Birth control, otherwise known as contraception, is the act of preventing pregnancy. Several types of birth control exist to target various steps toward pregnancy. For instance, condoms, diaphragms, cervical caps, and contraceptive sponges prevent sperm from getting to the eggs, birth control pills, patches, shots, vaginal rings, and emergency contraceptive pills prevent the ovaries from releasing eggs, and IUDs prevent fertilization of the egg. Sterilization is another option in which a person is permanently prevented from getting pregnant or getting someone else pregnant.

Birth control carries inherent risks, and abstinence is the only form of birth control that is one hundred percent effective at preventing pregnancy. Contraception can additionally be targeted toward men or women, although there is more research and available birth control options for female-focused birth control.

One type of female-focused birth control is female sterilization (tubal ligation), in which a woman’s fallopian tubes are sealed via surgery to prevent eggs from traveling down them, which could induce pregnancy if sperm is encountered. This procedure, though almost 100% effective, is not reversible and does not protect against sexually transmitted diseases (STDs). A similar sterilization process exists for males, known as vasectomy. This procedure seals the ends of the vas deferens, which are the ducts that carry sperm.

Since sterilization is not reversible, other forms of birth control are more commonly used among men and women. Hormonal contraceptives for women prevent the body from releasing hormones that trigger ovulation. Types of hormonal contraceptives include a progestin arm implant (Nexplanon®), estrogen-containing birth control pills, vaginal ring (NuvaRing®), and patch (Xulane®). Birth control pills are much more effective than barrier-focused birth control methods like condoms, but if a woman does not take the pill regularly, she risks getting pregnant.

Barrier-focused birth control methods aim to block the sperm from reaching the egg during intercourse. The most common form is the male condom, which prevents semen from entering a woman’s vagina. Male condoms also protect against STDs, but a woman’s risk of pregnancy increases if the condom breaks. Women also have the option of using female condoms, diaphragms, cervical caps, and sponges as barriers.

Pointed Summary

• Birth control is aimed to prevent pregnancy. There are many types of birth control for men and women.
• Birth control includes sterilization, hormonal contraception such as pills, and barrier-targeted contraception such as condoms.
• The history of birth control in the United States has been very complex. Margaret Sanger, the founder of what would later become Planned Parenthood, was a leading advocate for birth control access.
• Access to birth control is impacted by factors like socioeconomic status, and disparities exist across racial and income-level strata.

Relevance

Birth control research and accessibility have been continuously evolving since the 19th century. The rich history of birth control outlines trials and tribulations ranging from the complete illegality of contraception to the current dialogue surrounding birth control and abortion. While contraception was legal in the United States for most of the 19th century, the 1873 Comstock Act prevented the mailing of any written material or object aimed towards the prevention of contraception or the encouragement of abortion.

From the 1873 Comstock Act arose state-level outgrowths of similar contraceptive restrictions, known as the Comstock laws. These restrictive laws remained largely unchallenged until the advocacy of Margaret Sanger began. In 1916, Margaret Sanger opened the first birth control clinic in the United States and eventually founded the American Birth Control League, which was the precursor to the Planned Parenthood Federation of America. In 1950, Planned Parenthood launched research to formulate a birth control pill, which entered clinical trials in the late 1950s and early 1960s. By 1965, one out of every four married women in America under 45 had used the pill.

The legislative restrictions on birth control were also gradually rolled back, with a major judicial victory in 1965. In Griswold v. Connecticut, the Supreme Court ruled that states could not pass laws to restrict the use of contraceptives by married couples since it would violate the right to marital privacy. In 1972, in 1972, the Supreme Court case Baird v. Eisenstadt legalized birth control for all, including unmarried couples.

Today, contraception is much more accessible in the United States, with 64.9% of women aged 15-49 using contraception. The most common contraceptive methods currently used by women in that demographic are female sterilization (18.6%), oral contraceptive pill (12.6%), long-acting reversible contraceptives (LARCs) (10.3%), and male condom (8.7%). However, inequities exist in birth control access, which manifest in disparities in earlier initiation of sexual intercourse, adolescent pregnancy, and adolescent childbirth.

These inequities often fall along socioeconomic and racial lines. Examining teen birth rates along racial lines yields conspicuous differences of adolescent childbirth among White, Black, and Hispanic women. The adolescent birth rate among White women aged 15-19 was 2.6%  among White women, 6.1% among Black women, and 8.2% among Hispanic women. Hispanic people in particular have had the highest overall rate and smallest decrease over the past 15 years of adolescent childbirth. When examining birth control access and uses, Black (22%) and Hispanic (20%) women are more likely to use female sterilization compared to only 16% of White women.

Interestingly, however, the pattern is reversed for male sterilization with 8% of White women relying on male sterilization versus 1% of Black women and 3% of Hispanic women doing the same. Low-income women face health system barriers to contraceptive access because they are more likely to be uninsured and have higher rates of nonuse of contraceptives or higher usage of less effective prevention methods such as condoms.

