Birth Control Doesn’t Have to Mean the Pill
By MICHELLE ANDREWS
Published: August 20, 2010
THERE was a time when Becky Thurmond Fowler neglected to take her birth control pills for days on end. But she didn’t worry, because she and her husband, Dan, wanted to have a child at some point. “It wouldn’t have been the end of the world if I got pregnant,” she said.
That attitude changed after Ms. Fowler had a daughter, Emerson, now 2 1/2. But with a new baby demanding all her attention, Ms. Fowler, now 33, found herself becoming even more forgetful about taking the pills. Soon she began to worry about the possibility of an unexpected pregnancy: “We were just rolling the dice.”
Many women struggle to find a birth control strategy that is effective given their particular circumstances. About half of all pregnancies — three million annually — are unintended. About half of the women who have an unplanned pregnancy are using birth control at the time, according to a 2009 study by the Guttmacher Institute.
The pill, which celebrates its 50th anniversary this year, is by far the most popular contraceptive choice among women. When used consistently, it is more than 90 percent effective. The problem, as countless women have found, is that it is easy to forget to take the daily dose.
“Women, and men, just can’t take a daily pill,” said James Trussell, director of the Office of Population Research at Princeton.
Women choose a form of contraception for any number of reasons: reliability, convenience, familiarity. While the pill is the most frequent choice, it is not always the most appropriate. Pills are relatively inexpensive month-to-month, but a method with heftier upfront costs may be a better buy in the long run.
“An unplanned pregnancy is emotionally and financially expensive,” said Dr. Steven J. Sondheimer, a professor of obstetrics and gynecology at the University of Pennsylvania who directs its family planning program.
Ms. Fowler, a technology security analyst at the University of Missouri, decided to try something more suited to her life and kinder to her pocketbook: a small, T-shaped intrauterine device, or I.U.D., that slowly releases the hormone progestin, which prevents pregnancy in part by altering the uterine lining. Ms. Fowler paid $100 in outpatient surgery charges for the insertion; her insurance covered the roughly $700 cost of the device.
Even if she had had to pay the full cost herself, the I.U.D. — which prevents pregnancy for five years — would still be more cost-effective than birth control pills, which typically cost $15 to $50 a month. And of course there is no forgetting with an I.U.D.
For women who realize the time has come to re-evaluate their birth control strategy, there are many methods to choose from: I.U.D.’s, hormonal implants, shots, the “patch” and the vaginal ring, to name a few. Here are some factors to consider.
LONG-TERM OPTIONS If you have a hectic job or small children, or are caring for elderly parents, the pill may not be the best method for you, said Dr. Vanessa Cullins, vice president for medical affairs for the Planned Parenthood Federation of America.
The I.U.D. is the gold standard for the attention-challenged, Dr. Cullins said, as it remains effective for up to 12 years. On a dollar-for-dollar basis, it is also clearly the most cost-effective method, unless you plan to stop birth control altogether in the near future.
Similar options include hormonal methods like the Ortho Evra Patch, which is replaced once a week; the NuvaRing vaginal ring, which remains in place for three weeks; the Depo-Provera shot, which contains pregnancy-preventing hormones effective for three months; and Implanon hormonal implants.
INSURANCE COVERAGE While most insurance plans include contraceptive services and supplies, they may not cover all possibilities.
Twenty-seven states require health insurance plans that cover prescription drugs to cover the full range of Food and Drug Administration-approved contraceptive methods, according to the Guttmacher Institute. The plans may not, however, cover every type of device or drug, experts caution. Some plans cover only generic birth control pills, for example, not brand-name pills.
Since coverage varies widely, you will need to inquire about specific options you are considering. Your policy may cover the doctor’s visit, for instance, for a Depo-Provera shot or to insert Implanon hormonal implants and I.U.D.’s — but not the shot or the device itself.
More than half of America’s employees work for companies with self-financed plans, which pay employees’ health claims directly. Those plans are not bound by the state coverage requirements. Small-business and individual policies also tend to provide less comprehensive contraceptive coverage, experts note.
Whatever the type of plan, co-payments and co-insurance charges can be steep, sometimes discouraging women from picking the method that best suits them.
High-deductible plans can pose a particular challenge. They may not cover any birth control costs at all until patients meet a deductible of $1,000 or more.
Those out-of-pocket costs can be a serious barrier to women considering other options. A study of patients at Kaiser Permanente Northern California published in 2007 found that when co-payments totaling hundreds of dollars per patient were eliminated for longer-acting methods like I.U.D.’s and implants, their use increased sharply.
The new health care law may help women faced with high out-of-pocket costs. The law requires new health plans to provide certain preventive benefits with no cost-sharing, and family-planning advocates are pushing for birth control to be included among them. Federal regulations are expected within a year.
AN EXPERIENCED PROVIDER The options presented by your doctor may not include the best choices for you. Some physicians’ practices are not very familiar with longer-acting, more expensive methods like I.U.D.’s, implants and shots, or do not stock them.
“If you’re not getting requests for I.U.D.’s, it can be expensive to keep it on the shelves,” said Adam Sonfield, a senior public policy associate at the Guttmacher Institute. “For small practices, that can be a big deal.”
If your doctor has limited experience with the range of options, visit a larger practice or a family-planning clinic, where they are more likely to offer the full range of F.D.A.-approved products.
Family-planning clinics like Planned Parenthood are a good choice, too, particularly if you are unemployed or do not have insurance, as are state and county health departments and some university clinics, said Laura Hessburg, senior health policy adviser at the National Partnership for Women and Families. These facilities serve all comers, and fees are generally based on a sliding scale for limited-income women.
TRIAL AND ERROR Many women like the pill and other hormonal methods for reasons unrelated to preventing pregnancy: to regulate their periods, for example, or to reduce heavy menstrual flow.
While most women can use most F.D.A.-approved methods, experts say, it may take some trial and error to find a method that minimizes side effects.
For Whitney Hauser, 45, from Plymouth, Minn., birth control pills set off migraines. Switching to an I.U.D. three years ago solved the problem.
“I love it,” she said. “I don’t have to think about it anymore.”