that the effect of the Dobbs decision could be a warning about what will happen next to contraception. (For more information, see story in this issue on the anti-contraception social media movement.)
“Once people expect to control their fertility, we don’t know how long it takes for them to lose hope in their ability to control their fertility,” Stevenson says.
The study’s findings that more people accessed college during the contraception expansion years in Colorado suggest decades of positive benefits to the state’s society and economy.
“You would expect women with college degrees to go into the workforce, stay in the workforce, and have higher-paying jobs,” Yeatman says.
A 9% increase in women finishing a college degree by age 24 years should affect income and earnings.
“There’s more need than ever to prevent unwanted pregnancies,” Yeatman says. “There’s more need than ever to invest in contraception and to provide this important care.”
Robert A. Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board, has long appreciated the work in Colorado. He notes a recent New York Times article about declining teen birth rates.4
“[The article] noted teen births have fallen by more than three-quarters in the past three decades. [The author] describes this fall as ‘the fall of improbable magnitude,’” Hatcher explains. “Teen births fell by 77% since 1991. The fall was about the same in white, Hispanic, and Black girls and young women. The fall occurred in every state. Today, just 6% of 15-year-old girls become pregnant every year.”
Many factors were noted that contributed to the fall of teen birth rates. “Contraceptive use has grown and shifted to more effective methods. Adolescent sex has declined,” Hatcher explains. “It is important to note that abortion does not have appeared to have driven the reduction.”
The Affordable Care Act, which requires insurance plans to carry contraception for free, played a major role in the fall of teen births, Hatcher notes.
“Every last one of us wanting to see effective contraception continue to be available in our country must inform his or her representatives in Congress of the good-news stories occurring because of the provision of excellent, voluntary contraceptives today,” he says. “Therefore, I promise to discontinue my retirement and work to spread this message.”
REFERENCES
- Yeatman S, Flynn JM, Stevenson A, et al. Expanded contraceptive access linked to increase in college completion among women in Colorado. Health Aff (Millwood) 2022;41:1754-1762.
- Stevenson AJ, Genadek KR, Yeatman S, et al. The impact of contraceptive access on high school graduation. Sci Adv 2021;7:eabf6732.
- Colorado Department of Public Health and Environment. Taking the Unintended Out of Pregnancy: Colorado’s Success with Long-Acting Reversible Contraception. 2017.
- DeParle J. Their mothers were teenagers. They didn’t want that for themselves. The New York Times. Dec. 31, 2022.
The results of Colorado’s contraception expansion experiment are in, showing a dramatic improvement in women’s lives during the period in which Title X programs were fully funded through a grant. The Colorado Family Planning Initiative profoundly affected adolescent girls and young adults, resulting in a 6% to 12% increase in women obtaining their college degrees compared to earlier cohorts that did not benefit from the expanded contraception program, according to study results.
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