July 31, 2014 — Summary of "Game Change in Colorado: Widespread Use of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women," Ricketts et al., September 2014.
The growing acceptance of long-acting reversible contraceptives (LARCs), like intrauterine devices (IUDs) and implants, for adolescents and young women "is fundamentally changing the landscape of reproductive health," according to researchers Sue Ricketts and Greta Klingler -- both of the Colorado Department of Public Health and Environment -- and Renee Schwalberg of the Maternal and Child Health Epidemiology and Statistics Program at the Altarum Institute. However, there are barriers to access, including the methods' high initial costs and low public awareness of their availability, appropriateness and safety.
To determine how increased access to LARC -- particularly, the removal of cost barriers -- affects pregnancy and birth rates among low-income women, the researchers examined results of the Colorado Family Planning Initiative (CFPI), a privately funded program that provides IUDs and implants at no cost through the state's Title X family planning clinics.
The researchers analyzed the CFPI's effectiveness at the program and population levels among women ages 15 to 24. They assessed caseloads at Title X-funded clinics prior to and after the start of the CFPI, as well as LARC use among patients at the clinics during the same time period.
The researchers also assessed fertility trends among low-income women by comparing observed and expected rates; high-risk births, defined as those to women who were unmarried, under age 25 and did not have a high-school education; abortion rates; and monthly caseloads for Colorado's Women, Infants and Children (WIC) program.
In 2011, Title X-funded clinics in Colorado served 64,938 clients (54,762 women and 10,176 men), a 23% increase from 52,645 (46,348 women and 6,297 men) in 2008. More than half of the female clients were under age 25 in both 2008 and 2011, and most had incomes at or below 150% of the federal poverty level in both years (83% and 92%, respectively).
Prior to the launch of the CFPI, fewer than 5% of women ages 15 to 24 receiving services at Title X-funded clinics in Colorado used LARC. In 2011, 19% were using LARC methods. Specifically, implant use increased by more than 10 times and IUD use increased by nearly three times from 2008 to 2011. During the same time period, use of oral contraceptives decreased from 49% to 36% among the same population.
Cumulatively, 8,435 low-income patients ages 15 to 24 had received a LARC method by 2011, compared with 620 who received one in 2008.
Fertility rates among low-income women ages 15 to 19 in counties with clinics receiving CFPI funding were 80 births per 1,000 women in 2010 and 67 per 1,000 in 2011, compared with expected rates of 94 and 95 per 1,000, respectively. "These observed differences of 15% and 29% were statistically significant," the researchers wrote.
Likewise, fertility rates among women ages 20 to 24 in the same counties were 3% and 14% lower than expected in 2010 and 2011, respectively.
The fertility rates declined for all women ages 15 to 24 in Colorado between 2009 and 2011, the researchers noted. They estimated that 74% to 77% of the decline among those ages "can be attributed to the decline in births among low-income women in the CFPI counties."
In CFPI counties, high-risk births fell from 4,052 in 2009 to 2,940 in 2011, representing a 24% decline in the proportion of births that were high risk.
In 2008, before the CFPI began, there were 11 abortions per 1,000 women ages 15 to 19 and 22 per 1,000 women ages 20 to 24. In 2011, the rate among 15- to 19-year olds dropped by 34%, to seven per 1,000. For women ages 20 to 24, the rate fell by 18% from 2008 levels, reaching 18 per 1,000.
WIC Infant Caseload
The number of infants receiving WIC benefits had increased "steadily" in the two years prior to the CFPI, "[c]ontinuing a decades-long trend," the researchers noted. The number of infants receiving the benefits "leveled off" in 2009, the year the CFPI started, but then rose again by March 2010.
However, the number then "dropped sharply," reaching "a level well below that for any month since early 2005" by March 2013. Overall, the number of infants receiving WIC benefits decreased by 23% in the three-year period starting in March 2010.
Discussion and Conclusions
The researchers found that "increased access" to LARC via the CFPI "was immediately followed by a substantial reduction in the birthrate among" young, low-income women. The observed declines in fertility among the study population were "surprising, given that trends prior to the initiative indicated that small increases in fertility in the low-income group were expected in 2010 and 2011," they wrote.
The researchers noted that these declines were paralleled by "measurable declines ... in abortion rates, births to young unmarried women with limited education and numbers of infants receiving WIC services."
The CFPI "produced a radical game change in the state," the researchers wrote, adding that "the Affordable Care Act (PL 111-148) has the potential to replicate the success of the Colorado experience across the nation" by reducing cost barriers to highly effective contraceptive methods.
In addition, "[t]his fundamental change should help to alleviate the burden of unplanned pregnancy and its associated personal, economic and social costs," the researchers concluded.