A scorecard on curtailing unwanted pregnancy

Behind the ever-boiling battle over abortion in America sits a quieter but still central issue: access to contraception. And the news there may be surprising.

In a report released Tuesday, the New York-based Guttmacher Institute ranked all 50 states in their efforts to reduce unintended pregnancy and found a diverse collection of states at the top. California ranked first and New York ranked fifth, a result that may seem predictable, given both states' liberal orientations toward social issues. But between them in the highest rankings sit three conservative states - Alaska, South Carolina, and Alabama.

The reason, says the report's author, is that these states are acutely aware of the relationship between unintended pregnancy and dependence on welfare, and they see the economic and social benefit in helping women avoid unintended pregnancy. In turn, that helps women avoid the abortion question altogether.

"What you see in these results is that helping women avoid unintended pregnancy is not just a blue-state issue," says author Cynthia Dailard, a policy analyst at Guttmacher. The institute was at one time affiliated with Planned Parenthood, but is no longer.

"Alaska, Alabama, and South Carolina scored very high, even though we think of them as having an anti-abortion environment," says Ms. Dailard. "But they've really stepped up to the plate in terms of making family-planning services available, particularly to low-income women."

All 50 states and the District of Columbia were rated on three criteria: service availability, laws and policies, and public funding.

In Alaska, for example, 85 percent of counties have at least one family planning clinic. The state also devotes major funding, both from its own budget and from federal block grant dollars, to family planning.

South Carolina and Alabama are noteworthy in their expansion of family- planning services to low-income women through Medicaid.

Dailard says both of those states were at the forefront in the use of Medicaid waivers - special permission from the federal government to extend Medicaid eligibility for family-planning services to women who would otherwise not be eligible.

Among industrialized countries, the United States has one of the highest rates of unintended pregnancy. According to the latest figures, nearly half of the 6 million pregnancies that occur each year among American women are unintended. Of those, 1.4 million result in births, and 1.3 million result in abortion. Between 1981 and 1994, the latest year for which data are available, the rate of unintended pregnancy in the US declined, from 54.2 per thousand women of child-bearing age to 44.7.

There are no state-level statistics on unintended pregnancy, but a look at teen pregnancy rates can serve as a proxy. Nationwide, the teen pregnancy rate has been declining since its peak in 1991, due in part to improved use of contraception.

States that showed stronger efforts to improve access to birth control, by Guttmacher's ranking, have also shown higher drops in teen pregnancy: In California and Alaska, the rates declined by 39 and 34 percent, respectively, between 1992 and 2000. In Nebraska, the lowest-ranking state in the Guttmacher report, teen pregnancy declined by 17 percent during that same period.

Embedded in the Guttmacher ratings is a rejection of the "abstinence only" approach to sex education in schools and a preference for "comprehensive sex ed," which incorporates the abstinence message but also informs students about how they can protect themselves through contraception. California, for example, is one of the few states in the country to reject federal abstinence-only education funds, which boosts its Guttmacher score.

While much attention is paid to efforts in state legislatures to limit access to abortion, some states are pressing ahead, too, with legislation to increase access to contraception. In 2005, states enacted 22 measures. Last year, the legislatures in Connecticut, Indiana, Massachusetts, and Texas directed their states to apply for federal permission to expand eligibility for Medicaid-funded family-planning services. Arkansas and West Virginia passed laws requiring private health insurers to include coverage of contraceptives if they cover other prescription drugs.

In addition, Massachusetts and New Hampshire now allow pharmacists to dispense emergency contraceptives without a prescription. According to Guttmacher, eight states now have such policies.