Contraception is prevention

Since the beginning of debate surrounding the drafting and passage of the Affordable Care Act, preventive health care has received considerable attention. In fact, provisions within the ACA require that preventive care be provided without cost-sharing to most people with insurance by 2018. Congress left the final decision of the definition of preventive services to the Department of Health and Human Services (HHS). The Institute of Medicine (IOM) released a report on July 20, 2011 detailing recommendations to HHS regarding specifically which services will be free. Women’s health advocates, myself included, are thrilled that all contraceptive services, including contraceptive counseling, sterilization, IUDs, condoms, and hormonal methods are included in this list of recommended preventive services.
Is contraception a preventive service? We haven’t typically thought about it that way. Most people think about things like immunizations, colonoscopies, cholesterol tests, mammograms and Pap smears when they consider preventive care. But as a primary care doctor, I can tell you, absolutely, that not only is contraception preventive care, it is for many young women the single most important reason they go to see a doctor. Reconceptualizing contraception as a basic preventive health care service is critical if we want to improve our country’s comparatively abysmal maternal and infant mortality rates and if we are serious about empowering young women, their partners, and their families.
I love immunizations, colonoscopies, lipid profiles, mammograms, and pap smears as much as anyone, and at the end of the day my exam room is in need of restocking the requisition forms for these services as much as any other family doctor. I know that these services all improve health and well-being and are (for the most part) cost-effective. But I also know that a young woman in front of me is more likely to face an unintended pregnancy in her life than she is to suffer from breast or cervical cancer. In any given year, about 5% of women will have an unintended pregnancy, and nearly half of women will have at least one unintended pregnancy by the time they reach age 45. The high rate of unintended pregnancy in the US drives a rate of abortion that is much higher than that seen in most other developed countries, and may also play a role in our relatively high maternal and infant mortality rates.
While many of our nation’s public health challenges have stymied prevention researchers (notably obesity and diabetes), preventing unintended pregnancy is relatively simple (though always complicated by culture, societal norms and behavior). We know that nearly all women who do not wish to be pregnant want to use contraception. We know that women who are counseled on contraception during a primary care encounter are 3 times more likely to use contraception than those who aren’t. We know that eliminating copays leads to dramatic increase in uptake of all contraceptive methods, particularly the most highly effective reversible methods (IUDs and implants). We also know that money spent on contraception is a wise investment; for every $1 spent on contraception, nearly $4 is saved. Add all these up and we have: Contraception counseling available from primary care providers who can offer a wide variety of free, highly effective methods appropriate for each patient will lead to decreased unintended pregnancy and significant cost savings for our society.
I applaud the IOM’s report because it can refocus all of us on our common needs. Almost everyone needs contraceptive services at some time, and everyone knows someone who needs contraceptive services. Those of us in primary care need to remember our role in contraception provision and to advocate for copay-free contraceptive methods, especially those methods that have been out of reach for many women due to cost, or whose cost has led to frequent gaps in contraceptive coverage. An IUD can easily cost over $1000, and while it is the most cost-effective method because it lasts for up to 12 years, the up-front cost is significant and prevents many from choosing it. Co-pays for methods requiring monthly refills, such as the birth control patch or ring, can cause women to delay refilling their prescriptions, putting them at risk for unintended pregnancy.
The bottom line is that contraception is a basic preventive health care need. The IOM has wisely recognized this, and I urge HHS to put aside politics and require that all insurers cover the full spectrum of contraceptive options. Contraception is prevention, and it’s time for all of us to recognize that.