This article first appeared in the St. Louis Beacon, July 28, 2011 - On July 19, a governmental advisory group recommended health insurance plans cover contraception at no cost. The recommendation caught many people by surprise. But free contraceptives are available already to thousands of area women participating in a large-scale study offering them a range of birth control methods.
Called the Contraceptive Choice Project, the study is expected to sign up nearly 10,000 area women by fall, said Dr. Jeff Peipert, the principal investigator and a professor of obstetrics and gynecology at Washington University. The study seeks to determine whether removing financial barriers to contraceptives will decrease the frequency of unintended pregnancy.
Peipert's work predates by nearly four years the Institute of Medicine's recent recommendation that health insurance plans offer women a range of free preventive services, including contraception. The Department of Health and Human Services has to decide whether this proposal will be adopted as part of the Affordable Care Act.
Peipert had no idea that free contraceptives would become part of the health-reform debate when he began his study in 2007. He said the government should adopt the institute's recommendation since teen pregnancies and unintended pregnancies are serious public-health problems. He points to reports showing that nearly 50 percent of all U.S. pregnancies are unplanned, one of the world's highest rates, and that between 74 percent and 95 percent of teen pregnancies are unintended.
The Washington University study is financed by a foundation that wants to remain anonymous, he said. The foundation called the university about the project in 2006 and planning began the next year. "It does seem like they had a crystal ball and could see this (institute's report) coming in the future."
The thinking of the foundation, he said, "was wouldn't it be great if we had birth control free of charge and we had universal access regardless of the women's means to pay? Anyone could get what they wanted -- and what would happen?"
Women opt for IUDs, implants
What has happened so far, he said, is that women in the study tend to choose those reversible birth-control methods regarded as the most effective ways to prevent unintended pregnancy -- intrauterine devices, or IUDs, and hormonal implants. These methods are used by fewer than 2 percent of women nationally, he said. He adds that the project didn't push any specific approach but did inform women about the pros and cons of various methods.
While birth control pills are the most widely used method, he said, the unintended pregnancy rates are 10 times higher among women choosing pills, patches and rings than those using IUDs and implants. The study includes women across the economic and racial spectrum in St. Louis and St. Louis County, Peipert said, adding pregnancy is hardest for those who are poor or lack health insurance.
"They have a much higher percentage of unintended pregnancy. But in our study, women of all socio-economic groups are choosing the most effective methods at a very high rate, regardless of insurance and race. When we wiped out the issue of co-payments and payment methods, almost all of the women, close to 70 percent, are choosing the most effective methods, the IUDs and implants.''
In spite of the popularity of the pill, he said, what's overlooked is the tendency to forget to take them.
"Anyone who takes a pill whether it's you or me or whoever, can miss a pill. If you miss a (birth control) pill, that's when pregnancies occur."
IUDs are inserted into the uterus and can remain in place for five to 10 years. They can be removed at any time at the woman's request, he said. Hormonal implants are placed under the skin of the upper arm and are effective for three years.
Women in the study are given the contraceptive of their choice, free of charge. The foundation believes the most effective methods are unaffordable for many women to buy on their own, Peipert said. He notes that that the upfront cost of IUDs and patches can exceed $500.
"We tell women that there are many doctors and clinicians who are reluctant to put in the IUD or are untrained to put in an implant. But we can do any of those methods."
Asked about the perception of infections associated with IUDs, Peipert says improvement in technology in both IUDs and implants might lead to greater acceptance of these methods in preventing unwanted pregnancies.
He concedes that there are "very, very small risks" but adds there are risks associated with pills, patches and rings, too. In some cases, the pregnancy could pose a greater risk to the well-being of the woman than any of the contraceptives.
The Institute of Medicine's recommendation also calls for other services for women, including screening for gestational diabetes and at least one preventive care visit to the doctor each year.
The Washington University study offers free testing for sexually transmitted diseases and treatment for the patients and their partners for any curable infection. This service is likely to reduce STD rates, Peipert said.
Reaction to institute's recommendation
Although the Institute of Medicine recommendations created an outcry from some conservative groups, Peipert said the opposition to his study hasn't been strong.
"There has been background noise. But all the methods we're providing are not causing abortions and are not about ending a pregnancy. It's about preventing pregnancies from the beginning. We feel we're really moved forward with what we think is the future of prevention in women's health care."
He added, "Regardless of what side of the abortion debate you're on, most of us would like to reduce the number of abortions and unintended pregnancies. The way to do that is to provide contraceptives."
Even so, national and local conservative groups have opposed the institute's recommendation, fearing that it might open the door to using emergency contraceptive drugs that they say amount to abortion.
"If this is a call for free contraceptives, I'd like to remind people that they (the contraceptives) do not prevent (all) pregnancies," said Pam Fichter, president of Missouri Right to Life. "Also under the heading of contraceptives are things like the morning-after pill and the abortion pills. Missouri Right to Life would be opposed to contraceptives provided free of charge."
Paula Gianino, CEO of Planned Parenthood in St. Louis, said the recommendation marks a step toward giving women access to birth control through commercial insurance or government-funded programs. She said access to birth control and to health services in general has been hampered by the recession, joblessness and a loss of health insurance, and a reduction or elimination of some state health programs. The matter isn't helped by what she calls a resurgence of efforts to destroy family-planning programs.
"You've heard some groups being critical of the recommendation and saying this would only add to the cost of the Affordable Care Act. The fact is that prevention, particularly family planning services, not only saves women's lives and health but also saves taxpayer dollars. Prevention works. For every dollar we invest, we save almost $4 in other types of government funding."
She said Planned Parenthood services already are aligned with some of the institute's recommendations, including screening for gestational diabetes.
"In the context of a family planning visit for an annual gynecological exam, we do hypertension and diabetes screening," she says. "That has always been a part of our standard care and it should be the standard of care across the country."
The institute's recommendations offers help for addressing pregnancy among young people, said Allison Hile, executive director of Teen Pregnancy & Prevention Partnership in St. Louis.
"I think that the argument of prevention is being taken more seriously now than in the past," she said. "It also saves money in the long run. We live in a country that's absolutely saturated with messages about sexuality. The most important thing we can do to prevent unwanted pregnancies and abortions is to make contraceptives easily available."
She said society cannot treat teens as if they live in bubbles.
"Not giving them access to contraception is dangerous to their health. None of us want teens to have sex, but they don't ask us first. So if they are going to have sex, we want them to be safe. They can't be safe without access to contraception."
Funding for the Beacon's health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization that aims to improve the health of the people in the communities it serves.
