In France, contraception has been fully reimbursed for all women under 26 since January 2022. Yet the rate of non-use remains stagnant at 9% among women aged 18-49, at the same level as in 2016, even before free access was expanded. Removing the financial barrier was necessary. The obstacles that remain are of a different nature: informational, cultural, relational.

The Essentials

  • Free contraception for under-26s has not reduced non-use, stable at 9% since 2016 (CSF Survey 2023).
  • Persistent barriers are behavioural and cultural: information deficits, mistrust of health professionals, social norms in certain communities.
  • Formal universality of a right creates a blind spot: it masks inequalities in actual use by giving the illusion of achieved equality.
  • Targeted approaches exist—health mediation, strengthened sex education, consultations outside traditional settings—but their deployment remains insufficient.
  • The National Sexual Health Strategy 2017-2030 identifies these obstacles; its effective implementation is the challenge for the coming years.

Nine Percent: A Figure That Resists Everything

Nine percent of women aged 18 to 49 use no contraception despite not wishing to become pregnant. This figure, from the 2023 Survey on the Context of Sexuality in France (CSF), is identical to that measured in 2016. The coverage, previously reserved for minors for certain devices, was extended on January 1, 2022 to women under 26, meaning through age 25 inclusive. Three million young women are covered by this total coverage.

Contraceptive coverage remained globally stable between 2016 and 2023; these data do not allow us to isolate the causal effect of the free access introduced in 2022.

These descriptive data warrant cautious interpretation. A stable proportion of the women concerned report using no contraception; the survey does not establish that they are beyond the reach of free access. Among these 9%, we find women who report infrequent sexual relations and consider the risk negligible, others who stopped a method due to poorly managed side effects, and still others whose care pathways are fragile or whose relationship to the health system is distant. Money is not their principal barrier.

Data on Inequalities in Use

The aggregate picture masks important disparities. Women who do not use contraception despite a risk of unwanted pregnancy concentrate in specific social profiles: women with low educational attainment, women living in areas with insufficient health professionals, women from environments where taboos around sexuality are stronger.

An IFOP study conducted in 2024 on trust in contraception shows that mistrust of hormonal side effects has increased in certain population segments, fueled in part by narratives circulating on social media. This phenomenon particularly affects young women without regular medical follow-up, precisely those whom free access was meant to reach. Their relationship to contraception is mediated less through their doctor than through their peers, their online searches, or the complete absence of a trusted interlocutor.

Geography also plays a role. In medical deserts, and France has an increasing number of them each year, obtaining a prescription requires overcoming logistical obstacles that reimbursement does not resolve. Free access to a gynecologist’s consultation when no gynecologist exists within fifty kilometers remains theoretical.

Belgium Confirms: Same Access, Same Plateau

Belgian experience provides useful confirmation. In Belgium, supplementary reimbursement has existed for people under 25 since a reform prior to 2023; only certain contraceptives are free or more highly reimbursed. Available data do not allow us to establish how the rate of non-use among women at risk has evolved after the expansion of coverage.

This Franco-Belgian parallel suggests that the phenomenon exceeds national particularities. Pricing policies alone do not address all non-financial barriers to contraceptive use; their specific effect on these barriers must be evaluated. They are behavioural. They are relational. And they require different tools.

Formal Universality Can Mask Persistent Inequalities

This mechanism produces a secondary political effect: by making non-use statistically residual, universal coverage reduces pressure to design complementary responses. A small but stable proportion seems acceptable, even inevitable, when it actually reflects a concentration of difficulties in specific groups. Budget decisions naturally orient themselves toward measures whose beneficiaries are quantifiable quickly, at the expense of targeted approaches whose effects are observed over the longer term and on populations less visible in national surveys.

There is a well-documented mechanism in public health policy: when coverage becomes universal, it creates the illusion that access is equitable. Aggregate indicators improve, the number of women covered increases, the average cost per user decreases, but the populations most distant from care remain in the blind spot. They no longer count in access statistics, but they continue not to seek care.

This mechanism is well known in public health by the term inverse care law, formulated by British physician Julian Tudor Hart in 1971: the availability of quality care varies inversely with the need for it in the population. In the field of contraception, this notion invites examination of inequalities in access to care. Available data do not allow us to conclude that the priority beneficiaries of the measure remain outside the care system.

The National Sexual Health Strategy identifies populations with specific needs and recommends actions adapted to their determinants and situations. The strategy exists. Its funding and effective deployment remain the weak point.

