Not All Contraception Is Created Equal

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A new working paper finds that condoms, unlike other forms of birth control, don’t cut it.

By Dwyer Gunn

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A basket of free condoms. (Photo: Steven Depolo/Flickr)

Recently, the Centers for Disease Control and Prevention (CDC) announced that the teenage birth rate in the United States declined again in 2015. Brady Hamilton, a researcher at the CDC, told the Associated Press that “[t]he continued decline is really quite amazing.” The rate, which is still higher than those in other developed countries, has actually been falling since 1991, with particularly promising drops in the last few years.

Researchers attribute the trend to sex education programs in schools, teens delaying sex, and an increased use in contraceptives. Last year, researchers found that a program in Colorado providing free, long-acting forms of contraception to women led to a 40 percent decline in teen pregnancies in the state between 2009 and 2013, and a 42 percent decline in the abortion rate.

But a working paper released this week by the National Bureau of Economic Research highlights an important truth: Not all contraception is created equal. The researchers, Kasey Buckles and Daniel Hungerman of Notre Dame University, analyzed the effects of the free condom distribution programs many schools implemented in the 1990s in response to the HIV/AIDS epidemic.

Access to free (or very cheap) condoms at school increased teen fertility rates by 10 percent.

Such programs are, of course, controversial, and the theoretical effects of providing free birth control to teenagers actually are ambiguous. On the one hand, condoms can prevent pregnancy if used correctly. On the other hand, providing teenagers with free birth control might increase sexual activity, and thus have the unintended effect of increasing teen fertility.

While researchers have studied the effects of increasing teens’ access to the birth control pill or long-acting reversible contraceptives — and have generally found either no effects or reductions in teen birth rates — this NBER report is the first rigorous evaluation of the effects of free condoms specifically. The researchers found that access to free (or very cheap) condoms at school increased teen fertility rates by 10 percent.

Buckles and Hungerman note that the increase in teen birth rates was driven primarily by the counties where condoms were provided without any additional counseling — schools that provided the condoms along with mandatory counseling didn’t see the same increases in teen fertility rates. The authors also found a concurrent increase in gonorrhea infection rates in those counties that didn’t require counseling.

Buckles and Hungerman propose several possible explanations for their findings. Perhaps free condoms serve as a substitute for more reliable forms of birth control, such as the pill. Or perhaps they nudge a teenager who might otherwise be on the margins of becoming sexually active into engaging in sexual activity.

Ultimately, the authors suggest that their data best fits an interesting explanation that was first presented in a 1999 paper in the American Journal of Public Health, which found that condom use actually declined as condoms became more available in schools. Here’s how Buckles and Hungerman describe the theory:

To explain this result, the authors note that condoms in their setting were provided without mandatory counseling (in baskets), and that this provision without counseling may have created an unexpected effect wherein counselors or other health-center officials responded to condom provision by turning their attention away from promoting condom use. This shift in attention, aside from any substitution effect, may have impacted the quality and quantity of teen contraceptive use. Programs without mandated counseling thus may have created a moral hazard problem in that they unintentionally disincentivized school personnel from promoting contraceptive use or other conduct discouraging conception.

In other words, school health workers, no doubt understaffed and overworked, stick the condoms in a basket on the table and consider the contraception education portion of their job completed.

It’s not entirely clear if today’s teens would respond to free condoms in the same way as the ’90s-era teens of Buckles’ and Hungerman’s research. Today’s teenagers are less likely to be sexually active and have access to more reliable forms of birth control, research has found.

But Buckles’ and Hungerman’s findings suggest programs that provide free condoms to teenagers may have unintended effects if they’re not accompanied by education and counseling.

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