When it Comes to Family Size, Money Matters in More Ways Than One

A couple’s financial situation contributes significantly to their decision not to have more children, and requires the couple, especially the female partner, to pay more attention to contraception, according to a national survey.

In a summer 2011 HealthyWomen survey of more than 1,000 U.S. women ages 28 to 48 who are in committed relationships and have at least one biological child, 46% of women say financial circumstances impact their decision to say “my family is complete.”

This is not a new story. In a 2009, the Guttmacher Institute took a deep look at the impact of the recession on women’s family planning and pregnancy decisions. The institute survey found shrinking household budgets and the loss of job and health insurance caused many women to lose confidence in their ability to provide for their families.

Changed outlook

More than 4 in 10 of the women surveyed by the Guttmacher Institute said that because of the economy, they wanted to get pregnant later than they otherwise would have planned.

What’s more, 64% of women agreed with the statement, “With the economy the way it is, I can’t afford to have a baby right now.”

“Based on the present U.S. economic situation and poverty and unemployment reports in the recent census, we believe the dynamics remain the same today,” says Rachel Jones, Guttmacher senior research associate.

Kirsten Moore, president of the Reproductive Health Technologies Project, says women are shying away from expanding or starting a family out of fear of not being able to afford it.

Parents want to be there for kids, she says. “When they’re stressed and worried if they can make it from one pay check to another, they can’t.”

Front-line OB/GYNs like Stanford University’s Dr. Paul Blumenthal say, “In tough economic times, desired family size goes down. The concern about the cost of clothing, feeding and educating children causes family size to contract.”

And in Washington State, Dr. Sarah Prager, assistant professor in the OB/GYN department at University of Washington, says, “At my clinic, we’re no longer seeing decreases in abortion even though we are seeing increases in the use of more effective birth control. There are no data, but one conclusion is that patients are choosing NOT to have families.”

Blumenthal says that he recently saw a news report on waiting lists for vasectomies. “That’s the kind of marker that tells the story of what is happening in families financially,” he says.

For women, he sees the intrauterine device (IUD) making a huge comeback in his own practice and in the U.S because of its efficacy and long-acting contraception—a trend which other experts also note.

Vicious circle

Finances also play a part when it comes to birth control methods. The recession is leading women to be more careful about birth control, with some even considering permanent sterilization like tubal ligation and hysteroscopic sterilization, like the Essure method and Adiana. At the same time, the 2009 Guttmacher survey found females are having a harder time paying for birth control.

It’s a vicious circle, says Blumenthal, noting a dollar spent on family planning is a cost savings that averts four to seven times the costs of unintended pregnancies—a U.S. health care tab that Guttmacher reports averages $11.3 billion annually.

And, ironic. Says Dr. Sarah Prager, assistant professor in the OB/GYN department at University of Washington, all of these [most effective methods] are more expensive upfront, but are cheaper over time.

Workarounds: women and their docs

Money worries are prompting women to be more “strategic” when it comes to planning, according to Blumenthal. He’s seen more women schedule appointments at the end of the year to get any prescriptions or services into the new year while they still have coverage because they are uncertain of their future job security.

“It’s all part of the economic equation,” says Blumenthal, noting that the equation extends to doctors’ orders as well. It’s not just discussing family planning and what’s right for a particular woman, he says. OB/GYNs must consider the most effective prevention in terms of health, money and a woman’s age in relation to her insurance coverage.

A new kind of patient

Women’s job insecurities aren’t unfounded. Clare Coleman, president of National Family Planning and Reproductive Health Association (NFPRHA), which typically services low-income and largely uninsured women earning under $22,000 per year, says NFPRHA is now seeing a surge of new patients.

The most recent 2009 statistics report 134,000 patients received subsidized care, says Coleman. “That’s the greatest leap in one year in the last 10 years,” she says. “This group primarily comprises people who had higher incomes, lost their jobs and insurance, and came tumbling into lower income categories.”

It’s not uncommon to hear these women say, “’I never thought I’d have to ask for this kind of help; I’d never thought I’d be here.’”

Previously, these women would have dropped in for one visit between jobs or insurance plans for a prescription refill, but are now staying for two or more years.

NFPRHA patients traditionally fell into the 20-to-24-year-old category; now the fastest growing age for them is women between 40 and 44. “This tells us what has happened to the world of work and how people who are used to having private insurance and a visit with a ‘real’ doctor are being driven into publicly-funded programs in which they know they can get contraceptives at lower cost.”

Some good news

The Obama administration’s recent announcement that as part of the Patient Protection and Affordable Care Act (PPACA) insurance plans must cover birth control for free effective August 2012.The hope, says Moore, is that removing the copay for contraception will incent more women to use birth control.

Eliminating cost sharing takes away the artificial decision making around contraceptive cost relative to what’s right for a woman, her finances, her time of life and her family relationships, says Coleman.  But if insurance companies are still able to manage the benefit, it’s hard to tell how the cost of payment for devices and brands combined with office visits will play out.