Principal investigator: Adriano Valladão Pires Ribeiro
Article title: HOW MUCH CAN EXPANDING ACCESS TO LONG-ACTING REVERSIBLE CONTRACEPTIVES REDUCES TEEN BIRTH RATES?
Article authors: Jason Lindo and Analisa Packham
Location of the intervention: Colorado, USA
Sample size: 20.376 observations
Main theme: Health Insurance
Type of Intervention: Expansion in access to long-acting reversible contraceptives
Primary variable of interest: Birth rate among teenagers
Evaluation method: Differences in Differences
Policy Problem
The teen pregnancy rate in the United States has been declining over the years, but it is still higher than the average in other developed countries, according to... data According to the World Bank, public policies to reduce the number of unintended pregnancies focus on decreasing the frequency of sexual intercourse, increasing the use of contraceptives, and using more effective contraceptives. Long-acting reversible contraceptive methods, such as intrauterine devices (IUDs), are more effective in preventing pregnancy and require no attention for several years compared to the inconsistent use of birth control pills, rings, and condoms. Therefore, it remains to be seen how much an expansion of access to long-acting contraceptive methods would reduce the adolescent birth rate.
Evaluation Context
Despite the ease and benefits of long-acting contraceptives, in 2013 only 5% of teenage girls in the US opted for IUDs, and only 8.5% of all women chose this method. Factors explaining these low numbers include a lack of awareness of long-acting methods, misinformation about their safety, discomfort from the implant and potential side effects, as well as a high initial cost of acquisition and implementation. From the perspective of healthcare clinics, the two main barriers are the lack of knowledge and misinformation among some doctors and nurses. In cases where clinics provide the methods free of charge, there is a limited capacity to provide the service to many clients.
Intervention Details
In January 2009, the Colorado Department of Public Health (DPHE) implemented the Colorado Family Planning Initiative (CFPI) with the goal of reducing unplanned pregnancies by increasing the availability of long-acting reversible contraceptive methods. An anonymous donation of $23 million funded free contraceptive methods for low-income women at clinics. Title X (clinics responsible for providing birth control and pregnancy care to low-income individuals who would not be able to afford the services).
The money was distributed to the clinics. Title X In 37 counties in Colorado as of June 2015, the allocation criterion was proportional to the number of clients and the projected number of contraceptive implants. In addition, the CFPI provided IUDs, advice and expertise on the implementation of long-acting contraceptive devices, and technical assistance for clinic management.
In Colorado, people below the poverty line are not charged for any services at clinics. Title XPeople above that income level would receive a discount or have to pay for the entire service depending on their income level. Clinics must accept verbal communication of income, and no verification is required. It is noted that 90% of clients meet the income criteria and do not have to pay anything for contraceptives or the doctor's visit. The program was very successful and directly addressed some of the barriers that limit access to long-acting contraceptive methods, such as the provision of devices and the reduction of implantation costs. Although not focused on adolescents, they represented a significant portion of the clinics' clientele. Title XIn the state, in 2008, the use of long-acting contraceptives by young people was less than 3%, jumping to almost 25% in 2014. Finally, in the years following the program, the teenage pregnancy rate in Colorado decreased by 40%; however, it should be noted that the rate was already decreasing throughout the country, and this entire difference cannot be attributed solely to the CFPI.
Exclusive
To evaluate the effect of CFPI on the adolescent birth rate in the state of Colorado, all counties in the state that had a clinic were used as the treatment group. Title X In 2008, the control group consisted of all other counties in the U.S. The National Center for Health Statistics contains information on all births between 2002 and 2013 in the U.S., including the mother's age and the county of birth. In addition, demographic information on young women throughout that period was used, along with county unemployment as an index of economic activity and indicators of contraceptive legalization and prescription requirements for contraceptive purchases.
The way to measure the program's effects is by comparing the trajectory of the average birth rate of teenage mothers in counties in Colorado that had clinics. Title X (treatment group) with the trajectory of the other counties (control group). Note that by using all the information described in the previous paragraph, and considering the fact that the adolescent birth rate was similar for the US and the state of Colorado between 2003 and 2008, the control group would be a good counterfactual, that is, what would the number of births in the counties in Colorado be like if it were not for the CFPI.
Finally, since the program was intended to help low-income women access long-acting contraceptive methods, it was also investigated whether the effects of CFPI were greater in counties where a larger proportion of the population was low-income.
Results
The results of the measurement exercise indicate that, on average, the program reduced the birth rate among teenagers by 6,4% per year. The effect is close to 1% in the first year, becoming more pronounced from the second to the fifth year, with a notable 10% drop in the third year. When the exercise was focused on counties with income below the state median income, the average effect was even greater, approximately 8% per year. Again, the program's effect in the first year was small, but it reached an average of over 10% in reducing the birth rate among teenagers over the last three years evaluated.
Lessons in Public Policy
The CFPI was the first major program to encourage the use of long-acting reversible contraceptives in the U.S., and although adolescents were not the primary focus, the program helped reduce the birth rate among young women in Colorado. The reason for its success lies both in the reduced cost of inserting contraceptive devices and in the reduction of misinformation about the methods. The fact that the program had even greater results in lower-income counties corroborates this learning.
Reference
Beautiful, Jason M.; Packham, Analisa. “How Much Can Expanding Access to Long-Acting Reversible Contraceptives Reduce Teen Birth Rates?.” American Economic Journal: Economic Policy, vol. 9, no. 3, p. 348-76, 2017.
