A recent study at Washington University aims to determine whether removing financial and educational barriers to contraceptives will reduce the number of unintended pregnancies.

Called the Contraceptive CHOICE Project, the study showed that when price is not an issue, women tend to choose those methods of birth control considered to be the most effective at preventing pregnancies—intrauterine devices (IUDs) and hormonal implants.

“We planned that IUDs would be more popular after we removed the barriers, but we never planned for how popular they would be,” said Dr. Jeffrey F. Peipert, the study’s principal investigator and a professor of obstetrics and gynecology at Washington University School of Medicine.

The study, which began in 2007, provided more than 9,000 women with free contraception of their choice as well as counseling on all forms of birth control. About 75 percent of women in the study chose the long-acting methods, and more than 50 percent of participating women chose IUDs.

These numbers are strikingly different from patterns of contraceptive use in the U.S., where only 5.5 percent of women using contraception choose IUDs, according to Dr. Brooke Winner, a resident at Barnes-Jewish Hospital and the study's lead author.

Cost barriers

This discrepancy is largely due to price, Peipert said. Long-acting reversible contraceptive methods can cost as much as $1,000 — enough to put them out of reach for many people.

The cost of birth control pills can be as low as $4-$9 a month, according to Peipert.

“The whole problem all along has been access to effective contraception. Many women might have preferred using a LARC, or long-acting reversible contraceptive, but couldn’t afford it,” Allison Hile, the executive director of Teen Pregnancy and Prevention Partnership, said.

It's a problem for the uninsured. And while many insurance plans cover contraceptives, the plans might have high deductibles and copays.  Some insurance companies also require pre-certification of the LARC procedure, which can pose another obstacle.

Dr. Jennifer Smith, an obstetrician-gynecologist in St. Louis County, says the high out-of-pocket cost of IUDs and implants is a problem for many of her patients. "People aren’t going to choose [LARC methods] if it’s going to cost $1,000 up front.”

Dr. Katie Plax, an associate professor of pediatrics at Washington University School of Medicine, also recommends that women use long acting reversible contraceptives, but agrees that price is a major issue. She serves as the medical director of the SPOT, or Supporting Positive Opportunities with Teens, where youth can come for assistance and health services, including contraceptives.

“At the SPOT, 60 percent of the population we serve is uninsured,” Plax said. “We don’t have enough money to fund [IUDs and implants] for free.”

Education of patients and doctors

Another barrier to increasing usage of the LARC methods, especially IUDS, is education.

“When we did a survey before CHOICE and asked women their biggest concerns about the IUD, a lot of them weren’t even aware that it was available, and many of them had no idea that it was safe,” Peipert said.

The IUD received a bad reputation after many women reported frequent infections and miscarriages with the Dalkon shield in the 1970s. However, modern IUDs are safe and effective, according to Peipert.

In the first stage of the CHOICE Project, both young and old women chose IUDs and liked them. The second part of the study looks at continuation rates and satisfaction rates with each type of contraceptive after one year.

“IUDs and implants were far better than pills, patches, rings other methods,” Peipert said. “Close to 85 percent were continuing to use these methods after one year, compared to about 50 percent with pills, patch or ring.”

Hile believes this information will help others see the benefits of LARC methods.

“For so many years, physicians told women who had never had a baby that they couldn’t use an IUD. I think that this will open their eyes to the fact that it’s fine for teenagers who haven’t had a baby before to use an IUD,” she said.

Peipert hopes she's right. "Many clinicians are not comfortable putting them in or who don't believe in them for one reason or another. So it's their education now. My hope is that the New England Journal article will help with that," he said.

The next step

Now that the CHOICE Project results have been published in the New England Journal of Medicine, Peipert is looking ahead to the next step.

“The next thing we’re working on is the impact of CHOICE on our population. It is our belief that we are seeing already, in St. Louis, a marked reduction in abortion rates, repeat abortion rates, and I think unintended pregnancies,” he said.

According to calculations done by Peipert and his colleagues, the CHOICE Project saves more than 1,000 abortions a year.

“It doesn’t matter whether you’re pro-choice or pro-life. We all want to limit the number of unplanned pregnancies and the need for abortion,” he said. “And we can really cut that down, I think, with the best forms of contraception.”

The CHOICE Project will end in September 2013, potentially leaving the women once again without access to the expensive LARC methods.

“Once the cost barriers are back in place, if there’s no Affordable Care Act… they’ll go back to using condoms and pills because they can’t afford the up-front cost of the LARC methods. And where we’ve seen a reduction in unintended pregnancies we’re going to see a rise,” Peipert said.

If the Affordable Care Act remains intact, Peipert believes it will give many more women access to LARCs.

“My hope is that health care in the U.S. will change and (we'll) realize prevention saves money,” he said. “One dollar of family planning saves $3 to $4 down the road. As long as we keep ignoring that, we will be paying for it.”

Hile also feels that the Affordable Care Act would significantly help reduce the number of unintended pregnancies.

“Unwanted pregnancies are the root of many other problems, particularly for very young women,” she said. “If we can make it an easy option to contracept, we could reduce a lot of social problems that we have right now.”