Archive for the 'Contraception' Category

Advocate for LARC (Long Acting Reversible Contraception)

Tuesday, June 28th, 2016

IUD

This is a picture of an IUD in a mockup of a uterus.

The potential of LARCs (Long Acting Reversible Contraception) is so great that I am advocating that all voters advocate for them to be paid for by government. The savings–both financial and in terms of human potential–are enormous!


 

Your doctor tells you that she can prescribe either of two treatments, but that one is 20 times as likely to fail as the other. Which would you choose?

Over a quarter of women in the USA use birth control pills, which fail much more frequently than Long Acting Reversible Contraception. LARCs, as they are nicknamed, are amazingly effective yet not used as frequently as one might hope.

IUDs (Intrauterine Devices) are the most commonly used LARCs. There are four available now; they are all made out of flexible plastic in the shape of a “T”. Three emit a tiny amount of hormone into the woman’s uterus, where it is most effective. The fourth IUD uses copper to gain effectiveness. IUDs are usually well tolerated, although sometimes they can increase cramps or change menstrual flow. The best medical knowledge is that IUDs do not work by aborting pregnancies.

IUDs can stay in place for a maximum of 3 to 10 years, depending on which type. Since there is a string attached, they are usually easy to remove. The string also allows the woman to check that it is in the correct place. The pregnancy rate is vanishingly small—only a couple of LARC users in 1,000 will conceive each year. This statistic for “the pill” is much higher—almost 50 per thousand will experience an unplanned pregnancy. Apparently the high failure rate of oral contraceptives in the USA is due to noncompliance. In Europe the failure rate is significantly lower; European women take their birth control pills more regularly.

There are two major drawbacks to both IUDs and the implant: they are expensive and they need to be placed by an experienced clinician. IUDs have a further drawback—bad press.

It used to be that only women with health insurance or a plump checking account could afford LARCs, but that is changing. Thanks to the Affordable Care Act (“Obamacare”), any woman with insurance, including Medicaid, can get her chosen birth control without copay. In addition, one IUD, Liletta®, is priced much lower than the others. Here in Colorado there is a program that provides contraception, including LARCs, at little or no cost.

Placing an IUD is not difficult for a trained practitioner. The opening of a woman’s cervix may be tight is she hasn’t borne a child, but a little local anesthesia and gentle dilatation will help with the insertion.

The other type of LARC is the implant, Nexplanon®, which is as effective as an IUD. It is a thin plastic rod that is inserted under the skin of the woman’s arm, where it can stay for up to 3 years. It emits a hormone that is very effective in preventing pregnancy. Although it is in a very low level in the woman’s blood, it is sufficient to change menstrual patterns; most women with Nexplanon® will have spotting or breakthrough bleeding. Perhaps this is why less than 1% of women in the USA choose an implant, whereas about 6% use an IUD.

Unfortunately, reproductive health has become a political football. Here in Colorado a grant demonstrated that access to LARCs can give young women a better chance in life by decreasing teen pregnancies. By taking away the consideration of expense, the use of LARCs expanded 4 fold. Nevertheless, the false fear that IUDs might abort pregnancies kept our legislators from continuing funding to provide this effective contraception. The best way to prevent abortions is with effective birth control!

Ohio took a tip from Colorado with a program to provide LARCs. Part of that state’s motivation is to lower their infant mortality rate. They are targeting young teens and women who have just had a child, since these two groups are at high risk of having an infant die if they were to get pregnant. They also note that the state saves almost $6 for every dollar invested in LARCs.

Ohio has been proactive in another way. Some healthcare providers have misconceptions about IUDs. They think that they should only be used if a woman already has delivered a baby, or that an IUD makes a woman more susceptible to sexually transmitted infections, or teens shouldn’t use IUDs, or that IUDs can lead to sterility. All of these perceptions are wrong! Indeed, almost every woman can safely use an IUD, and start her family as soon as it is removed.

Safe, effective contraception is an important step in empowering women. We should advocate for making LARCs available to all women!

