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Obamacare Simulation's Dramatic Effect on Teen Pregnancy Really a Technology Tipping Point

What got triggered when 9,000 women were offered free birth control in a recent study was a technology shift in a microcosm.

By now many Americans have read the basics: 9,000 St. Louis women are offered their choice of contraceptives for free. Two years later, the teen pregnancy rate has dropped to 6 per 1000 instead of the country average of 34. The abortion rate is 4.4 to 7.5 per 1000, less than half the rate of other St. Louis women. The researchers—whooping like miners who have just struck the public health mother lode—go national with their story.

But the real story is even bigger. What got triggered when 9,000 women were offered free birth control was a technology shift in a microcosm. When presented with comprehensive information and a buffet of no-cost options, a majority of the study’s participants, almost 75%, shifted from 1960’s contraceptive technologies to state-of-the-art long acting reversible contraceptives known in the industry as LARCs. And they liked them.

It was a perfect example of how private philanthropy combined with government action can seed a market for new technologies and changes in the private sector that benefit the public at large. The benefits accrue both to taxpayers, who see their joint investment produce dividends in public wellbeing, and to risk-taking innovative businesses that serve the public interest. 

The most widely used contraceptive in the U.S. is the Pill, released almost half a century ago and refined in intervening years to reduce the hormone load and side effects. The Pill has been a game changer, but it is far from perfect, especially from a human factors standpoint.  Very few human beings are able to take a daily medication with perfect consistency, and that fact alone largely accounts for an annual pregnancy rate of 1 in 12 for women on the Pill. (For couples using condoms, the rate is 1 in 8.  With no contraception it is over 8 in 10.)

The limitations of the Pill were recognized almost immediately, but early stage contraceptive research is a risky, low-return endeavor, not very interesting to most pharmaceutical companies that have stockholders to please. The gap was filled by, among others, the Population Council, a global not-for-profit that channels money into research around reproductive health technologies and programs. (Their latest contraceptive technology, now in clinical trials, is a ring that lasts a year and also protects against HIV.) In the 1970’s, the Pop Council pioneered two IUD’s, one copper and one hormonal, which they then licensed to pharmaceutical companies. These two went on to become the Paragard and Mirena, the only two IUD’s currently available on the U.S. market.  In the 1980’s they developed the first widely adopted implant, now sold internationally (but not in the U.S.) as Jadelle

In the real world, long acting reversible contraceptives have 1/10 to 1/50 th the failure rate of Pills, and they are cheaper in the long run. But the upfront cost is substantial, as much as $1000 for the device and insertion. The result is that women who are living month to month often choose old technologies and then pay the price, and even middle class women with health insurance may balk at the lump sum. Taking the money out of the equation changes the bottom line. 

America’s high rates of teen pregnancy and unintended pregnancy (and consequent abortion) have been attributed to a number of factors: Puritan sexual sensibilities that interfere with candid conversations about sexuality; a “virginity myth” that inclines teens to prefer impulsive, unsafe sex over “premeditated” sex; a wobbly ladder of opportunity combined with welfare incentives that make it more enticing for some young women to get pregnant than to pursue financial independence. All of these may be real, but it is striking that a simple shift in access to better technologies trumps them all, producing a teen pregnancy rate on par with that in Europe’s most thriving social democracies. 

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