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Overview
Despite the debate over reproductive health in Washington, DC, 99.3 percent of American women have used at least one method of contraception to practice safe sex, according to the 2015 National Survey of Family Growth. In the years following the Affordable Care Act’s contraceptive mandate taking effect in 2012, oral contraceptives were responsible for a 63 percent drop in average out-of-pocket spending on retail drugs. Specifically, women saved $1.4 billion in out-of-pocket costs on birth control pills in 2013 alone. This is significant for the 61 million American women of reproductive age, and with epidemics such as the opioid crisis and outbreaks such as the Zika Virus, access to contraception is more important than ever.

In the final piece of our four-part Harm Reduction series, we explore contraceptives as a method to reduce rates of sexually transmitted diseases and unintended pregnancies, as well as a way to mitigate the negative effects of the opioid crisis and the Zika Virus on infants.

Sexually Transmitted Diseases
According to warnings from the CDC, rates of sexually transmitted diseases (STDs) are on the rise. In fact, the CDC’s most recent data says 2.3 million cases of the three nationally reported STDs – chlamydia, gonorrhea, and syphilis – were reported in the United States in 2017, the highest number ever. This is particularly troubling since the U.S. nearly eliminated syphilis a decade ago, and yet there were 30,644 cases of syphilis in 2017, a 76 percent jump from 2013. This has also led to a sharp increase in congenital syphilis, which occurs when the infection is passed from a mother to her child during pregnancy.

The CDC estimates that nearly 20 million new sexually transmitted infections occur every year, costing almost $16 billion in annual health care costs to treat. For example, antibiotics can cure certain STDs such as chlamydia, gonorrhea, and syphilis, but others do not have a cure and can only be treated, such as human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). Other STDs such as the human papillomavirus (HPV) and Hepatitis B & C can sometimes lead to cancer, reproductive health complications including infertility, and other STDs such as HIV. More information on the dozens of STDs the CDC encourages using contraception to protect against can be found HERE.

Despite the CDC’s warnings, more than half of state and local STD program budgets have been cut in recent years, limiting access to diagnosis and treatment services because of staff layoffs, reduced clinic hours, and increased patient co-pays. More information on the CDC’s STD prevention work can be found HERE.

Unintended Pregnancy
There are roughly 61 million women in the U.S. of reproductive age (15-44) and about 43 million of them, or 70 percent, are at risk of an unintended pregnancy. That is to say, they are sexually active and not planning to become pregnant, but could do so if they and their partners do not use contraception correctly and consistently. While condoms are the only method of contraception to prevent against most STDs (some can still be contracted via contact), there are several effective birth control methods, such as oral contraceptives, injectables, IUDs, patches, and more. More information on each and their rates of effectiveness can be found HERE.

The rate of unintended pregnancy in the U.S. in 2011 was 45 percent, with significant disparities between women based on age, socioeconomic status, and other factors. While that is a decrease from 2008 when 51 percent of pregnancies were unplanned, it still costs the U.S. about $21 billion in direct medical costs per year. However, U.S. investment in family planning programs have shown to save money in the long run. According to the CDC, public sector investments in family planning programs in 2010 resulted in net government savings of $13.6 billion, or $7.09 saved for every public dollar spent. While the rate of unintended pregnancy has steadily declined, so has the rate of abortion. The CDC reported that from 2005 to 2014, the rate of abortion decreased by 22 percent reaching a historic low in the U.S.

According to the American College of Obstetricians and Gynecologists (ACOG), unintended pregnancies have higher rates of costly and long-term complications, including preterm birth and maternal mortality. Because of this, the U.S. Department of Health and Human Services’ Healthy People goal for 2020 is to increase the rate of intended pregnancies by 10 percent. If reached, this goal would have wide-ranging, positive effects on the health of moms and babies across the U.S.

Epidemics
The average rate of unintended pregnancy in the U.S. is high at 45 percent, but it is even higher among women with opioid use disorder where the rate is 86 percent. ACOG urges increased access to contraception to reduce opioid overdose deaths and rates of neonatal abstinence syndrome (NAS). NAS is a result of being exposed to drugs in the womb and causes babies to go into withdrawl, which can include symptoms such as low birth weight, tremors, and breathing problems. Due to the opioid crisis, NAS has risen dramatically over the past decade. According to the CDC, as of 2012, there was an average of one baby born with NAS every 25 minutes in the U.S, costing approximately $1.5 billion in healthcare spending that year alone.

According to the CDC, the rate of opioid use disorder among pregnant women more than quadrupled over a 15-year period ending in 2014. The CDC and ACOG’s guidelines for prescribing opioids urge contraception counseling for women that could become pregnant.

Aside from the opioid epidemic ravaging communities over the past several years, the U.S. also experienced the outbreak of the Zika Virus beginning in 2015. One of Zika’s most devastating outcomes can be birth defects such as microcephaly found in newborns whose mothers were infected with the virus while pregnant. According to the CDC, since the beginning of the outbreak in 2015, 2,474 pregnant women in the continental U.S. and 4,900 pregnant women in U.S. territories exhibited laboratory evidence of a possible Zika Virus infection. Of those, a total of 116 and 167 newborns were born with Zika-associated birth defects in U.S. states and territories, respectively.

