People who are opposed to contraception or who simply think it isn't that important often object, "How can there possibly not be enough birth control? Condoms are cheap and easy to get. And anyway, lack of access to birth control isn't the problem — look at all the women who have abortions who were using birth control."
While on the surface it may seem that women in the U.S. have adequate access to contraception — ninety-nine percent of women who have had sex have ever used contraception — the bare statistics obscure some underlying access issues. For one thing, not all methods work equally well for all women's situations. A woman who can afford condoms but would be better served by the pill or an IUD has an access problem if she can't afford to go to the doctor to get those methods prescribed for her.
Let's look more closely at those figures from women who have had abortions. It is true that 54% of women who have abortions used some form of birth control during the month when they conceived. Of course, that doesn't mean that they remembered to use it every time, or used it correctly. Proper counseling — one of the services recommended by the Institute of Medicine to be covered without copays under the Affordable Care Act — could help with that. But inconsistent use can also be due to an access problem. For instance, a staggering 76% of women who used the pill report using it inconsistently. Many of them could be having trouble getting their pills on time every month. Most women can only get one to three months' worth of contraception prescriptions at a time; one study showed that allowing low-income women to get twelve months' worth of pills at a time decreased the odds of unintended pregnancy by 30%, and the odds of an abortion by 46%. Alternatively, some women may need a method that doesn't have to be remembered every day, such as an IUD, but those can have a large up-front cost. Reproductive coercion is another factor that can cause women to use contraception inconsistently. Though it isn't strictly an access issue, family planning clinics and other health care providers have a role to play in helping women recognize and prevent reproductive coercion. Reproductive coercion often accompanies partner violence, and screening for such violence is also recommended by the IOM. Finally, some of the women who report using contraception were actually using ineffective methods such as withdrawal. They could benefit from counseling and access to more effective methods.
If 54% of women who have abortions were using contraception during the month when they conceived, that means 46% weren't. Twelve percent of these women directly cited barriers to access as a reason for contraceptive nonuse. Another 10% reported that their partners didn't want to use contraception; again, this could be reproductive coercion at work. Others didn't know they were at risk for unintended pregnancy; counseling could certainly help there. Still others cited concerns about side effects or bad experiences with contraception in the past. Many of these women could benefit from assistance to help them find and afford a method that works well with their particular bodies.
Access is a complicated issue; it's not simply a matter of whether a woman can afford a packet of pills every month or whether the pharmacy down the block sells condoms. There is still plenty of room for improvement in the way we make contraception information and methods available to women. If the Department of Health and Human Services accepts the IOM's recommendations, more women will get the help they need to avoid unintended pregnancy and abortion.