What Happened in Delaware Following a Statewide Contraceptive Initiative?

Policy Points The 2015 to 2020 Delaware Contraceptive Access Now (DelCAN) initiative followed other long-acting reversible contraception-focused contraceptive initiatives in Colorado and in St. Louis, Missouri. and preceded statewide contraceptive-access initiatives in South Carolina, Massachusetts, and North Carolina with additional initiatives planned. Our principle conclusion is that the DelCAN did not achieve its goal of reducing the fraction of births from unintended pregnancies. However, we find evidence of a substantial magnitude of decrease in unplanned pregnancies that can be attributed to the initiative, and that this decrease occurred entirely among Medicaid-covered women.

Context: The 2015 to 2020 Delaware Contraceptive Access Now (DelCAN) initiative was motivated by Delaware's having among the highest rates of unintended pregnancies in the United States, of which were either wanted later or unwanted. The expectation of the DelCAN initiative was that by providing greater contraceptive access, especially to long-acting reversible contraception, Delaware's unintended-pregnancy rates could be substantially reduced. In this study, we assess the role of the DelCAN in explaining, for live births, changes in women's pregnancy intentions around the time of conception.

Methods: We examine not only pregnancy intentions, but also the planned status of the pregnancies, including whether the woman was trying to get pregnant and whether she or her partner was using contraception when an unplanned pregnancy occurred. We use the Pregnancy Risk Assessment Monitoring System data with difference-in-difference estimators to compare Delaware with six states in 2007 to 2020 with respect to the planned status of pregnancies ending in births and with 14 states in 2012 to 2020 with respect to the intended status of pregnancies ending in births. Because several components of the DelCAN were designed to facilitate contraceptive access for low-income women, we conduct both an overall analysis and separate analyses for Medicaid-covered and non-Medicaid-covered women.

Findings: The DelCAN was not associated with reductions in unintended pregnancies ending in births in Delaware relative to comparison states but was associated with an increase in pregnancies that were wanted sooner. DelCAN was also associated with an increase in planned pregnancies concentrated among Medicaid-insured women and produced through reductions in pregnancies occurring when not using contraception.

Conclusions: Pregnancy intentions and pregnancy planning should be treated as distinct concepts in contraceptive-access program design and evaluation. Programs should attend to both pregnancies wanted later and pregnancies wanted sooner to address public health goals in concert with enhancing women's reproductive autonomy.