By Janet P. Realini,
MD, MPH
Let me tell you about Jessica
(not her real name). She is 21 and has a 3-year-old. She and her son live
with her parents, and she works part-time and also
takes classes at a community college. She has a new
boyfriend and came in for birth control. However,
the visit did not go as she planned. She is shocked
when her pregnancy test is positive and becomes
tearful. She did not think she could get pregnant.
She and her boyfriend have been using condoms “sometimes” and withdrawal “sometimes.”
She is worried that another baby will mean she
cannot continue with college. She will need to
work more hours, and she is not sure if her mom
will agree to help with another baby. She feels
especially overwhelmed, because she is not sure
how her boyfriend will react.
Jessica’s story is typical of many young
women, especially those who are low-income
and uninsured. Unplanned pregnancy is epidemic
in Texas, and it costs the state dearly, both in
human and economic terms. In 2003, 44 percent of births (nearly 166,000) were unplanned, and, in addition, more than
76,000 abortions were reported. Medicaid cost estimates for unplanned pregnancies
in 2005 exceeded $1.1 billion.
Pregnancies that are planned, wanted, and welcomed are much more likely
to be healthy pregnancies. Preventing unplanned pregnancies will reduce the
incidence of low birth weight, school failure, poverty, single parenthood, and
abortion in Texas.
Reducing unplanned pregnancy will require increasing knowledge about and
access to effective contraception. Progress will also require increasing motivation
to avoid unplanned pregnancies, especially among young adults. Threequarters
of unplanned pregnancies are to women under age 30, and seven in
10 pregnancies to unmarried women in their 20s are unplanned.
This summary outlines proposal ideas to reduce unplanned pregnancy and,
in turn, improve maternal, child, and family health in Texas.
1. Maximize access to contraception
for low-income and uninsured women
Poor women have disproportionately high rates of unplanned pregnancy
and abortion. Measures to address this in Texas include:
• Repeal of arbitrary distribution rules that have reduced the availability of
birth control in some communities (Appropriations Rider 60);
• Fixing the implementation problems of the new Medicaid Women’s Health
Program, and promoting the program to women and to providers;
• Maintaining or increasing public funding for Titles V, X, and XX Family
Planning programs;
• Restoring funding previously diverted to non-clinical services (Alternatives to
Abortion); and
• Increase the reimbursement rate for oral contraceptives under Titles V, X, XX,
and the Women’s Health Program to an amount that will allow health care
providers to continue to dispense birth control pills.
2. Maximize coverage of contraceptives
by health insurers
Women with health insurance need improved access to contraception, as well.
Many plans do not cover birth control, especially in states without mandated coverage,
such as Texas. Measures to improve contraceptive coverage include:
• Mandating contraceptive coverage by health insurers that cover
prescription drugs;
• Requiring health plans to inform consumers — and prominently display —
to what extent they cover contraceptives;
• If contraceptives are not covered, allowing consumers to purchase coverage
on their own, at a group rate; and
• Requiring plans to cover dispensing a minimum of three months’ supply
(if prescribed).
3. Minimize barriers to obtaining
contraceptives
Even with funding and insurance coverage, some women encounter obstacles
to obtaining contraceptives. Potential policies to address these issues include:
• Enacting safeguards for timely patient access in case of pharmacist refusal; and • Assuring access to emergency contraception for survivors of sexual assault.
4. Change the social norm:
All pregnancies should
be planned
Dramatic reductions in unplanned pregnancy
will require changing attitudes among men as well
as women. All should recognize the value of planning
pregnancies in order to form healthy and
strong families.
• Institute a social marketing campaign to promote
planned pregnancy.
5. Integrate effective
pregnancy planning into the
health care system
Educational programs should target health
providers, and systems should be devised to ensure
that patients are screened routinely for family planning
needs. Contraceptive services should be incorporated
into routine medical care.
• Integrate family planning education and care into
preconception care efforts; and
• Devise methods for health systems to ensure that
men, as well as women of childbearing age, are
routinely screened and counseled for family planning
needs.
6. Ensure appropriate sex
education for young adults
Young adults need balanced and accurate information
about sex, relationships, abstinence, and
contraceptives in order to plan healthy pregnancies.
Measures to educate young people should begin
early and include:
• Promoting the use of evidence-based educational
programs in Texas schools;
• Develop and evaluate pilot programs to promote
parent-child connectedness and communication
about abstinence and sexuality; and
• Provide education about abstinence and birth control
to young adults in college and in the workforce.
There is no one easy solution to such a sensitive
and wide-spread problem as unplanned pregnancy.
But there are answers. And they involve every aspect
of society, from young people, to parents, to educators,
to religious and business leaders, to politicians,
and, of course, medical care providers.
It will take all of us, working together, to change
this pattern. It will not change overnight, but reducing
unplanned pregnancy is possible. And it will
mean healthier mothers and babies — as well as
stronger families — for our community.
Dr. Realini is a family physician
working in public health. Her
interests include adolescent health,
teen pregnancy prevention, and
family planning.
Calculations assume 56 percent of 2005 Texas births are
paid for by Medicaid (Texas DSHS estimate); 55.3 percent
of these are unplanned (Texas 2004 PRAMS); each
Medicaid-paid birth costs $9,207 (SFY 2006 Texas
HHSC data).
CDC. Recommendations to improve preconception
health and health care — United States: A report of the
CDC/ATSDR Preconception Care Work Group and the
Select Panel on Preconception Care. MMWR 2006; 55
(RR-6):1-23.
National Campaign to Prevent Teen and Unplanned
Pregnancy. Unplanned Pregnancy: Key Data. Accessed
at: http://www.thenc.org/ resources/pdf/FactSheet-KeyData.pdf, 26 February, 2008.
Boonstra HD, et al. Abortion in Women’s Lives. New
York: Guttmacher Institute. 2006.
Sonfield A, et al. U.S. insurance coverage of contraceptives
and the impact of contraceptive coverage mandates.
Perspect Sex Reprod Health 2004; 36 (2):72-9.
SIECUS Policy Update, March 2005. Judge Rules
Pharmacist Violated Code of Ethics — Shines New
Light on Pharmacist Refusal Debate. Accessed at
http://www.siecus.org/policy/PUpdates/pdate0163.html,
6 June, 2006.
CDC. Recommendations to improve preconception
health and health care — United States: a report of the
CDC/ATSDR Preconception Care Work Group and the
Select Panel on Preconception Care. MMWR 2006; 55
(No. RR-6).
One model is the Michigan Quality Improvement
Consortium Guideline. Prevention of Unintended
Pregnancy in Adults 18 Years and Older, June 2007.
Kirby D. Emerging answers 2007: Research findings on
programs to reduce teen pregnancy and sexually transmitted
diseases. Washington, DC: National Campaign
to Prevent Teen Pregnancy, 2007.
Lezin N, et al. Parent-Child Connectedness. Implications
for research, interventions, and positive impacts on
adolescent health. ETR Associates, 2004.
One model is the Michigan Governor’s Blueprint for
Reducing Unintended Pregnancies Talk Early and Talk
Often program. Accessed at: http://www.michigan.gov/
miparentresources/0,1607,7-107-37383—,00.html,
9 September, 2007.
