Reproductive rights have been curtailed in the US in recent years. The latest restriction is the Trump administration’s freeze on federal funding for subsidised access to contraceptive services for millions of Americans (The Guardian 2025). Economists and policymakers who want to predict the consequences of this abrupt policy reversal should look to Sweden. My analysis of Swedish data – which indicates that small changes in the sales of contraceptives, when driven by access costs, can have large consequences for teen childbearing (Ragan 2025) – suggests the Trump administration’s restrictions on contraceptive services will be borne by American teenagers, who will become parents earlier than if they’d had access to contraception.
Background
Oral contraception (‘the pill’) was introduced in Sweden 60 years ago. Although the contraceptive technology frontier has advanced over the last six decades, new contraceptive methods mirror the pill in important ways, such as requiring physician prescriptions or controlling distribution through pharmacies. Recent studies have highlighted the impact of out-of-pocket costs on contraceptive choice among uninsured (Bailey et al. 2023 and 2024) and low-income Americans (Lindo and Packham 2017), as well as access costs in the form of distance to clinics (Kelly et al. 2020, Lu and Slusky 2019) in shaping fertility outcomes.
Although separated by more than a half century, circumstances surrounding the pill’s introduction in Sweden mirror the constraints many women in the US face today. This is particularly true when it comes to abortion rights. In Sweden, a national abortion ban was in place when the pill was introduced. Since the 2022 US Supreme Court decision in Dobbs v. Jackson Women’s Health, constitutional protections for abortion rights have been rolled back, leading to significant restrictions on abortion access in some states (Myers 2025). Recent research has found increased fertility in places with restricted abortion access relative to unaffected states (Dench et al. 2024, Myers et al. 2025). This poses challenges to understanding how a funding freeze will impact women in states where abortion is out of reach. Will the impact of limited abortion rights interact with increased contraceptive access costs to create a double disadvantage? Who will bear the burden of funding cuts for contraceptive services in places where abortion access is restricted?
From legal access to access costs
Much of the economic literature surrounding the pill’s introduction has focused on legal access (Goldin and Katz 2002, Bailey 2006), but my work (and that of others, such as Bailey 2012) has emphasised the role of access costs. Using sales data to directly quantify the impact of access costs on the pill’s diffusion, my research is the first to elaborate this important link on the causal chain from legal access to pill use and fertility. My study goes beyond the binary legal access measure to study how differences in access costs influence the pill’s diffusion. This approach makes my analysis relevant for a broad range of policy actions related to access costs.
Policy can influence access costs in many ways, be it through subsidising clinics, the margin affected by a funding freeze, or shaping access to pharmacies where women purchase the pill, as was the case in Sweden. By constructing detailed measures of women’s access to pharmacies, and linking this with local pill sales, I quantify the impact of access costs on pill sales. Figure 1 maps sales of the pill (SEK per woman) in the top-left panel beside a measure of pharmacy access in the top-right panel. The close association between pharmacy access and pill sales seen in the maps is highly robust to the inclusion of regional trends for population density and changing education attainment trends among young women. The relationship between access costs and sales is much stronger when cities are omitted, suggesting these costs are particularly important for women outside of urban areas.
Figure 1
An overview of the pill and teen fertility in Sweden
Turning to pill sales and teen fertility, the bottom panel of Figure 1 illustrates a striking association between the pill and teen births. Blue lines depict births per 1000 teens in above median pill sales areas (dark blue) and below median (light blue) from 1961 to 1979. Before the pill’s introduction (denoted by the black vertical line), teen fertility was identical and rising in lockstep across areas. After the pill, previously identical areas diverged. Teens in areas with high sales saw immediate fertility declines. Teens in areas with low sales experienced increased fertility followed by decline, but never converging with teens in areas with high sales. Sweden saw a generation of teens without the right to abortion separated by the extent of pill sales in their communities, with striking consequences for young women. Teens in areas with above median pill sales had almost three fewer births per thousand teens than those in areas with low sales.
Three births among 1,000 teens may not sound large, but this is comparable to 10% of births in areas with both high and low pill sales in the beginning of the sample. To put this comparison in perspective, Figure 2 uses the same above/below median sales division to plot births per thousand teens in the first column (blue), women aged 20–24 in the second column (orange), and women aged 25–29 in the third column (green). Fertility rates are noted on the left axis, and they differ substantially across the different age groups. The bottom panels of Figure 2 plot difference-in-difference estimators for the same age groups with cluster robust confidence intervals, which show the percentage change in births relative to 1965 for women in high versus low sales areas. For teens in high sales areas, this translates to 10–15% fewer births; for women aged 20–24, declines were between 5 and 10%; for women aged 25–29, relative declines were insignificant. Together, the data suggest that contraceptive sales are particularly important for young women’s childbearing outcomes.
