By now many Americans have read the basics: 9000 St. Louis women are offered their choice of contraceptives for free. Two years later, the teen birthrate rate is at 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 9000 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 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 1/50th 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.
- Traditional contraceptives have a big gap between “perfect use” and “real world.” Short acting hormonal methods like pills and patches, and barrier methods like diaphragms and condoms all have major gaps between how well they work under “perfect use” or laboratory conditions, and how well they work in the real world. For timing methods like Natural Family Planning, withdrawal, and abstinence the gap can be enormous, because they require a level of knowledge, self-awareness, control and communication that is beyond most people. By contrast, with a LARC, what you see is what you get. Once a LARC is in place, it works in the real world just like it works in the research.
- LARCS are better at blocking pregnancy.— If you keep in mind that 85 women out of 100 will get pregnant in a year of unprotected sex, the contraceptive effect of the Pill is dramatic. In a perfect world where pill-taking never got disrupted by bounced checks, marital disputes or forgetfulness only two women out of every hundred would get pregnant on the Pill. Not bad, unless you’re one of the two. Even so a well settled LARC leads to far fewer. It’s anywhere from 2/800 (copper IUD) to somewhere around 2/4000 (implant).
- Fewer side effects means higher continuation.— In the St. Louis study, 85 percent of the women who chose a LARC were still using it a year later, compared with about half of those who had chosen a short acting method like the Pill or ring or patch. Part of the difference may be the hassle factor, but also short acting methods like the Pill or ring or patch require a larger dose of hormone than an IUD. No contraceptive works the same for everyone, but on average a lower dose means fewer side effects. And fewer side effects means women are less likely to go through risky gaps when they are changing methods.
- LARCs toggle the fertility default. Imagine if the light switches in your house all turned themselves back on after a certain amount of time whether you wanted them on or not. That’s how fertility works. It turns on at adolescence and stays on for the next forty years whether a woman wants it on or not. During that time she may want to have one child or four or none. The rest of those forty years, some 400 reproductive cycles, she has to either switch it back off or avoid having a fertile egg come in contact with sperm. The Pill requires her to flip the switch off every day. A LARC means she can hit it as infrequently as once every twelve years –and still flip it back on when she wants to have a child. In recent years, behavioral scientists have learned quite a bit about default effects—how much human behavior is driven, not by choice but by indecision or inattention or inconvenience or inertia or impulse. LARCs take these factors out of the equation for long periods of time, making pregnancy an active and more often mutual decision.
It all adds up to a technology leap that is huge, especially for people who are already up against the hard edges of life: teenage girls who haven’t quite figured out what they want for themselves, or how to say no; families that are struggling to make ends meet; fundamentalist women for whom either another baby or an abortion would feel like a nightmare; tired moms who just want to relax about sex, confident that intimacy won’t mean another 6000 diapers.
As an American, two of my cherished values are freedom and opportunity. As a woman, the ability to manage my fertility is fundamental to both, and I want that same ability for my two daughters and the other young women in my life. That’s why the St. Louis “Obamacare Simulation” is such an exciting example of how philanthropy, government, and private enterprise can team up to trigger the technology tipping points that create my dream future. Philanthropists had seeded socially beneficial technologies. Corporations were eager to distribute them and reap a profit. And yet, without a publically funded program that lowered barriers, most women would have gone on using old technology at best. (Only five percent of contracepting women in the U.S. use some kind of LARC. Contrast that to over 25 percent in Norway.) Enter the third member of the team, government, and the equation changes. Radically.
Sometimes when I think about the Pill, I think about my old Apple IIc. It changed the way I operated, but I’m really, really glad people kept innovating. I’m glad that dreamers drove forward ideas that otherwise would have languished. I’m glad that government invested some of our pooled resources in building and regulating the internet. I’m glad that philanthropy and government made information technology available in public universities, schools, and community centers. I’m glad that the power of the market brought information to my fingertips. Technology change takes a village.