Because the virus can also be transmitted by having sex, the CDC strongly recommends using contraception to prevent getting pregnant for a period of time after a possible infection could have occurred, such as traveling to an area with risk of Zika.

Looking Ahead
In the long run, the U.S. saves billions of dollars in healthcare costs each year by spending a fraction on family planning programs and STD prevention. In 2018 contraceptives can be purchased for little or no cost, available over the counter and by prescription without cost-sharing. Yet, the costs associated with misuse or no use of contraceptives can be staggering. It costs approximately $16 billion to treat the 20 million new cases of STDs every year, roughly $21 billion to cover direct costs of unplanned pregnancies, and about $1.5 billion to treat NAS in infants each year. Yet in 2010, the public cost to provide family planning and related sexual and reproductive health services was just a fraction of that at $2.2 billion.

Despite what we know about the safety, cost saving, and health benefits of access and coverage of contraception and other reproductive healthcare services, we should expect the debate in Washington to rage on.

Definitions
● STD: Sexually transmitted diseases are passed from one person to another through intimate physical contact and from sexual activity. They are very common as there are dozens of different STDs.
● Unintended pregnancy: Pregnancy that is reported to have been either unwanted (the pregnancy occurred when no children, or no more children, were desired) or mistimed (the pregnancy occurred earlier than desired). Unintended pregnancy mainly results from not using contraception, or inconsistent or incorrect use of effective contraceptive methods. Unintended pregnancy is associated with an increased risk of problems for the mom and baby.
● Opioid use disorder: A problematic pattern of opioid use that causes significant impairment or distress. A diagnosis is based on specific criteria such as unsuccessful efforts to cut down or control use, or use resulting in social problems and a failure to fulfill obligations at work, school, or home, among other criteria. Opioid use disorder has also been referred to as “opioid abuse or dependence” or “opioid addiction.”
● Microcephaly: A birth defect where a baby’s head is smaller than expected when compared to babies of the same sex and age. Babies with microcephaly often have smaller brains that might not have developed properly.

Key Statistics
● 99.3 percent of women have used at least one form of contraception in their lifetime.
● The U.S. experiences nearly 20 million new cases of STDs per year, costing almost $16 billion in healthcare costs to treat.
● 70 percent of the 61 million American women of reproductive age (15-44) are at risk of an unintended pregnancy, which costs about $21 million in direct healthcare costs each year.
● The average rate of unintended pregnancy in the U.S. is 45 percent, and 86 percent among women with opioid use disorder.

Links to Other Resources

CDC National Survey of Family Growth: https://www.cdc.gov/nchs/nsfg/key_statistics/c.htm#contraception

Kaiser Health: https://www.healthsystemtracker.org/brief/examining-high-prescription-drug-spending-for-people-with-employer-sponsored-health-insurance/#item-start

Reuters: https://www.reuters.com/article/us-usa-obamacare-contraception/u-s-states-mull-contraception-coverage-as-obamacare-repeal-looms-idUSKBN14W1CD

CDC Reported STDs in the United States, 2016: https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/STD-Trends-508.pdf

CDC Contraception: https://www.cdc.gov/reproductivehealth/contraception/index.htm

CDC Sexually Transmitted Diseases: https://www.cdc.gov/std/general/default.htm

CDC National Health Statistics Report: https://www.cdc.gov/nchs/data/nhsr/nhsr086.pdf

CDC Unintended Pregnancy: https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm

CDC Prevent Unintended Pregnancy: https://www.cdc.gov/sixeighteen/docs/6-18-evidence-summary-pregnancy.pdf

CDC Neonatal Abstinence Syndrome: https://www.cdc.gov/grand-rounds/pp/2016/20160816-neonatal-addiction.html

American College of Obstetrics and Gynecologists: https://www.acog.org/-/media/Departments/Government-Relations-and-Outreach/201708FactsAreImportantOpioidTreatment.pdf?dmc=1&ts=20180816T1542179631

CDC Opioid Use Disorder Documented at Delivery Hospitalization: https://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm?s_cid=mm6731a1_w

CDC Pregnant Women with Possible Zika Infection: https://www.cdc.gov/pregnancy/zika/data/pregwomen-uscases.html

CDC Outcomes of Pregnancies with Possible Zika Infection: https://www.cdc.gov/pregnancy/zika/data/pregnancy-outcomes.html

CDC Women and Their Partners Trying to Become Pregnant: https://www.cdc.gov/pregnancy/zika/women-and-their-partners.html

New England Journal of Medicine Unintended Pregnancies: https://www.nejm.org/doi/full/10.1056/NEJMsa1506575

CDC Opioid Overdose Commonly Used Terms: https://www.cdc.gov/drugoverdose/opioids/terms.html

CDC Facts About Microcephaly: https://www.cdc.gov/ncbddd/birthdefects/microcephaly.html

Milbank Quarterly – Benefits and Cost Savings of Family Planning: https://onlinelibrary.wiley.com/doi/full/10.1111/1468-0009.12080

CDC 2017 STD Report: https://www.cdc.gov/nchhstp/newsroom/2018/press-release-2018-std-prevention-conference.html