The Contraception Contradiction

[Editor's Note: This article was originally published one year ago in the May 2011 issue of Catholic World Report.] 

New York City is the abortion capital of America. More than 40 percent of pregnancies in New York City end in abortion (excluding miscarriages), nearly twice the national rate. The abortion rate among the city’s black residents is a jaw-dropping 60 percent. In 2009, New York City saw more than 87,000 abortions—one roughly every six minutes.

Not surprisingly, New York City also has one of the country’s most pro-abortion political establishments. When the New York Post interviewed the City Council’s 51 members in 2010 about the city’s abortion rate, only five would allow that it was too high. One council aide even fretted that a lower abortion rate might bankrupt the city.

Asked to comment on how her city could best lower its rates of unintended pregnancy and abortion, Council Speaker Christine Quinn told the Post, “We can reduce the number of unintended pregnancies…by expanding access to contraceptives and increasing sex education.”

A similar analysis was offered in 2008 by Deborah Kaplan, deputy commissioner of New York City’s Department of Health and Mental Hygiene. Responding to questions about the city’s high abortion rate, she told Crain’s business journal, “To me, the problem is access. If we improved access to contraceptives, there would be a reduction in abortion.”

Quinn and Kaplan were echoing the conventional wisdom about the relationships between contraception, unintended pregnancy, and abortion. The theory holds that since most abortions are the result of unintended pregnancies, efforts to reduce unintended pregnancies will reduce the number of abortions. And since contraceptives can reduce the number of unintended pregnancies, expanding access to contraceptives will lower the abortion rate.

But that logic has not worked very well in practice. If New York City is the abortion capital of America, it is also the contraceptive capital of America. Free or low-cost birth control is available through dozens of publicly-funded programs at more than 200 places throughout New York state, most of them in New York City and its suburbs.

The city’s health department distributes a pocket-size guide showing teenagers where they can get low-cost or free contraception, information that is also available on the city’s 311 phone and Internet hotlines. New York City hands out three million free condoms every month at thousands of venues. The city even has its own brand of condoms, NYC Condoms.

In February, the city introduced the world’s first condom app to help New Yorkers with smartphones find a condom when they need one. “We want New York City to be the safest city in the world to have sex,” announced Dr. Monica Sweeney, the city’s assistant health commissioner, during the Valentine’s Day launch.

The new campaign was unveiled a month after health department statistics revealed a 2009 abortion rate of 41 percent. At a January news conference to discuss the new statistics, Timothy M. Dolan, the Catholic archbishop of New York, was the first to raise the contraception contradiction.

“My word, what have we done the last 30 years?” he told reporters. “There’s candy bowls on people’s desks with condoms, they’re dropping them from airplanes, yet nothing seems to improve, so they’ve been on the wrong track here.”

Catholic moral theologians and others have long maintained that by changing the way people think about sex and pregnancy, contraceptives don’t merely fail to lower rates of unintended pregnancy and abortion. They may in fact increase them.

Many policymakers take the opposite view, arguing that insufficient access to contraception is the main obstacle to lowering rates of unintended pregnancy and abortion. In recent debates over public funding for Planned Parenthood, the country’s largest abortion provider, the organization claimed that without taxpayer funding of its contraceptive services the number of abortions would grow by a half million a year.

This view is the basis for widespread promotion of sex education in schools, public funding of contraception, and the movement to “de-medicalize” contraceptives that require a prescription, including oral contraceptives, to make them easier to obtain.

But growing evidence suggests that the “more contraceptives, fewer abortions” theory is flawed. A January 2011 study published in the medical journal Contraception found that a 63 percent increase in contraceptive use over 10 years among Spanish women corresponded with a 108 percent increase in the abortion rate in Spain.

At the heart of the issue are complicated questions such as: How has access to contraception and abortion altered the way people think about sex and pregnancy? And in what ways has the availability of abortion changed the way people think about and use contraception?

The most common methods of contraception are barrier methods such as condoms and diaphragms, hormonal contraceptives such as the pill, the patch, and intrauterine devices (IUDs), as well as spermicides and sterilization.

Nearly 40 percent of the most common contraceptives are abortifacients. These include IUDs, the pill, the patch, and emergency contraception. All act to prevent implantation onto the uterine wall of some fertilized eggs, distinct human beings. Contraceptives are widely and cheaply available throughout the United States. The government has subsidized contraceptives for low-income women for more than 50 years, through programs such as Medicaid and Title X.

Millions of government employees receive insurance coverage for contraceptives. Nine in 10 employer-based insurance plans cover a full range of prescription contraceptives. Twenty-seven states have laws requiring insurers that cover prescription drugs to provide coverage for most contraceptive drugs and devices.

The health care reform law enacted in 2010 mandates that insurance companies cover a variety of preventive services at no out-of-pocket cost. Depending on how the Department of Health and Human Services ends up defining “preventive services,” coverage may include prescription contraceptives. Guidelines are expected to be issued by August.

Most American women use contraceptives. According to the Centers for Disease Control and Prevention (CDC), 98 percent of all women who have ever had sexual intercourse have used at least one method of contraception. Eighty-nine percent of the 42 million fertile, sexually active American women who say they do not want to become pregnant are practicing contraception.

Among sexually active Americans who do not use contraception, only a small percentage fails to do so because of lack of access to contraceptives. In a 2001 study, the Guttmacher Institute (GI), a public policy organization that analyzes reproductive trends, surveyed 10,000 women who had abortions. Of those who were not using contraception at the time they conceived, 2 percent said they did not know where to obtain contraception, and 8 percent said they could not afford it.

