Treble-Up: Using Three Forms of Birth Control

The United States has the highest rate of teen pregnancy in the developed world,[1] and my own state—Texas—is fifth highest in the 50 states.[2]   That’s not surprising, given that 25% of Texas schools don't even teach sex education and almost 60% teach abstinence-only.[3]  

The figure above shows the 2012 birth rates in the various states.[4]  As you can see, Texas sits right in the middle of a hot-bed of teen pregnancy and births, along with New Mexico, Mississippi, Arkansas, Louisiana, Oklahoma, Kentucky and West Virginia.

It’s not just teens having accidental pregnancies either.  In Texas, a full 54% of all pregnancies are accidental.[5] 

The situation has worsened recently in those Texas counties that used to be served by Planned Parenthood.   In 2011, Texas defunded Planned Parenthood, leaving many counties without substitute services.[6]  A new study on the fallout reports that those counties previously served by Planned Parenthood had a 27% increase in Medicaid-covered births in the 18 months following defunding, whereas counties that were not previously served by Planned Parenthood showed an 8% decrease in Medicaid-covered births.[7] 

At a cost of some $11-12,000 for each Medicaid birth, there are some significant dollars at stake here.[8]  In fact, in 2010, more than 57% of accidental births in Texas were publicly funded at a cost of nearly 3 billion—almost a third of which was paid by our state.[9]  That’s our tax dollars, paying for a preventable problem.  

In addition to the significant federal and state costs for births resulting from accidental pregnancy, there is significant social cost.   Compared with peers who delay childbearing, teenage girls who have babies are:

·      Less likely to finish high school;

·      More likely to rely on public assistance;

·      More likely to be poor as adults; and

·      More likely to have children who have poorer educational, behavioral, and health outcomes over the course of their lives than do kids born to older parents.[10]

It’s not just teens and their children that are poorer due to accidental pregnancy either.  Our country as a whole loses out, each student dropping out of school presenting some $260,000 in lost earnings, taxes, and productivity.[11]

Pregnancy is not the only unintended consequence of sex—disease is another consequence and a potentially fatal one.  Texas ranked 3rd among the 50 states in the number of HIV[12] diagnoses in 2013.  Texas also ranks 13th in syphilis, 10th in chlamydia, and 12th gonorrhea.[13]   In fact, Austin has more sexually transmitted disease cases than the 50 other cities surveyed, and Dallas is 9th![14]   

The disease risk is higher for young people too. Of the 20 million new STD[15] cases every year, about half in 2000 occurred among young people aged 15 to 24.[16]

A book entitled "Marital Education in Texas—Treble-up: Use 3 Forms of birth control" is available online at   The book aims to make a dent in those numbers, providing marital education in an easy to read, non-judgmental fashion. Why “marital” education” instead of “sex” education?  We chose this name in the hopes of reaching those parents who voted for abstinence-only education.  

If abstinence-only education works—and it may have a positive benefit in delaying the onset of sexual activity[17]—then the natural result is marriage at an earlier age.  However, in a no education or an abstinence-only educational setting, those young couples will have inadequate information on how to plan their family.  Thus, even though they are married, young parents are still at risk for dropping out of school with all of the negative consequences.

The book provides a basic education in the types of family planning methods available, and importantly, discusses their failure rates and the common reasons for failure. It makes suggestions for doubling or trebling-up on the different methods to improve ones odds of avoiding accidental pregnancy.


[1] Kearney M.S. & Levine P.B., Why is the teen birth rate in the United States so high and why does it matter? J. Econ. Perspect. 26(2):141-66 (2012) (“Teens in the United States are far more likely to give birth than in any other industrialized country in the world. U.S. teens are two and a half times as likely to give birth as compared to teens in Canada, around four times as likely as teens in Germany or Norway, and almost 10 times as likely as teens in Switzerland. Among more developed countries, Russia has the next highest teen birth rate after the United States, but an American teenage girl is still around 25 percent more likely to give birth than her counterpart in Russia.”).

[2] According to the National Campaign to Prevent Teen and Unplanned Pregnancy, available online at    The worst state is New Mexico, followed by Mississippi, Arkansas, and Louisiana.  Oklahoma is tied with Texas at fifth highest teen pregnancies.

