Q&A: On contraception studies and the Supreme Court's Hobby Lobby case

The Supreme Court recently ruled in a 5-4 decision that the government cannot require certain employers to provide insurance coverage for birth control if they conflict with the employer’s religious beliefs. The controversial ruling in the Burwell v. Hobby Lobby Stores, Inc. case sparked sharp dissent from Justice Ruth Bader Ginsburg, who cited findings from the medical literature. One of those studies was by Dr. Aileen Gariepy, associate professor in the Department of Obstetrics, Gynecology & Reproductive Sciences at Yale. Here, Gariepy discusses her research, the implications of this ruling, and how contraception options for both women and men have evolved.

What is the main focus of your research?

I’m an obstetrician gynecologist with additional training in family planning and public health. I am committed to making women’s lives better through patient-oriented clinical research. My research focuses on diminishing the effect and rates of unintended pregnancy in the United States.

My clinical work has always driven my research interests. For example, in clinical practice I noticed that many women with private (non-governmental) insurance interested in using an intrauterine device (IUD) for contraception ultimately didn’t get one, and I wanted to know why.  IUDs have superior contraceptive efficacy and are very cost-effective. I wanted to know what barriers were preventing women from using IUDs when they had initially chosen that method. 

I found that, even with private insurance, the out-of-pocket expense for women varied widely from $0 to $850 for an IUD, and that cost influenced IUD utilization. Women who had to pay more than $50, were 11 times less likely to obtain an IUD than women who had to pay less than $50. This research reinforced the tenet that patients make health care decisions based on their pocketbooks.

"The ultimate goal of medical research is to help patients. But doing good research is only part of the equation. The next step is to have our findings reach those in power ..."

How does your work fit in with the Hobby Lobby case?

This case debated whether some specific forms of contraception, including the intrauterine device had to be covered by for-profit companies with religious objections as part of the Women’s Health Amendment to the Affordable Care Act.

I was ecstatic when I learned my research was cited by Justice Ruth Bader Ginsburg in the dissenting opinion to support the assertion that women are blocked from using one of the most effective forms of contraception available when it is not fully covered by their insurance.

The ultimate goal of medical research is to help patients. But doing good research is only part of the equation. The next step is to have our findings reach those in power, whether it’s other physicians, insurance companies, politicians, or the Supreme Court. The only better outcome here would be to have been part of the majority opinion that struck down the Hobby Lobby claim.

What are the implications of this case on women’s reproductive rights?

The court’s decision in this case is a major setback for women’s health care and their reproductive rights. Making women’s health care subservient to politics and religion is harmful. The medical literature on this is clear and irrefutable. Access to the most effective methods of contraception, including the IUD, decreases unintended pregnancy, which decreases abortion. Universal access to no cost contraception should be something that we can all support.

Politics should not be able to trump medicine. Part of the Hobby Lobby case alleged that certain forms of contraception cause abortion. This is medically false.  So in addition to saying that corporation’s beliefs are more important than women’s (and their partner’s) beliefs, it also showed that those beliefs are not based on science.

Are contraceptive methods for women evolving?

Absolutely. The emergence of long-acting reversible contraception (IUDs and implants) has dramatically changed the landscape of women’s options for birth control. If a heterosexually active woman wants to have two children (the national average), she will spend almost 30 years of her life trying not to get pregnant. We have now smartened up to that reality and are creating methods that last for years, to meet that need. As I teach the medical students and Ob/Gyn residents, women don’t fail the Pill, the Pill fails women. Yet the Pill is the most common method of contraception used by American women. If a woman doesn’t want to be pregnant for five years (e.g. while in medical school), why are we promoting a method that you have to take every day, at the same time no less?

What are women’s options for birth control?

Women’s options for pregnancy prevention can be broken into three categories, based on effectiveness, because not all contraception is equal. There are major differences in how well certain birth control methods work.

The top tier of contraception has less than a 1% annual rate of failure and includes the reversible contraceptive implant that lasts for three years and IUDs that can last for 3 to 10 years, and irreversible methods such as male and female sterilization.  The second tier of contraception has an average 10% annual failure rate and includes the oral contraceptive pills, the patch, the vaginal ring, and the injection that lasts for 3 months. The third tier has an average 20% failure rate and includes male and female condoms, withdrawal or “pulling out,” fertility awareness-based methods, the diaphragm, and spermicide.

And we know from large studies that women (and their partners) using second-tier methods are 20 times more likely to experience contraceptive failure than women in the first tier. That’s information that everyone needs to know.

Other than vasectomy, are there other male birth control options on the horizon? 

Not many. Currently male contraception centers on mechanical blockage of sperm, whether it’s temporary (condoms) or permanent (vasectomy). There is ongoing research of hormonal methods to interrupt sperm production, but no major breakthroughs appear on the horizon.