Effect of Providing Contraception Free of Charge

In this issue of AJPH, Gyllenberg et al. (p. 538) examined the effect of providing highly effective, reversible contraception free of charge in Vantaa, Finland. They found that initiation of these contraceptive methods more than doubled and that the abortion rate decreased 16% after implementation of the program. The birth rate did not change, presumably because no logistical impediments exist for women who choose abortion for unintended pregnancies (the cost of an abortion to a woman is modest: only €33 [$41]). Therefore, the rate of unintended pregnancy most likely was reduced. However, there were negative cost savings because the cost savings among women aged 15 to 19 years (€25 000 [$30 636]) were more than offset by the loss among women aged 25 to 44 years (−€67 000 [$82 099]). Therefore, the results were mixed.

Although it seems intuitively obvious that implementation of the Affordable Care Act in the United States would have led to increased use of prescription contraceptives when they became available free of charge (at least 1 method in each of 18 types), the few studies that have examined this theory found no such expected effect. Although out-of-pocket expenses decreased substantially, no change in overall use or method mix was sustained.^1–4

In an earlier study, Trussell and Wynn⁵ noted that the most effective methods of contraception were infrequently used by women in the United States and argued that unintended pregnancy could be reduced in three ways: (1) decrease the proportion of women at risk for unintended pregnancy who use no method of contraception, (2) change the method mix among contraceptive users to greater use of the most effective methods, and (3) increase dual use of contraceptive methods. The emphasis has been on increasing the use of highly effective, reversible methods. However, a recent analysis has shown that women’s decisions about which methods to use have less effect than their decisions about whether to use contraception at all.⁶ In other words, decreasing the fraction of at-risk women who use no contraception has more effect than switching from less effective to more effective methods.