Unplanned Pregnancies Decreased by 25% in Delaware, Thanks to Equitable Contraceptive Care

Illustrations show a person putting a birth control implant in their arm, a hand holding condoms, and a hand holding up an IUD

Even those who are enthusiastically involved in their reproductive health will likely tell you how hard it can be to obtain birth control in the U.S. 

Between hurdles with private insurance companies, long waitlists to see an OB-GYN, astronomical prices for folks without coverage, or even having trouble finding the right form of contraception, it is no easy feat to prevent an unintended pregnancy.

These unplanned pregnancies have major, individual impacts: derailments of work or career goals, increased maternal and child health risks, further barriers to economic security, and, of course, even persecution or legal trouble for those who may pursue an abortion in some states.

That said, nearly half of all pregnancies in the United States are unplanned, and many of those come from folks who use contraceptive methods such as birth control pills and are doing what they can to avoid an unplanned pregnancy. 

Still, contraception can fail them, and in turn, so does the healthcare system at large.

Especially in a time when reproductive health is so shrouded in shame — and political concern — Mark Edwards, co-founder of Upstream USA, realized that the key to this crisis was to start at the helm.

A screenshot of a webpage explaining various forms of birth control methods.
Upstream trains primary care doctors to offer information on contraceptive care — but there are also many resources on the organization's website. Photo courtesy of Upstream USA

Upstream’s mission is to provide patient-centered contraceptive care in primary care systems. Rather than seeing a specialist to provide contraceptives, patients would be able to obtain this care from their primary care doctors. 

To do this, Upstream provides high-quality training and technical assistance to healthcare providers, allowing them to provide patients with all the information they need to make contraceptive decisions that work best for them.

Edwards has worked to decrease poverty throughout his career and in 2009 founded an organization called Opportunity Nation, a bipartisan coalition of 300 national nonprofits dedicated to expanding economic mobility through community college and employment.

In this work, he spoke with many young people about the challenges that derailed their life trajectories. He began to see a trend with unplanned pregnancy.

He realized that the problem wasn’t coming from the irresponsibility of young people; it was coming from inequitable access to the full range of contraceptive methods.

Mark Edwards wears a blue shirt and smiles
Mark Edwards co-founded Upstream in 2014. Photo courtesy of Upstream USA

So, in 2014, along came Upstream.

“By transforming the approach to contraceptive care and embedding it into primary care settings, we’re working to ensure that all people from all socioeconomic backgrounds have access to the type of contraceptive care they need and deserve,” Edwards told Good Good Good. 

And it’s not just a quick conversation about the pill. The FDA has approved 18 different methods of birth control (some of which are even 20 times more effective than others). 

The execution of Upstream’s programming is this: In a standard doctor’s visit, no matter why a patient comes in for care — they are asked a super-simple screening question: “Do you plan to become pregnant in the next year?”

An Upstream team member gathers in front of a group of people in a classroom
Upstream team members train healthcare professionals to better offer all forms of birth control to their patients. Photo courtesy of Upstream USA

If the answer is ‘yes,’ providers can open up a different conversation, but if the answer is ‘no,’ the patient would be offered the full range of FDA-approved contraceptive methods, with all pertinent information, and leave that visit with the birth control of their choice in their hands. 

This approach has seen astonishing success. Upstream began its work as a state-wide program in Delaware. Between 2014 and 2017, births from unintended pregnancies dropped by 25% in Delaware.

Edwards shared even more optimistic stats in his 2023 TED Talk. Three years after Upstream’s intervention in Delaware, the state saw a 24% decrease in births from unplanned pregnancies overall (compared to 3% nationally), a 37% drop in abortions, and a 24% decrease in infant mortality. 

25% reduction in births from unintended pregnancies in Delaware. A graph shows decreasing percentages of births from unplanned pregnancies
Upstream saw impressive results in Delaware before expanding to other states. Photo courtesy of Upstream USA

Now, the organization is working in over 100 health centers, across 16 states — all with varying political identities.

“I think we can all agree that people having access to birth control so they can plan their families or decide if they want to have one or not, isn’t a blue, red, or purple state idea,” he shared in his TED Talk. “It’s a smart, just, empowering idea for everyone.”

“What we’ve found is that equitable access to patient-centered contraceptive care is a nationwide need,” Edwards added in an interview with Good Good Good.

That’s the other element of success: patient-centered care. The goal of Upstream’s work is not just to decrease unintended pregnancy, but to put patients at the center of the decision-making about their bodies.

In Delaware, surveys showed the following results:

  • 98% of patients did not feel pressured to choose a specific method of birth control
  • 99% of patients made their own choices about birth control
  • 98% of patients felt that health center staff listened to them and their preferences

This patient and justice-centered framework might seem like common sense, but it’s a radical approach in a system that has long made reproductive health seem like a specialty offering.

“Contraceptive care has historically been treated by our healthcare system as specialty care, when in actuality, contraceptive care is primary care,” Edwards said. 

“When we integrate contraceptive care into the primary care setting, as Upstream has in our proven model, we increase equitable access to contraceptives, without logistical barriers, which inevitably improves health equity for all women.” 

All of this work is done on a pro-bono basis, providing already stretched-thin healthcare providers with easy-to-implement training and resources. 

A white man in a blue plaid shirt uses medical equipment
Upstream provides free resources to healthcare providers, so contraceptive care can easily be accessed in primary medicine. Photo courtesy of Upstream USA

“In all my years as a medical professional, I’ve never encountered a public health initiative that has made such a dramatic impact on practice change in such a short period of time,” Dr. Karyl Rattay, the Director of Delaware’s Division of Public Health, shared on the Upstream website.  

Proving itself a worthy approach, Upstream has been expeditiously funded by the Audacious Project, the grant-giving arm of TED, which invests in social impact solutions. 

With this support, Upstream aims to reach over 700 health centers in the U.S, and serve 5 million people of reproductive age by 2030.

This work could not come at a more crucial time. Equitable access to contraceptive care is clearly a more effective route to reducing abortions, than, say, banning them, and Edwards says birth control has strong bipartisan support across diverse political environments.

“We’ve reached a crucial point in our history, calling for an expanded approach to dramatically improve contraceptive access,” he said. “We envision a future where patient-centered contraceptive care is an integral part of healthcare for all people.”

While Upstream is zeroing in on states with the highest need of support, Edwards knows contraceptive access is vital — especially in a post-Roe America. 

He encourages folks to have a conversation with their primary care providers about how they are equipped to provide their patients with the full range of birth control methods. 

Starting that conversation can open a door to implementing solutions.

“We need to continue to break down long-standing healthcare silos in order to empower patients with the opportunity to decide if and when they become pregnant,” he said. “Giving them that autonomy puts them in charge of their physical, mental, and maternal health.”

“We want them to have the freedom to focus on their future on their own terms, and, if desired, become intentional parents — when they’re ready.”

Header image courtesy of Upstream USA

Article Details

June 8, 2023 8:37 AM
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