Despite the pervasiveness of contraception, nearly half of pregnancies among American women are unintended, and four in 10 of those end in abortion, according to GI and the CDC. Part of the problem is contraceptive failure—all methods sometimes fail to prevent pregnancy.

But a more significant problem is that most sexually active people who use contraception use it inconsistently. According to a GI study, a majority of women (54 percent) who had abortions used a contraceptive method (usually a condom or the pill) during the month they became pregnant. Another GI analysis found that nearly half of women seeking to avoid pregnancy had periods of nonuse of birth control (15 percent) or used their method inconsistently or incorrectly (27 percent).

Erratic contraceptive use is often rooted in ambivalence about pregnancy. Another GI study found that nearly one in four women who were not trying to become pregnant said they would be very pleased if they found out they were pregnant.

Such ambivalence baffles many policymakers. To understand this phenomenon, it helps to try to understand the circumstances in which women who have unintended pregnancies make reproductive decisions. Although all types of women experience unintended pregnancies, a disproportionate number are young and poor. Many already have at least one child and are in unstable relationships with their sexual partners.

For many women at high risk of unintended pregnancy, feelings about pregnancy change often—just as often as their feelings about the long-term prospects of the relationships they are in. And when people are uncertain about whether or not they want to become pregnant, they can be erratic about contraceptive use. Ambivalence about pregnancy makes it more likely that sexually active people will leave the condom in a wallet or neglect to refill an oral contraceptive prescription.

As Rachel Jones, a GI senior research associate, put it to the New York Times, “[T]he high rate of unwed pregnancy and abortion among poor women is a sign of ambivalence. They are torn between the desire to have a baby and the realization that it would be hard to bring up a child as a single mother.”

Reproductive decision-making is complicated further by the availability of induced abortion. Statistics suggest that though it is marketed as a method of birth control used only when other measures fail, abortion has become a method of birth control used in place of other measures.

Few people would admit to using abortion as birth control, but the evidence is in the data. After Roe v. Wade, the US Supreme Court’s 1973 decision legalizing abortion nationally, pregnancies grew by 30 percent even as births decreased by 6 percent. After Roe, which suddenly made abortion much easier to obtain, many Americans began using contraceptives less consistently.

The results are seen in the number of women who have multiple abortions. Consider that of the more than 1.3 million women who obtained abortions in 2001, about half (650,000 women) had had at least one previous abortion. About a quarter (325,000 women) had obtained at least two previous abortions. And roughly 15 percent (195,000 women) had already obtained at least three abortions.

Those numbers haven’t changed all that much. Of the 1.21 million abortions performed in 2008, half were performed on women who had already had at least one abortion. These disturbing statistics highlight the moral hazard of abortion. The wide availability of abortion diminishes the expected cost of sexual intercourse, because the pregnancy can be aborted in the event of unwanted conception, thus avoiding many of the costs associated with unwanted pregnancy.

So, by giving men and women a relatively safe and inexpensive way to eliminate the unintended outcome of risky sexual behavior, liberal abortion laws encourage more and riskier sexual behavior. In other words, the wide availability of abortion discourages people from using contraceptives.

Abortion’s effect on contraceptive use doesn’t only influence rates of unintended pregnancy. It also affects exposure to sexually transmitted diseases. A 2006 paper by Jonathan Klick and Thomas Stratmann in the Journal of Legal Studies found that by lowering the cost of sexual activity, legalized abortion leads individuals to engage in more sex and to use condoms less often, causing an increase in sexually transmitted diseases.

The authors found that, all else being equal, abortion legalization led to an increase in gonorrhea and syphilis rates potentially by as much as 25 percent. The authors concluded, “[O]ur results attributed a large increase in gonorrhea and syphilis rates to changing sexual behavior, which was induced by abortion law changes.” 

All of this was foreseen. In the 1930 encyclical Casti Connubii, Pope Pius XI condemned contraception as a violation of the natural law. In the 1968 encyclical Humanae Vitae, Pope Paul VI famously predicted that if the Church’s teaching on sexuality and artificial birth control were ignored, it would “lead to conjugal infidelity and the general lowering of morality” and give man the idea that he has unlimited “domination over his own body and its functions.”

Humanae Vitae was published three years after the US Supreme Court decision in Griswold v. Connecticut, which legalized contraception for married people, and five years after the pill arrived on the American market. Even those not sympathetic to the Church’s view of sexuality have made the connection. In 1979, Malcolm Potts, former medical director of the International Planned Parenthood Federation, predicted, “as people turn to contraception, there will be a rise, not a fall, in the abortion rate.”

A couple that uses contraception establishes a “contraceptive mindset,” so that even if a child is conceived that child is unintended and thus unwelcome. The US Supreme Court came close to acknowledging this idea in its 1992 decision upholding the right to abortion. In Planned Parenthood v. Casey, the court stated, “In some critical respects abortion is of the same character as the decision to use contraception. For two decades of economic and social developments, people have organized intimate relationships and made choices that define their views of themselves and their places in society in reliance on the availability of abortion in the event that contraception should fail.”

Further research is needed to determine the precise relationship between contraception and abortion. GI estimates that of the 6.4 million pregnancies that take place each year in the US, nearly half—3.1 million—are unintended, and 1.3 million of them end in abortion. Millions of lives (not to mention billions of dollars) are at stake.