The Washington PostDemocracy Dies in Darkness

Almost half of pregnancies in the U.S. are unplanned. There’s a surprisingly easy way to change that.

Removing small barriers to getting an IUD has had big results in Delaware.


When a group of Yale college seniors was given information about the dangers of tetanus, nearly all of them indicated that they wanted to get a tetanus shot, yet only 3 percent actually did so. But when a second group of Yale seniors was given the same lecture, but also given a campus map with the infirmary circled, a list of times when appointments were available and a prompt to think about a convenient appointment time, the rate at which students went to get a shot was more than nine times higher. Simply making their desired choice a little bit easier to carry out was enough to move them from intention to action. (And if you’re dismissing these students as “kids these days” with no common sense — this study took place in 1965.)

Again and again, research shows that people are more likely to follow through on the things they themselves want and intend to do — if it is made easier to do. We’re more likely to eat healthy if fresh salads are placed at eye-level in the cafeteria. We’re more likely to donate blood when the blood mobile shows up in our company parking lot.

But one of the most intriguing new applications of this idea involves one of our most important, life-changing decisions: whether to have children, and when.

Currently, an astonishing 45 percent of the 6 million pregnancies in the United States each year are unintended. Every year, millions of women, married and unmarried, young and not so young, are getting an outcome — pregnancy — that they didn’t plan on or desire.

The impact on women, their babies and society at large is enormous. Unplanned babies may receive delayed prenatal care, are more likely to be born prematurely and face greater likelihood of health challenges throughout life. Beyond the obvious stress of an unplanned major life event, women facing an unplanned pregnancy are less likely to complete college and also face decreased economic opportunities, which can in turn affect the health and economic opportunities of their children. The costs to society, in health-care dollars, economic supports and lost wages, are significant.

But why are there so many unplanned pregnancies in the first place?

Many women get pregnant while using birth control. From a behavioral economics standpoint, the most widely used forms of birth control in the United States — the pill and condoms — are pretty terrible. They require frequent and specific action, offer little room for error, require action in times of emotional distraction, and have comparatively high rates of failure: For every 100 women who rely on the pill for one year, nine will get pregnant; for every 100 women who rely on condoms for one year, nearly 20 will get pregnant. By contrast, if 100 women rely on the IUD (intrauterine device) or the implant (a matchstick-sized plastic rod inserted just below the skin in the arm that releases pregnancy-preventing hormones) for one year, just one, or possibly none, will get pregnant.

From oral contraception, to the IUD, to the patch, women have numerous options for birth control. Those same non-permanent options have been limited to men. (Video: Victoria Walker/The Washington Post)

What makes the IUD and the implant so effective is that they are “set it and forget it” methods. Once in place, they require no additional steps to continue doing their job. And our natural human tendencies — to dislike hassle (such as picking up a prescription), to get distracted in moments of passion (and skip the condom), or to forget things (such as taking a pill at the same time every day) — don’t impede them from fulfilling their purpose.

Yet only 7 percent of American women are taking advantage of these highly effective methods. Some of the obstacles to the widespread use of IUDs and implants are fairly obvious: The upfront cost can be higher, with other methods requiring smaller ongoing costs spread out over time. Doctors simply may not ask women if they want something other than the pill. Many women aren’t aware of the disparate levels of effectiveness of different kinds of birth control. And some women don’t, or can’t, visit an OB/GYN.

But other obstacles are more subtle. For instance, if a health provider isn’t trained to insert the IUD or implant, he may unconsciously nudge the woman toward something he can offer, such as a prescription for the pill. Or a health center may not stock the items on site, only ordering them as needed, thus requiring the woman to come back for a second appointment (which, as suggested by the Yale tetanus-shot experiment, is a more powerful deterrent than one might think).

Billing quirks can play a surprisingly big role in how and when women choose their birth control. In some states, if a patient is on Medicaid, a doctor may refuse to insert the IUD or implant right after delivery of a baby because he can’t charge for the insertion if it’s done immediately after birth (when it would be considered part of the birth services), but can charge Medicaid several hundred dollars for it if the woman comes back another day. Doctors thus have a financial incentive to encourage women to wait. But that has consequences: Since low-income women face even more obstacles than most in trying to return for a second appointment (no maternity leave, inflexible work schedules, lack of reliable transportation), they may not make it back for the second appointment, and wind up without any birth control at all.

Four years ago, the state of Delaware embarked on an ambitious experiment to find out what would happen if these obstacles were removed. In partnership with the nonprofit Upstream USA, Delaware created a comprehensive statewide program designed to help women become pregnant only if and when they wanted to, by improving access to the full range of birth control methods and removing the obstacles that had previously prevented women from choosing the most effective ones.

It was successful. From 2014 to 2016, unplanned pregnancies in Delaware among women ages 20 to 39 who were served by publicly funded Title X family planning clinics fell by 15 percent. If such an initiative had taken place nationwide, there would have been thousands, even hundreds of thousands, fewer unplanned pregnancies across the country.

Seen through the lens of behavioral economics, the approach in Delaware makes abundant sense. In order for women not to be deterred by having to come back for a second appointment, Upstream showed health centers how they could offer same-day access to IUDs and implants — by tweaking their systems around ordering and stocking the items, and training their staff on how to insert the IUD and implant in their own offices.

To reduce costs for women, they trained providers on how to upgrade billing and coding systems so that upfront costs were not incorrectly passed along to patients. They also worked with state officials to fix Medicaid reimbursement policies, so that doctors would no longer have a financial incentive to delay insertion of the IUD or implant if the patient wanted it right after giving birth.

And to make sure that more women were educated about the full range of birth control choices, they instituted a “pregnancy intention” question, so that every time a woman in Delaware sees a health-care professional — even for a wellness checkup or a case of the flu — she’s asked, “Do you intend to become pregnant in the next year?” It’s a no-lose question: If the answer is yes, the provider has an opportunity to provide information about prenatal vitamins and pregnancy care; if the answer is no, the provider can start a conversation about contraception.

While things often get controversial when politics and women’s health mix, things went fairly smoothly in Delaware because they stayed narrowly focused on one goal: reducing unplanned pregnancy. Skeptical lawmakers, uncertain about getting involved with any initiative involving birth control, were persuaded by the significant financial savings to the state — savings in health-care dollars, social supports and women’s economic opportunities that would otherwise have been lost. Other states have taken notice: Upstream recently announced statewide partnerships with Washington and Massachusetts, and other states are pursuing similar initiatives, either alone or in partnership with other organizations like Upstream.

Like the Yale students who got tetanus shots at a significantly higher rate when education was combined with the removal of logistical barriers, women opt for the most effective birth control methods at higher rates when education is combined with the removal of logistical obstacles. When it gets a little easier to match your actions to your intentions, you’re more likely to do it. And while greater use of tetanus shots is a worthy public health goal, it’s hard to compare to the importance of improving babies’ health, giving women greater control over their lives, saving public dollars — and trying to ensure that every baby is born into the arms of parents eager to have him.