‍Current Stances

Despite tremendous strides made in birth control accessibility, the fight for universally affordable contraception remains avid and necessary. Yet, contraception remains an avenue of vigorous debate. Some oppose widespread contraceptive use on moral and religious grounds. Contraception distinguishes sex from the bearing of a child and promotes sex as a form of pleasure and intimacy, which may contract against religious fundamentalism.

Additionally, contraception may be seen as a mechanism to making abortion more accessible. Contraception promotes the notion of people having autonomy over their fertility, which is a case that many pro-abortion advocates make for the justification of abortion. Aside from moral arguments, birth control is not without its adverse health effects. Hormonal birth control for women (i.e. pill, patch, and ring) have  been linked to increased risk of blood clots. Although the risk of blood clots remains very rare, these birth control products triples a woman’s risk from 1 in 100,000 to 3 in 100,000.

Hence, hormonal birth control is not recommended for women with pre-existing risk factors like smoking and a history of cardiovascular diseases that could exacerbate the dangers of blood clots. IUDs can also have rare but serious complications such as bacterial infections, uterine wall punctures, ovarian cysts, and ectopic pregnancies. A trade-off also exists with barrier-based contraceptives: while serious health conditions are usually negligible, the risk of pregnancy increases, as these methods are usually more prone to dysfunction. 

Tried Policy

A variety of government policies have been implemented to both expand and restrict birth control access. The Contraceptive Action Plan (CAP) project was a partnership formed between the CDC’s Department of Reproductive Health, Cicatelli Associates Inc. (CAI), and the Washington University School of Medicine in St. Louis. CAP led to the formation of the Contraceptive CHOICE Project aimed to reduce financial barriers to contraception, promote the most effective methods of birth control, and reduce unintended pregnancy in the St. Louis area.

Additionally, CAP focused on providing healthcare teams with support and skills to deliver quality, client-centered, and culturally competent contraceptive services to women and teens. This involved staff training programs, implementation tools, job aids, and clinician mentorship resources.

Aside from CAP, the CDC has also launched various community-wide initiatives to reduce the rates of teen pregnancy and promote birth control access. The CDC focused on four key components to target: community mobilization and education, evidence-based programs, increasing youth access to quality sexual and reproductive health services, and working with diverse communities to promote health equity.

On the other hand, some policies have been implemented that could reduce birth control access, especially those targeting abortion. For instance, the Missouri legislature recently sought to block Medicare funding for Planned Parenthood, which would not only restrict abortion accessibility, but also several forms of emergency contraceptives like Plan B and IUDs. Emergency contraception is designed to prevent ovulation, and nearly 25% of women ages 22 to 49 have used emergency contraception. However, this legislation in Missouri did not pass.

Policy Problem

Stakeholders

Key stakeholders in regards to birth control include ordinary men and women, pharmacists, elected officials, employers, community leaders, religious officials, and educators. Methods of contraception are being developed and have already been developed for both men and women to use in order to avoid unplanned pregnancies, although renewed popularity in the idea of declaring fetuses the legal status of “personhood” has incentivized elected officials to propose legislation that aims to curb access to contraception. Several states also allow pharmacists to refuse filling legally authorized prescriptions for contraceptive care. Religious leaders and anti-abortion advocacy groups, as elaborated upon later, also play a significant role in their communities in swaying public opinion in opposition to contraception.

Educators, also elaborated upon later, have the power to control what kind of sexual education their students receive, which has led to discrepancies in knowledge about contraception among adolescents. Employers also have the ability to exclude contraceptive care in their employees’ health insurance plans. However, many advocacy groups exist which support the ability of women to access safe contraceptive care, most notably Planned Parenthood, which actually began searching for an oral form of contraception as early as 1950. Other notable groups include the American College of Obstetricians and Gynecologists (ACOG) and NARAL Pro-Choice America.

Risks of Indifference

Ever since the first hormonal contraceptive pill was approved by the Food and Drug Administration in 1960, access to safe methods of birth control has been incredibly advantageous to women in the United States. The Supreme Court delivered a legal victory to advocates of contraception in 1965 with its decision in Griswold v. Connecticut, as well, meaning that no state could restrict the use of contraceptives by married couples. With access to birth control, women could finally take control of their reproductive cycles and claim power in their relationships, and many women in the 1970s entered the workforce as a result of this newfound bodily independence.

However, not all women have benefitted from expanded access to birth control: women with lower socioeconomic statuses are more likely to become pregnant and deliver children as adolescents. These women are also less likely to have health insurance, preventing them from accessing alternative, more effective methods of contraceptives (besides condoms). Minority women have also expressed more ambivalence towards pregnancy compared to White women, which correlates with a higher rate of unintended pregnancy and a lower rate of usage of contraceptives.

Moreover, with the Supreme Court poised to overturn its landmark decision in Roe v. Wade this summer, states could once again begin (and have already begun) imposing heavy restrictions on abortion and access to contraceptives, which would continue to hurt low-income minority women who aren’t financially able to cross state lines in order to receive safe contraceptive care. 

Nonpartisan Reasoning

Disparities in access to birth control in the United States can be attributed to a few key factors: socioeconomic status, cost, and healthcare coverage, moral and cultural objection, and lack of knowledge. Firstly, socioeconomic status can determine whether or not a woman is financially able to access such contraceptives as well as bear the cost of settling an unplanned pregnancy via adoption or abortion.

