Pregnancy Intention—More Important Than Ever

Pregnancy—either preventing it or achieving it—affects essentially every American at some point in life, either directly or indirectly. It has been estimated that the average US woman spends about 5 years being pregnant, postpartum, or trying to become pregnant and more than 30 years trying to avoid becoming pregnant.¹ The nation has made progress in preventing pregnancy when it is unwanted and perhaps also in achieving it when it is wanted. But events such as the recent spread of the Zika virus into the Americas, with consequences of devastating birth defects and poor infant health outcomes, remind us of the renewed need for careful pregnancy planning efforts.^2–4 Having served as the Acting Director of the US Department of Health and Human Services (HHS), Office of Population Affairs for more than 3 years, I can say I have never seen a greater need, or a better opportunity, to help Americans achieve their family planning goals.

The nation has turned a corner on unintended pregnancy, as demonstrated by sharp declines in teen childbearing and a recent reduction in total unintended pregnancies for women of all ages from 51% in 2008 to 45% in 2011.⁵ However, too many Americans still have poor reproductive health outcomes. Each year, approximately 2.8 million women have an unintended pregnancy. Approximately 42% of these end in abortion, and the cost of unintended births exceeds $20 million annually.^5,6 More than 250,000 teens gave birth in 2014,⁷ and the public cost of teen pregnancy was estimated in 2010 to be almost $10 billion annually.⁸ In addition, about one-third of all US pregnancies occur too soon after a previous pregnancy (i.e., within 18 months of a preceding birth).^9,10 This close birth spacing contributes to poor infant health outcomes, including 9.6% of infants born preterm and 8.0% born with a low birthweight in 2014.⁷

The threat of local spread of Zika virus to the United States in 2016 has elevated the need for expanded access to quality family planning services to an emergency level. According to the Centers for Disease Control and Prevention, as of August 3, 2016, there had been 1,825 cases of Zika infection reported in the continental United States; 1,818 of those cases were travel-related and one was laboratory-acquired. In the US territories, 5,548 cases of Zika infection have been reported, 5,525 of which were locally acquired.¹¹ Infection with the Zika virus in a pregnant woman is linked to microcephaly and other problems, such as absent or poorly developed brain structures, eye defects, hearing deficits, and impaired growth.^2–4 The future impact of Zika in the United States is not yet known, but the geographic range of the Aedes mosquito that transmits the virus covers many states (Figure 1), and local transmission of Zika by mosquitoes has been identified in one neighborhood in Miami, Florida.¹²

Figure 1.

Estimated range of Aedes aegypti and Aedes albopictus in the United States, 2016.^{a a}Maps have been updated from a variety of sources. These maps represent the Centers for Disease Control and Prevention’s (CDC’s) best estimate of the potential range of A. aegypti and A. albopictus in the United States. The maps are not meant to represent risk for spread of disease. Source: CDC (US). Surveillance and control of Aedes aegypti and Aedes albopictus in the United States. http://www.cdc.gov/chikungunya/resources/vector-control.html. Accessed July 11, 2016.

Fortunately, we have the tools needed to address these challenges. Family planning services (ie, contraception to prevent pregnancy; pregnancy testing and counseling; services to achieve pregnancy, including basic infertility care; services for the prevention and management of sexually transmitted diseases; and other preconception health services) can help individuals and couples achieve their desired number and spacing of children and improve the chances that children will be born healthy. The nation has an unprecedented opportunity to increase access to and use of these services. The Affordable Care Act expanded access to contraceptive and other family planning services for more than 20 million American women and men.¹³ Evidence-based clinical recommendations have been developed for how to provide quality family planning services for women and men in a safe, effective, and client-centered manner, and these recommendations include services for preventing and achieving pregnancy, the true complement of “family planning.”^14–19

We have the needed technology. A wide range of safe and effective methods of contraception is available, including the long-acting reversible methods of contraception (LARC) (i.e., intrauterine devices and implants).²⁰ A robust effort is underway to develop and disseminate the use of clinical performance measures to drive change in contraceptive care.²¹ These measures encourage the use of the more effective methods of contraception and address the critical need to ensure that services are offered in a client-centered, noncoercive manner.²² Furthermore, we have a mechanism to pay for these technologies. New payment strategies have been designed to remove barriers to contraceptive use and support same-day provision of all methods of contraception, including LARC.^23–25 These payment strategies are being considered by Medicaid²⁶ and may be adopted by private health plans as well. A growing body of research shows that contraception results in a substantial economic return on investment.^27–30

What should we do now to seize the opportunity to help Americans achieve their family planning goals? First, health-care providers should screen all female and male clients of reproductive age for pregnancy intention and then follow federal and professional medical association recommendations to provide quality family planning services. Providers should educate their reproductive-age clients about the potential risk of Zika infection before the client decides to get pregnant and help pregnant women avoid infection through mosquito bites or unprotected sex with an infected or exposed partner.^31,32

Second, women and men of reproductive age should become aware of the clinical care that is available to them, plan pregnancies for their own well-being and the well-being of any children they have, and seek family planning services that will help them to do so. Finally, private and public health plans should take steps to remove barriers to the delivery of contraceptive and other family planning services. Doing so will both improve reproductive health and save money.

We have the knowledge and the tools needed to reduce the rates of unintended pregnancy in the United States and improve birth spacing. Doing so will benefit women and men as they achieve their desired number and spacing of children, as well as the infants born to them. In addition, health plans and taxpayers will save money. Zika has increased the visibility and urgency of action. There is no time to waste.

Author Biography

Susan B. Moskosky is Acting Director of the US Department of Health and Human Services Office of Population Affairs in Rockville, Maryland.