Archive for the 'Contraception' Category

Reduce Barriers to Family Planning

Sunday, December 24th, 2017

There’s no good news about male contraceptives yet, but there is much progress in the field of family planning for women. This column will touch on some of the high points.

Perhaps the best news is that, globally, more women who want to avoid pregnancy are using an effective contraceptive method. The number who weren’t using modern contraception was estimated to be 225 millionin 2014but is 214 million now. The decrease is partly due to huge efforts from Family Planning 2020 to make better family planning available in developing countries. With local support as well as funding from rich countries and foundations, FP2020 has provided over 30million women with effective contraception.

The goal of FP2020 is to reach 120 million previously unserved women with effective family planning by the year 2020. In many places couples only had access to one or two methods, such as condoms or tubal ligation. FP2020’s strategy includes avoiding coercion and offering a choice of several methods.

Please remember that it is not just developing countries that wrestle with unintended fertility. In 2008 in the USA 51% of pregnancies were unintended. There is good news here, too; it is now just 45%. This decrease, and the significant decrease in abortions, is thought to be due to Long Acting Reversible Contraception—LARCs. These methods include IUDs, implants and the 3-month shot. One in 7 women in the USA is now using these most reliable types of birth control.

LARCs have two shortcomings, however. In general they are expensive—but remember that dollar-for-dollar, contraception saves more than any other health intervention!

The other problem with LARCs is convenience, since most require a health care professional. An exception is the 3-month shot, “Depo” or DMPA. This has been in use for birth control for almost 50 years, but requires a clinic visit 4 times a year.

Sayana Press® is an innovative solution that is accepted very well. It is a small plastic bubble filled with the medication and a short attached needle. The woman just punctures her skin, squeezes the bulb and she is protected against pregnancy for 90 days.

Malawi, a small East African country with large families, compared women who went to the clinic to get their shots with women who injected the medicine themselves. They found that women who were given the first shot at the clinic then took home 3 Sayana Presses® were much more likely to use the medication for a full year.

Birth control pills are available without prescription in many countries, and the USA will be following suit if Daniel Grossman has any say. Grossman and I may be distantly related, and we are very close in our belief that “the pill” is amazingly safe and there should be minimal barriers to its access. Grossman has started the “Free the Pill” campaign. This would follow the way Emergency Contraceptive (EC) pills have gone over the counter; Amazon.com now sells EC pills!

Another physician named Grossman—Jessica—heads up Medicines 360. This organization has as its mission “…to expand access to medicines for women regardless of their socioeconomic status, insurance coverage, or geographic location.” Their first product is a big success! Liletta® is an IUD that releases a hormone over 4 years, is safe and very effective, and decreases menstrual bleeding and cramping. It is primarily sold to clinics and is significantly less expensive than similar IUDs.Recently there is good news about all IUDs; they reduce the risk of a woman getting cervical cancer.

When Trump reinstated and expanded the Global Gag Rule, the Dutch started “SheDecides” to replace essential funding for reproductive health. More countries, foundations and individuals have stepped up to pledge $200 million! This amazing organization’s goal is to make it possible for “…girls and women to decide freely and for themselves about their sexual lives, including whether, when, with whom and how many children they have.”

Most couples in the USA use contraception at some time in their lives, even if their religion opposes birth control. In much of the global south, however, this is not the case. There the Roman Catholic hierarchy turns most women away from birth control. This might change, however. The Pontifical Gregorian University in Rome will be holding a series of talks on the 50th anniversary of Humanae Vitae, according to the National Catholic Register.

Despite political forces in this country that are trying to erect barriers around access to family planning, there is a lot of good news about contraception for women.

© Richard Grossman MD, 2017

Revisit the Real Pioneers of Family Planning History

Saturday, June 24th, 2017

    

Although I am not much of a historian, I have followed the history of family planning and of the concern about human population growth—and was surprised to learn that two commonly held beliefs are not correct.
Thanks for reading!
Richard

Revise your Ideas of Family Planning History

Malthus was the first person to make the connection between increasing human population causing problems, correct? And, of course, Margaret Sanger was the first to teach poor women about family planning.

Both of these notions about the history of family planning are wrong. These two firsts actually belong to people who have almost been lost to history.

Hong Liangji was a minor governmental official who lived in the Yangzi Valley of China in the 18th and early 19th centuries. He wrote several essays about politics and other subjects. In an essay from 1793 titled “On Governance and Well-being of the Empire” he voiced his view that increasing population would interfere with peaceful rule. Apparently he felt that it was his duty as a Confucian to criticize the emperor. The emperor did not receive this well; he ordered that Hong be decapitated. Fortunately the sentence was reduced to banishment to a minor post.

The background to Hong’s writing was that highly productive new crops allowed China’s population to grow rapidly. This was welcomed by the government, but was recognized by a few as being potentially problematic.

“But in the matter of population, it may be noted that today’s population is… not less than twenty times as large as that one hundred years ago.” Hong wrote. A twenty-fold increase may have been an exaggeration, but his was definitely a time of very rapid population growth.