In fact, nearly half of all pregnancies in the United States are unplanned, and the impact of this reality is severe: births resulting from unplanned pregnancies equated to nearly $13 billion in government expenditures in 2008. About 48% of women ages 15-44 have experienced an unplanned pregnancy, and for this same age group, about twenty-two unsafe abortions occur per 1000 women. A woman’s inability to settle an unplanned pregnancy also applies to her inability to access methods of contraceptives, which are often costly, that could prevent the pregnancy from occurring in the first place. Low-income minority women are more likely to be uninsured and experience unplanned pregnancies compared to high-income women, and low-income women are also less likely to access and use methods of contraception. Secondly, the variety of sexual education programs within the United States vary in nature, which contributes to a lack of knowledge about contraceptives in some parts of the country.

Abstinence-only education has proven to be as popular in the United States as it is ineffective, and when adolescent students are not made aware of the resources available to them in order to engage in activities of a sexual nature safely, the risk of unplannned pregnancy and contracting sexually transmitted infections and/or disease increases when they ultimately decide to engage in such activities. When abstinence-only education is combined with the inability of those receiving it to afford contraceptive care, the chance of unplanned pregnancy also increases. Furthermore, in recent years, legislatures across the United States have proposed new measures to restrict access to contraceptives. Twenty states currently restrict the ability of minors to access contraceptives, and legislators have proposed removing the ability guaranteed by Title X of minors to receive contraceptive care confidentially.

Laws have also been introduced to weaken contraceptive access for employers in more than a dozen states, and in 2012, the Supreme Court ruled in Burwell v. Hobby Lobby Stores that the First Amendment protects the ability of employers to exclude contraceptives in their employers’ insurance plans. It’s also important to keep in mind that religious and moral objections to contraception have begun to manifest in the healthcare sphere. The Catholic Church sponsors ten of the twenty-five largest healthcare facilities in the United States, and when these work with other hospitals, access to contraceptives decreases. Some pharmacists also reject filling prescriptions for contraception or providing emergency contraception, which can create a plethora of challenges for women to obtain such contraception if access to an alternative pharmacy is unavailable or they live in a rural area.

Six states explicitly protect the ability of pharmacists to refuse filling prescriptions for contraceptives even though they are legally prescribed. Social attitudes towards pregnancy are also important to keep in mind: ambivalence towards pregnancy, especially among minority women, often correlates with the decreased likelihood of using effective contraception and the increased likelihood of unplanned pregnancy. Black women and Hispanic women indicate more ambivalence towards pregnancy compared to White women.

There are also stark differences between methods of birth control available for men and women in the United States, with women having access to more methods of birth control compared to men. Women have access to a variety of options, the costs of which vary, including birth control implants, IUDs (intrauterine devices), birth control shots, vaginal rings, patches, birth control pills, condoms (external and internal), diaphragms, and sponges. Men, on the other hand, primarily have access to condoms (which are 98% effective against STIs and impregnating) and vasectomies as means of contraception, although the development of a male birth control pill is underway (with high demand) as well as a contraceptive body gel, although whether or not this method is entirely effective remains to be seen. 

Policy Options

Legislators have several policy options for eliminating disparities in access to birth control and expanding methods of contraception. For starters, only eight states explicitly prohibit pharmacists from refusing to fill prescriptions for contraceptives; legislation prohibiting such refusal at the national level would relieve many low-income women, particularly those living in rural areas, from the burdens they face with having to find alternative methods of obtaining contraception.

Moreover, in order to solve a lack of knowledge regarding contraception, Congress could propose a standardized sexual education curriculum and incentivize states to implement it, although the efficacy of this proposal may not be perfect and societal ambivalence towards pregnancy may not change all that much. Furthermore, as stated before, efforts to expand male birth control are also gaining popularity; while condoms remain available and effective, and vasectomies are available to men who are intent on not being able to have children, the development of male contraceptive pills is already underway and has so far proven to be widely popular.

71.4% of men of various nationalities between the ages of 18 and 50 expressed interest in taking a contraceptive pill, and women, who feel that they bear too much of a burden in their relationships by being the only ones to take contraceptives, also support the development of a male contraceptive pill. Moreover, the 2014 partnership between the Center for Disease Control’s Division of Reproductive Health and the Washington University School of Medicine, which created the Contraceptive Action Plan (CAP), could also be revitalized, having proved to be successful in the St. Louis area.

Given that a post-Roe America seems imminent, providing women with equal access to quality birth control and safe contraceptive care should be an important priority for state and federal legislatures in the foreseeable future. State legislation that aims to curb access to contraception and abortion could continue to disproportionately harm low-income and minority women, who are uninsured at higher rates and sometimes display more ambivalence towards pregnancy compared to White women. The federal government should also pursue measures, such as developing a standardized sexual education curriculum for American schools, to increase knowledge about contraception among high-risk groups for unplanned pregnancies, such as adolescent students. Federal legislation ensuring safe abortion access, such as codifying Roe v. Wade, would also provide women another outlet to obtain safe reproductive care beyond birth control and contraception.