The Burden of Living in a Contraceptive Desert

In the United States, there are 19 million women who need publicly funded contraception but can't access it because they live in a "contraceptive desert," according to the nonprofit organization Power to Decide.

People in contraceptive deserts don't have reasonable access to a range of birth control options, such as the pill, patch, shot, intrauterine device (IUD) and implant. Having "reasonable access" to contraception is defined as at least one health provider or center with birth control options per 1,000 women.

Of the 19 million women in contraceptive deserts, approximately 1.2 million live in a county without a single clinic to access birth control, said Raegan McDonald-Mosley, M.D., M.P.H., an OB-GYN in Baltimore and the CEO of Power to Decide, based in Washington, D.C.

For such women, obtaining birth control could mean finding a babysitter, taking time off work and traveling long distances—which isn't always possible.

About 65 percent of American women ages 15 to 49 used contraception from 2017 to 2019, according to the Centers for Disease Control and Prevention (CDC). But contraceptive access is not equitable. Barriers to care plague people with low incomes, people of color and people who live in rural areas at disproportionate rates, McDonald-Mosley said.

Policies impact the existence of contraceptive deserts

Birth control is not a divisive issue to most Americans. A 2019 telephone survey of 1,004 people by Power to Decide found 86 percent of adults, regardless of race, ethnicity, region and political affiliation, support access to the full range of birth control methods. Surveys from the Kaiser Family Foundation and PerryUndem found similar results.

Unfortunately, dispensing birth control pills is often left to policy.

"States can choose whether or not they want to pass laws that expand Medicaid, allow pharmacists to prescribe birth control, extend the supply of prescribed birth control, or protect contraception access and insurance coverage," explained Jennifer Lincoln, M.D., an OB hospitalist and lactation consultant in Portland, Oregon. "Those that don't have these kinds of laws on the books do not have adequate protections in place or have access to additional government funds to fund health centers that would provide birth control."

Title X is the only federal program dedicated to reproductive health care and family planning. The program works by allocating funding to health centers so they can provide low- and no-cost contraceptive care to patients.

Without insurance, out-of-pocket costs for birth control can rack up a sizable annual bill: up to $50 per month for the pill, $300 for an implant and $1,300 for an IUD.

The Trump administration issued changes that barred providers from giving nondirective pregnancy counseling or mentioning abortion services, even if a patient requested it. Due to these changes, the network of Title X providers drastically reduced; the Biden administration has reversed many of these changes, but the strain still shows.

An additional challenge is that Title X faces persistent underfunding, McDonald-Mosley said. Political attacks to weaken the program have placed a strain on the ability of many Title X clinics to continue providing such urgently needed, high-quality care.

Title X also provides care to people who are uninsured. Without insurance, out-of-pocket costs for birth control can rack up a sizable annual bill: up to $50 per month for the pill, $300 for an implant and $1,300 for an IUD.

The limitations of mail-order birth control

Birth control by mail is a proposed solution for people living in contraceptive deserts. Unfortunately, birth control apps do not accept commercial insurance or Medicaid, so the reach of these apps is limited, McDonald-Mosley said. Many companies also charge fees for the telehealth and membership services that come with these apps.

Additionally, mail-order birth control can't offer certain types of contraception, such as IUDs and implants, which require an in-person office visit. Since not everyone can use hormonal contraceptives, this limited mail-order selection excludes people seeking the nonhormonal copper IUD.

Accessible birth control is an imperative

"Access to contraception has improved the overall quality of life for millions of people," McDonald-Mosley said.

"Many people use contraception for noncontraceptive benefits, such as decreased cramping and bleeding, preventing menstrual migraines, treatment of acne or preventing the symptoms of premenstrual syndrome [PMS] or premenstrual dysphoric disorder [PMDD]," McDonald-Mosley said.

Birth control helps people space out their pregnancies, allowing for stronger maternal health outcomes and fewer complications. Unplanned and mistimed pregnancies make up nearly half of all pregnancies in the United States, according to Lincoln. Per the CDC, unintended pregnancy rates are higher for low-income people—widening access to contraception could improve pregnancy planning and spacing.

'Many people use contraception for noncontraceptive benefits'

Having an unintended pregnancy causes both physical and mental implications.

"Those who get pregnant when they aren't planning to are less likely to have been taking prenatal vitamins, have optimized their health prior to conception, or be financially prepared for a baby, and they are more likely to experience things like perinatal mood disorders," Lincoln said.

All of these potential factors mean worse outcomes for the pregnant person and their baby.

According to a 2012 survey of over 2,000 women conducted by the Guttmacher Institute and published in the international reproductive health journal Contraception, respondents predominantly said birth control allowed them to take better care of themselves and their families, support themselves financially, complete their education or find and secure a job.

Women use birth control to better plan for their future and achieve their life goals.

"When people have the power to decide if, when and under what circumstances to get pregnant and have a child, they have the opportunity to pursue the future they want for themselves," McDonald-Mosley said.

"The best thing we could do is make birth control over-the-counter and still covered by insurance, while at the same time increasing funding and access to publicly funded contraception," Lincoln concluded. "We know that OTC birth control can be done safely, and the American College of Obstetricians and Gynecologists fully supports this."