[3] Conspiracy of Silence: Sexuality Education in Texas Public Schools in 2015-2016, available online at

[4] Excerpted from Sexual Health of Adolescents and Young Adults in the United States (2014), published by the Henry J. Kaiser Family Foundation, available online at

[5] State Facts About Unintended Pregnancy: Texas, published by the Guttmacher Institute and available online at

[6] Thomson-DeVeaux A., How Defunding Planned Parenthood Could Affect Health Care, FiveThirtyEight (2017), available online at (“Texas . . . embarked on a series of efforts to divert funding away from Planned Parenthood in 2011. First, the legislature instituted broad cuts to family planning services, spurring the closure of 82 clinics, one-third of which were affiliated with Planned Parenthood.”).   For more information on Texas efforts to defund reproductive healthcare, see Deteriorating Access to Women’s Health Services in Texas: Potential Effects of the Women’s Health Program Affiliate Rule, by the Department of Health Policy, School of Public Health and Health Services at George Washington University, available online at; also Charts: This Is What Happens When You Defund Planned Parenthood, MotherJones (2013), available online at

[7] Stevenson A.J., et al., Effect of Removal of Planned Parenthood from the Texas Women’s Health Program, New Engl. J. Med. 374:853-860 (2016), available online at (“The percentage of women who underwent childbirth covered by Medicaid within 18 months increased from 7.0% to 8.4% in the counties with Planned Parenthood affiliates and decreased from 6.4% to 5.9% in the counties without Planned Parenthood affiliates (estimated difference in differences, 1.9 percentage points; P = 0.01).”).

[8] Selby, W.G., Democratic legislators say more than half of Texas births funded by Medicaid, PolitiFact Texas (2012), available online at, (“[Texas Health and Human Services] commission spokesman Geoffrey Wool . . . add[ed] that in 2010, 56.9 percent of Texas births -- or 220,899 out of 388,447 total births -- were covered by Medicaid, at an average cost of $11,600. . .  the state’s share of the $2.2 billion annually paid by Medicaid for Texas births and related services is about $900 million.”).

[9] (“In Texas in 2010, the federal and state governments spent $2.9 billion on unintended pregnancies; of this, $2,057 million was paid by the federal government and $842.6 million was paid by the state.”). 

[10] From Teen Pregnancy and Childbearing, published by the Department of Health and Human Services, available online at

[11] Shuger L.,Teen Pregnancy and High School Dropout: What Communities Can Do to Address These Issues. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy (2012), available online at (“Nearly one-third of teen girls who have dropped out of high school cite early pregnancy or parenthood as a key reason. […] According to the Alliance for Excellent Education, it is estimated that over the course of his or her lifetime, a single high school dropout costs the nation approximately $260,000 in lost earnings, taxes, and productivity. Put another way, if students who dropped out of the Class of 2011 had graduated from high school, the nation’s economy would likely benefit from nearly $154 billion in additional income over the course of their lifetimes.”).

[12] HIV is human immunodeficiency virus, which will eventually cause AIDS—acquired immunodeficiency syndrome, and death.   

[13]Texas – 2015 State Health Profile, published by the CDC, available online at

[14] 10 US Cities with Most Positive STD Tests, STDCheck (2015) available online at Cf. Different surveys include different diseases, and thus STD statistics are highly variable.  This particular survey did not include HSV1 or Hepatitis A, but did include Chlamydia, gonorrhea, HSV-2, hepatitis B and C, HIV-1 and -2, and syphilis.

[15] STD is “sexually transmitted disease”, also known as “STI” for “sexually transmitted infection” or “VD” for “venereal disease.”

[16] Statistics, American Sexual Health Association, available online at, (“there are 19.7 million new STIs every year in the U.S… About half of all new STDs/STIs in 2000 occurred among youth ages 15 to 24.”).

[17] Jemmott III, J.B., et al., Efficacy of a Theory-Based Abstinence-Only Intervention over 24 Months, Archives of Pediatric Adolescent Medicine 164.2 (2010): 152, available online at, (“The abstinence-only intervention compared with the health promotion control intervention reduced by about 33% the percentage of students who ever reported having sexual intercourse by the time of the 24-month follow- up, controlling for grade, age, and intervention- maintenance condition.”).  Cf. Trenholm C, et al., Impacts of Four Title V, Section 510 Abstinence Education Programs Final Report. Princeton, NJ: Mathematic Policy Research; submitted to U.S. Dept. Health & Human Services, Assistant Secretary for Planning and Evaluation, 2007. Most studies report, however, that overall teen pregnancies are higher with abstinence only education. Stanger-Hall, KF & Hall, D.W., Abstinence-Only Education and Teen Pregnancy Rates: Why We Need Comprehensive Sex Education in the U.S, PLoS One. 2011; 6(10): e24658, available online at (“Using the most recent national data (2005) from all U.S. states with information on sex education laws or policies (N = 48), we show that increasing emphasis on abstinence education is positively correlated with teenage pregnancy and birth rates. This trend remains significant after accounting for socioeconomic status, teen educational attainment, ethnic composition of the teen population, and availability of Medicaid waivers for family planning services in each state. These data show clearly that abstinence-only education as a state policy is ineffective in preventing teenage pregnancy and may actually be contributing to the high teenage pregnancy rates in the U.S.”).