Figure 2
The elasticity of births to pill sales
How important are access costs in driving these divergent fertility responses? Using variation across all local markets – not just the binary comparisons depicted in the figures – and comparing fertility changes with only the sales that are correlated with pharmacy access, the data reveal that small changes in sales driven by access costs lead to large changes in fertility for young women and teens. Fertility elasticities estimated using pill sales driven by access costs range from 1.65 (0.57) to -2.66 (0.76) for young women aged 16–17, depending on whether controls for other demographic or cost factors are considered. This means that even a 10% decline in sales driven by increased access costs could lead to a 16–26% increase in births among 16–17-year-old girls. For teens aged 18–19, a similar decline in sales driven by access costs would result in a 12–16% increase in births. Elasticity estimates reinforce the intuition revealed by the binary comparisons in Figures 1 and 2.
Fertility elasticity estimates are large. Responses to differences in sales driven by access costs are much larger than those estimated using observed sales alone. One interpretation of this outcome is that teens who are sensitive to access costs have larger fertility responses than the average teen. Increasing access costs may lead teens with the largest fertility responses to forgo contraception. The Swedish data suggest that for those teens who face the greatest risk of pregnancy, small differences in access costs can induce large changes in childbearing at the very first stage of the reproductive lifespan.
Implications for the current funding freeze
When the Trump administration freezes federal funds for contraception access, other actors must step up. Individual states need to take over these and other functions when the administration shrinks the federal government. Employers and educational institutions may also be important in providing access to contraceptive resources to fill the federal void. The recent approval of over-the-counter varieties of the pill (Harris 2024) and access to telehealth services in the domain of reproductive care (Ralph et al. 2024) may help mitigate gaps from the funding freeze. The Swedish case makes clear that teens will bear a large burden from increased access costs, and that burden will grow as the policy reverberates across women’s lives from high school graduation (Stevenson et al. 2021) to retirement (Lindo et al. 2020), and all points in-between (Bernstein and Jones 2019).
References
Bailey, M (2006), “More Power to the Pill: The Impact of Contraceptive Freedom on Women's Life Cycle Labor Supply”, Quarterly Journal of Economics 121(1): 289–320.
Bailey, M (2012), “Re-examining the Impact of Family Planning Programs on US Fertility: Evidence from the War on Poverty and the Early Years of Title X”, American Economic Journal: Applied Economics 4 (2): 62–97.
Bailey, M, V Wanner Lang, A Prettyman, I Vrioni, L Bart, D Eisenberg, P Fomby, J Barber and V Dalton (2023), “How Costs Limit Contraceptive Use among Low-Income Women in the US: A Randomized Control Trial”, NBER Working Paper 31397.
Bailey, M, L Bart, A Prettyman, V Wanner Lang and V Dalton (2024), “Who Is Financially Constrained in Their Choice of Contraceptive Method? Lessons from M-CARES”, AEA Papers and Proceedings 114, 442–48.
Bernstein, A and K Jones (2019), “The Economic Effects of Contraceptive Access: A Review of the Evidence”, Center on the Economics of Reproductive Health, Institute for Women’s Policy Research.
Dench, D, M Pineda-Torres and C Myers (2024), “The effects of post-Dobbs abortion bans on fertility”, Journal of Public Economics 234, 105124.
Goldin, C and L Katz (2002), “The Power of the Pill: Oral Contraceptives and Women’s Career and Marriage Decisions”, Journal of Political Economy 110(4): 730–70.
Harris, E (2024), “Over-the-Counter Birth Control Pill Now Available in US”, JAMA, 29 March.
Kelly, A, J Lindo and A Packham (2020), “The Power of the IUD: Effects of Expanding Access to Contraception Through Title X Clinics”, Journal of Public Economics 192, 104288.
Lindo, J and A Packham (2017), “How Much Can Expanding Access to Long-Acting Reversible Contraceptives Reduce Teen Birth Rates?”, American Economic Journal: Economic Policy 9(3): 348–76.
Lindo, J, M Pineda-Torres, D Pritchard and H Tajali (2020), “Legal Access to Reproductive Control Technology, Women’s Education, and Earnings Approaching Retirement”, American Economic Association Papers and Proceedings 110, 231–35.
Lu, Y and D Slusky (2019), “The Impact of Women’s Health Clinic Closures on Fertility”, American Journal of Health Economics 5(3): 334–59.
Myers, C, D Dench and M Pineda-Torres (2025), “The Road Not Taken: How Driving Distance and Appointment Availability Shape the Effects of Abortion Bans”, NBER Working Paper 33548.
Myers, C (2025), Myers Abortion Facility Database, 26 March.
Ralph, L, C Baba, M Biggs, C McNicholas, A Hagstrom Miller and D Grossman (2024), “Comparison of No-Test Telehealth and In-Person Medication Abortion”, JAMA, Jun 24:e2410680.
Ragan, K (2024), “Reproductive Right in Action: Evidence on the Pill’s Fertility Effects Across the Age Profile”, Rosenkranz Global Health Policy Research Symposium, Stanford University, 21 May.
Ragan, K (2025), “The Power of The Pill: Evidence from Oral Contraceptive Sales”, Economic Journal, 20 February.
Stevenson, A, K Genadek, S Yeatman, S Mollborn and J Menken (2021), “The impact of contraceptive access on high school graduation”, Science Advances 7: eabf6732.
The Guardian (2025), “Trump officials to cut Planned Parenthood family planning funds”, 1 April.
