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Glenn D. Braunstein, M.D.

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Just Say 'Yes' to Access for Women's Reproductive Health, Contraception

Posted: 08/15/2011 3:57 pm

It's the 21st century and the United States has witnessed more than two centuries of astonishing scientific and social advancement. But wouldn't you know it, once sex is involved, partisans and policy-makers alike might as well don dated Puritan garb and keep public health concerns as their least rather than foremost matter. Just consider recent events affecting women's reproductive well-being.

The U.S. Health and Human Services Department, based on sound research and recommendations from the prestigious Institute of Medicine, issued some new guidelines, the agency deciding that, under the Affordable Care Act, new private health plans would be required to offer certain preventative care for women without an additional cost, such as a co-pays, co-insurance or deductibles.

The regulations include a wide range of medical services such as improved screening for cervical cancer, counseling and screening for sexually transmitted infections, gestational diabetes screening, lactation counseling and equipment for pregnant women and new mothers, at least one well-woman care visit annually, and screening for all women and adolescent girls for domestic violence. However, the attention paid to this initiative has seized on a single aspect of the HHS announcement: contraception. The measure calls for a fuller range of education, counseling, methods and services both to prevent unwanted pregnancies and to help women leave enough time between pregnancies for their health, and the health of their children.

That alone has set off alarms in some quarters, where this singular item drives whole agendas. Contraception is an intensely personal choice, and for some, a religious matter. A number of religious groups, including the Catholic Health Association, have bristled at the requirement to cover contraception. The Obama administration already has released an amendment to the regulation that allows religious institutions that offer health insurance to employees the choice of whether to cover contraception.

Even as the Health and Human Services agency aims to expand reproductive health services to women, there's been a concerted effort in other areas of government to slash these offerings. Indiana in the spring became the first state to cut off funding to Planned Parenthood, cutting $3 million in public funds used for birth control, cancer screening and tests for sexually transmitted infection. Kansas and North Carolina similarly have passed measures banning public funds from going to Planned Parenthood -- an organization that is controversial because, while offering popular services like family planning and preventative care, it also provides abortions; the funding and administration for that procedure is kept separate. Earlier this year, the House passed and the Senate rejected a budget amendment to cut Title X, a $317 million program to aid family planning that serves more than five million women. It also would have barred Planned Parenthood from receiving any federal funds for any purpose.

The Institute of Medicine made a compelling case -- based on the numbers -- for family planning and other preventative services for women in its report "Closing the Gaps." Nearly half of all deaths in the United States are caused by modifiable health behaviors that could be changed. In fact, it has been estimated that an increase in the use of the clinical preventative services available today could save more than two million life-years annually.

Moves to increase access to preventative services are just common sense, including in the area of contraception. A staggering 49 percent of pregnancies in the United States are unintended -- and of those, 60 percent are mistimed (meaning the couple would have chosen to have a child eventually), and 40 percent are unwanted. Unintended pregnancy is most likely among women ages 18 to 24 who are unmarried, poor, poorly educated (they have not graduated from high school) and members of racial and ethnic minorities. In other words, they largely are women who would benefit greatly if they had insurance and it offered them access to contraception without additional charges.

The cost to human health is considerable when women experience an unintended pregnancy. They are unlikely to be immediately aware of their condition and may not obtain prenatal care promptly. They also may keep drinking, smoking, taking prescription drugs and other behaviors they might stop if they knew they were pregnant. According to a 1995 IOM study, women with unintended pregnancies are more likely than those who have planned for a child to receive delayed or no prenatal care, to be depressed and to experience domestic violence while expecting. Unintended pregnancy is associated with lower birth weights, increased infant mortality in the first year of life, higher likelihood of abuse and a lack of resources for a child's healthy development.

While half of U.S. pregnancies are unintended, it happens only a third of the time in France and only 28 percent of the time in Scotland. While 11 percent of U.S. women at risk for unintended pregnancy use no contraception at all, it's only 3 percent in France and the United Kingdom.
Besides preventing unwanted pregnancies, contraception may prove critical in ensuring pregnancies are spaced a healthy time apart -- at least 18 months. Shorter time between pregnancies has been linked to low birth weights and prematurity. Contraception also may be key for women with certain chronic medical conditions that require their health to improve before they can safely endure a pregnancy.

The cost in actual dollars is huge, too, for surprised moms. In a study based on data from 2002 -- the most recent year for which data was available -- the direct medical cost of unintended pregnancies in the U.S. was $5 billion. The amount of money saved by contraception -- by preventing pregnancies that would have otherwise occurred -- was $19 billion. Those are the direct medical costs alone and based on figures that assumed a fairly routine pregnancy with no complications. It does not take into account the costs to employers for women who take maternity leave or time women take off during pregnancy to obtain medical care.

For those morally or religiously opposed to the procedure, there's this data-driven reality: Unintended pregnancy leads to abortion. Four in 10 unintended pregnancies result in abortion; nearly a third of women ages 15 to 44 have experienced at least one abortion. The scientific data show that when contraception is more widely available, the number of abortions drops. When contraception use by unmarried women increased between 1982 and 2002, the rates of abortion dropped. Removing the cost barrier for women could help, as poor women are four times more likely than high-income women to have unintended pregnancies and three times more likely to have abortions.

No single form of birth control will do if we want to ensure optimal health for women, a serious reduction in the number of unintended pregnancies, and maximum effectiveness of contraception. Studies have shown that the most effective methods are those that require little to no compliance. That's why intrauterine devices, female sterilization and contraceptive implants are the most effective, with a less than 1 percent failure rate in the first year of use. The next best methods in terms of effectiveness are injectable and oral contraceptives. Their failure rates are higher, but that's because some women miss pills or put off an injection -- with the common reasons cited for this inaction including cost and insurance-related issues. A delay in getting a refill could lead to missed pills -- and unplanned babies.

Condoms -- while they're an important tool for stopping the spread of sexually transmitted infection -- fail 15 percent of the time. Other barrier methods also have higher rates compared to prescription contraception, IUDs and sterilization. Natural family planning methods -- variations on the old "rhythm" method -- have varying rates of effectiveness. The calendar-rhythm method has an average failure rate of 13 to 20 percent, and works best for women who have very regular cycles. A similar tactic known as the standard days method uses a bracelet with beads that help a woman track which days she is unlikely to be fertile and can have unprotected sex and which days she should avoid sex or use another method of birth control to prevent pregnancy. This tactic has a 12 percent failure rate. For those who are very practiced and have a high degree of self-control, allowing them to use this method perfectly every time, the failure rate is low. But for teens, the failure rate is as high as 31 percent.

Those couples who don't use any birth control method face an 85 percent likelihood of becoming pregnant over a 12-month period.

Math and science have shown that access to education and contraception results in healthier women, fewer abortions, healthier pregnancies and healthier newborns. If that improvement in human life isn't compelling enough, the savings in cold hard cash also argues not only for birth control but also for as much as we can do for the better health and well-being of women.