A similar dynamic is found in other domains of preventive health: the state necessary for vaccination progress in Africa showed that the availability of a vaccine is insufficient to achieve its adoption; trusted intermediaries, mediators, and presence in communities are equally necessary.

Tools That Work, and Why They Don’t Scale

Devices exist that directly address non-financial obstacles. Health mediation, professionals trained to link populations distant from care to the health system, has produced documented results in several countries. In France, contraception clinics can be organized in community locations, such as neighborhood associations, community centers, or social centers.

Midwives play a growing role. Since the HPST law of July 21, 2009, applicable from 2009-2010, midwives can provide contraception consultations, prescribe contraceptives within their scope of practice, and insert intrauterine devices in women without pathology. Their deployment in primary care structures, multiprofessional health centers, health centers, constitutes a response to the problem of geographic access. But their distribution across the territory remains unequal.

Sex education in schools is another lever. The law requires three sessions annually in each establishment. In practice, their implementation varies considerably by region, establishment, and teacher. Available evaluations show that quality sessions, with trained facilitators and appropriate pedagogical tools, durably modify representations and behaviours. Poorly conducted sessions, by contrast, produce no measurable effect.

The gap between legal obligation and on-the-ground reality is significant.

Finally, digital tools. Sexual health applications and platforms have emerged in recent years, some backed by public or semipublic services. They offer anonymous responses, available at all hours, without obligatory passage through a medical professional. For a portion of women who avoid face-to-face contact with health professionals, out of embarrassment, mistrust, or lack of time, these tools constitute a first point of contact. Their integration into care pathways remains to be structured.

Trust: The Central Variable That Reimbursement Cannot Touch

The difficulty also lies in the very nature of trust: it is not built by decree and degrades faster than it is restored. A negative experience with a health professional, a poorly explained prescription, or a normalized side effect is enough to establish lasting distance. Full reimbursement of a consultation does not, by itself, guarantee the relational quality of that exchange or the time necessary for shared decision-making.

Mistrust of hormonal contraception deserves separate treatment. Since the early 2010s, the use of the pill has declined in France, notably after the crisis of 2012-2013, in favour of other methods; this is insufficient to quantify an increase in mistrust across the entire population.

This mistrust is not irrational. The side effects of hormonal contraceptives are real and documented. The problem arises when it leads to abandoning all contraception without an alternative, rather than to a consultation allowing exploration of other methods. Copper intrauterine devices, non-hormonal and highly effective, remain underutilized in France compared to other European countries, partly because women are not informed about them, partly because doctors prescribe them less often to young and nulliparous women, despite evolving recommendations from the French Health Authority on this point.

Rebuilding trust requires health professionals capable of receiving concerns, naming them without minimizing them, and proposing a range of solutions. This requires consultation time, and in the current French health system, time is the rarest resource.

Objectives of the National Sexual Health Strategy for 2030

The Ministry of Health’s National Sexual Health Strategy 2017-2030 sets explicit objectives on these questions. It aims to reduce unwanted pregnancies, improve education on affective and sexual life, and strengthen access for the most vulnerable populations. Its operational axes include strengthening training for health professionals, developing mediation, and improving information tools.

The 2030 horizon is approaching. The question is whether the means allocated to these axes match the stated ambition. Free contraception has required a real and visible budgetary effort. Investments in health mediation, training, and consultations outside traditional settings are less spectacular, harder to measure in the short term, more difficult to defend in budget decisions. Yet they are the ones that condition the transition from formal access to real access.

Residual non-use of 9% represents, in absolute numbers, several hundred thousand women exposed to the risk of unwanted pregnancy. Behind each percentage point are concrete situations: an unwanted abortion, a pregnancy carried to term without preparation, a life disrupted. The public health issue is real, the tools to address it are identified, and the coming years will determine their effective deployment and sustained funding.

Sources

  1. Ministry of Health, World Contraception Day, National Sexual Health Strategy 2017-2030: https://sante.gouv.fr/actualites/actualites-du-ministere/article/journee-mondiale-de-la-contraception
  2. Survey on the Context of Sexuality in France (CSF 2023), INSERM / INED (reference data on non-use)
  3. IFOP, survey on trust in contraception, 2024
  4. French Health Authority, Recommendations on intrauterine contraception in nulliparous women
  5. Julian Tudor Hart, “The Inverse Care Law”, The Lancet, 1971