Hong illustrated his concern with an example. If a family that started with a large home and 3 children on a fair sized farm, at the end of a century they could end up with as many as 100 people (including servants) living in the same house and farming the same area of land. He wrote that the emperor could not stop the people from reproducing, but that harmony could be destroyed by the rapid growth. He observed: “… the resources with which Heaven-and-earth nourish the people are finite.“ He ended this essay on population “The food for one person is inadequate for 10 persons; how could it be adequate for a hundred persons? This is why I am worried about peaceful rule.”

Five years after Hong, Malthus published: “An Essay on the Principle of Population” in 1798. It is no wonder that we usually give Malthus credit for being the first to raise the alarm about population, however, because Hong wrote in Chinese (which few westerners understand), and he ended up in obscurity.

The first person to advocate for family planning was British. In 1823, more than half a century before Sanger was born, Francis Place published pamphlets about family planning for poor women. He taught two methods of birth control, withdrawal and use of a vaginal barrier. Here is a quote he wrote about the latter: “A piece of soft sponge about the size of a small ball attached to a very narrow ribbon and slightly moistened (when convenient) is introduced previous to sexual intercourse and is afterwards withdrawn, and thus by an easy, simple, cleanly and non-indelicate method, in no way injurious to health, not only may much unhappiness and many miseries be prevented, but benefits of an incalculable amount be conferred on society.”

Apparently many rich women knew about “pessaries” to prevent pregnancy, similar to what Place described. However he was the first person to pass this information on to “…the socially less privileged.” One of his pamphlets was named “To the Married of Both Sexes of the Working People and Similarly the Married Sexes in Genteel Life. The pamphlets were distributed widely throughout England, but the establishment called them “diabolical handbills”.

Place’s personal life is interesting, if perhaps antithetical to his later interest in family planning. He came from a poor family, married at age 19 (his wife was just 17) and they had 15 children! of whom 5 died young. Place educated himself by reading voraciously. He started a successful business that he turned over to his children so he could be politically active. Place’s goal was to improve the lives of the poor. He collaborated with some well-known friends, including Jeremy Bentham and John Stuart Mill.

Large families and rapid population growth affect both society and the individual. Hong wrote about the former; I have not been able to find out much about his personal life. Place was concerned about both later in life. His only book: “Illustrations and Proofs of the Principles of Population” was inspired by Malthus.

© Richard Grossman MD, 2017

 

 

Look Where We Need Family Planning the Most

Thursday, April 27th, 2017

“As we crawled through the city, we encountered a crowded slum area. The temperature was well over 100, and the air was a haze of dust and smoke. The streets seemed alive with people. People eating, people washing, people sleeping. People visiting, arguing, and screaming. People thrusting their hands through the taxi window, begging. People defecating and urinating. People clinging to buses. People herding animals. People, people, people, people.”   Ann and Paul Ehrlich in Population Bomb, 1968

Impact = Population x Affluence (consumption) x Technology

                                                Ehrlich and Holdren, 1971

 

Close your eyes for a moment and conjure up an image of overpopulation. Did you picture hundreds of people hanging off a train in India? or dark-skinned crowds in a street in a poor country?

Yes, family planning is important in those scenarios. Voluntary access to modern contraception is important for humanitarian reasons in the global south. You probably know the litany of its benefits: decreased maternal mortality, healthier children, economic savings, progress in standard of living and education, local environmental protection.

However, the need for effective, universal access to family planning and to safe, legal abortion is much more important in rich countries in the global north. This is because of the issue of consumption.

What! you might be asking. The average woman in many African countries has 5 or more children. Niger tops the list; the total fertility rate there is over 7! Surely the population explosion there must be causing problems. Yes, Niger is one of the lowest ranked countries in the UN’s Human Development Index. Repeated drought has caused famine; population pressure and overgrazing cause environmental degradation.

Let’s compare two countries in the Western Hemisphere—the USA and Haiti. They are, respectively, one of the richest and one of the poorest in the world. The carbon footprint of an average person in the USA is about 20 tons of CO2 per year, while that of a Haitian is 0.2 tons—one hundredth of ours! Thus it would take a hundred Haitians to equal the climate damage done by one of us.

Another way to compare the impact of a single person in the two countries is with Ecological Footprint. The ratio between the two countries is 16 to 1. Thus 16 kids of a really large Haitian family would have the same impact of a single-child family in the USA. I have to admit that there are several problems with this comparison: it doesn’t include the two parents, the average Haitian family size is just a little over 3 so I doubt that there are many as large as 16. The legacy of a large family grows over generations. In Niger, if each generation has 7 children, the number of grandchildren would be 49!

The two measures of impact are different. The carbon footprint is global, since carbon emissions into the atmosphere spread over the whole planet. The Ecological Footprint includes carbon emissions, but it also includes effects that are localized, such as damage to the local environment. In any case, the impact of a person in the USA is much greater than one in Haiti or Niger, and it is spread over the planet.

There is good news! The unintended pregnancy rate (this includes mistimed and unwanted pregnancies) has dropped significantly in the USA. Whereas this rate has hovered at about 50% for years, the latest information is that it has dropped to 45%. The news is especially good for young women, when an unintended pregnancy can be devastating. This decrease is due to increasing use of effective contraception. It is very concerning that the new administration threatens women’s reproductive health and may make contraception and abortion services either unaffordable or totally unavailable.© Richard Grossman MD, 2017

Creative Commons Attribution 3.0 United States
This work is licensed under a Creative Commons Attribution 3.0 United States.