If you ask 1,000 people which age group has the highest rates of unplanned pregnancy (and, as someone who works in reproductive health, this is exactly the kind of thing I am apt to do), most Americans will say teens. It makes logical sense, teens don’t have a reputation as the most responsible cohort, and in fact, 7 in 10 Americans subscribe to the “teen pregnancy wasn’t a problem in my day” theory of unplanned pregnancy.

But, in fact, teens are actually doing a great job at not getting pregnant.  Since peaking in the 90’s, teen birth rates are down 61% and teen pregnancy rates have dropped 55% (!!!). The group with the most stubbornly high rates of unplanned pregnancy?* Twenty-something women. Roughly half of all pregnancies in the United States are reported by women to be unplanned. But if you look at twenty-something women–specifically, unmarried young women age 20 to 29–that number skyrockets to nearly 70%, translating into roughly 1.3 million unplanned pregnancies in 2008 alone with no sign of trending down.** Until now.

In March, the Guttmacher Institute announced a record decline in unplanned pregnancies–the largest in 30 years. In fact, rates dropped nearly 20% between 2008 and 2011 alone. In public health these kind of outcomes call for Beyonce-at-the-Superbowl level of fireworks and celebration.



After we picked our jaws up off the floor, those of us in the field started asking why.

Why, after three decades has a number that was essentially unchanged, suddenly plummeted through the floor?  There must be some magic answer…did we finally crack the code to the abstinence education vs. comprehensive sex education debate (spoiler alert: yes but that’s not the reason for the dramatic declines). Did 20-somethings suddenly become paragons of virtue?

Turns out, it was none of the above. We simply started using better birth control.

There are a ton of contraceptive methods out there ranging from bad (not using anything at all) to OK (condoms which, while universally accessible AND the only method to prevent STDs are actually only about 82% effective) to great (IUDs and the implant are more than 99% effective at preventing pregnancy). So which method do you think leads to the least “oops!” moments and holy crap scares? Bingo–the great ones, also known as long-acting, effective methods (LARCs for short) like the IUD and implant.

There are a few reasons that these methods are the gold standard: their mechanism is incredibly effective (more than 99% effective) AND there is absolutely no possibility of user error. Consider this: with almost every other method of birth control, the user has to actually do something to make it work: take a pill, put on a condom, apply a patch, etc… While the user only has to take what appear to be minor steps to make the birth control work, things can still go wrong; the condom may go on too late, a pill may be missed, the patch may not stay fully adhered to the skin.

IUDs and implants take all that human error stuff out of the equation–they are “set it and forget it” birth control, good for three years to (in the case of the ParaGard IUD) up to 10 years.

So where is the connection? Well, starting right around 2007, women begin switching from those bad or OK methods of birth control to the great methods in droves (particularly IUDs). This simple switch from less effective to more effective methods tracks with the reduction in unplanned pregnancies. Consider this: the most popular method of birth control is the pill which has a failure rate of around 9% for typical use. Out of 100 women using the pill, 9 will become pregnant in a typical year whereas less than one IUD or implant user will experience a pregnancy in a typical year. When you take that kind of a reduction and apply it across multiple “good” methods of birth control, it makes a huge difference.

LARCs still have a long way to go to be considered as popular as the pill or condoms but this recent report shows that use has tripled since 2007. While there’s no clear reason for the sudden uptick, several factors are likely at play. With the advent of the Affordable Care Act, price barriers for LARCs–which previously could cost more than $500–have been eliminated. In addition, word of mouth plays a role; as more women use LARCs, they naturally share with their friends how much they love them. Word spreads and so does buy in and uptake.  And frankly who wouldn’t love them? In the case of an IUD, it’s inserted in an office visit and you don’t have to think about birth control for years. And speaking of office visits, 40% of family planning providers use the IUD. If that’s not a ringing endorsement, I don’t know what is.

Additionally more and more doctors are learning that all women–not just women who have already had kids–are excellent candidates for the IUD (the American Academy of Pediatrics has even begun recommending LARCs for teens, which is, frankly, groundbreaking).  In fact, you could argue that 20-something women are the best candidates for an easy-to-use, inexpensive, long-lasting method of birth control and providers are finally getting the message here.

LARCs aren’t perfect–they have different side effects for different women that sometimes make them deal breakers. But they are truly fantastic methods of birth control that provide nearly perfect protection. It’s no wonder that women are catching on.

* The women themselves reported the pregnancy as unplanned.
** Read more on unplanned pregnancy and birth control here.

Categories: Policy, Politics, + Pop Health, Pregnancy, Birth + Family Planning