© Richard Grossman MD, 2016

Listen to Representative Coram

Sunday, January 24th, 2016

LARC_combo

A recent Durango Herald article detailed the “New Year’s resolutions” of three Southwest Colorado lawmakers. There is an important issue that was not mentioned in this article, and Rep. Coram may have part of its solution.
Let me start by trying to summarize what is on each of the legislators has said. State Senator Ellen Roberts is focusing on rural healthcare costs—for good reason! Although we in the USA spend the most per capita of any country in the world, our health statistics lag behind many other countries. Senator Roberts is also concerned about problems brought up by the Gold King Mine spill. I am confident that her excellent legal mind can help pass a “good Samaritan” law for mine mitigation, and decrease barriers between states in dealing with emergencies. Finally, she is concerned about the monstrous wildfires we have experienced recently.
J. Paul Brown, our Representative in the Colorado House, rightly picks transportation and water as key issues for the legislative session that has just begun. He and I probably disagree about transportation because I support public transportation as well as highway improvement. But we definitely agree about water! J. Paul’s website states: “Water is the most precious resource on Colorado’s West Slope…. As your State Legislator, I will work tirelessly to protect our water.” Globally, water is the most precious resource.
Don Coram represents people a bit to the north and west of La Plata County, nevertheless he was included in this article. The only issue mentioned is voter registration, but I admire him for another topic. In 2015 he was one of the sponsors of a bill to provide safe, effective contraception to low-income women. A Republican, the bill had a Democratic cosponsor. Unfortunately, the bill failed. Fortunately, however, a coalition of private donors has temporarily picked up part of the slack.
You probably recall that a foundation funded provision of Long Acting, Reversible Contraceptives (LARCs) here in Colorado. LARCs consist of IUDs and a hormonal implant, all of which are safe and appreciated by women, but are usually out of the price range of those who don’t have insurance. They are much more effective than over-the-counter methods such as condoms, and are even 20 times as successful at preventing pregnancy as “the pill”. That grant was for a 5-year period which ended in 2015. This funding had a remarkable effect! There were fewer abortions in Colorado, and our teen pregnancy rate dropped by 40%.
Despite Representative Coram’s best efforts, the legislature would not approve funding to continue the program. The reason given for disapproval by other legislators was that IUDs sometimes cause abortions. The best medical knowledge is that IUDs do not cause abortions—but it is well known that unplanned pregnancies often end up being aborted.
Public health sources state that each dollar spent on family planning saves from 4 to 7 healthcare dollars. This is a better return on investment than just about anything else! Personal benefits, such as allowing a young woman to finish college are of even greater value. Other advantages, however, go beyond the obvious. The cost of insurance is lower if there are fewer unplanned pregnancies, Senator Roberts. Some of the highest healthcare costs are those associated with premature birth. The pregnancies that LARCs prevented in this study would have likely been to the women most likely to give birth prematurely—young and poor.
What is causing those terrible wildfires that we are having trouble paying for? Climate change is a major factor. What is the least expensive way to slow greenhouse gas emissions? You guessed it—family planning! Fewer people mean fewer emissions. LARCs won’t provide a short-term solution for either climate change or wildfires, but they can help in the long term.
Representative Brown, please remember that the more people who drive on our highways, the more costly they are to maintain. Likewise, the more people there are in Colorado, the greater the need for water. Most of the growth is on our state’s Eastern Slope. As its population increases, the pressure for them to get our Western Slope water will increase. Again, LARCs won’t solve transportation or water problems right away, but funding them can reduce the size of the problems that our children and grandchildren have to deal with.
Thank you for your courageous stand, Representative Coram. I am sorry that I cannot vote for you, but hope that you will find new allies in support of another bill to pay for LARCs.

© Richard Grossman MD, 2016

Provide Family Planning in the Democratic Republic of the Congo

Sunday, February 22nd, 2015

DR Congo woman & child small 

The London Summit on Family Planning was the start of something big. If kept, an array of promises made at the groundbreaking July 11 [2012] event could have a major impact on the lives of women and girls for years to come.

                                               Susan A. Cohen, Guttmacher Institute

 

In a prior article I wrote about how it was possible for one doctor to perform hundreds of tubal ligations in one day—but probably not honor the rights of the patients. The next column was about putting human and reproductive rights first and foremost. Today’s column focuses on one country where FP2020 is making amazing improvements in the lives of women and children.

FP2020 is the nickname of the ambitious program started in 2012 at the London Summit on Family Planning. Its goal is to reach 120 million women of the 225 million who are unable to access modern contraception, but wish to regulate their fertility. These are women in developing countries who currently have little or no access to reproductive health care. Typically they have high fertility rates and high rates of child deaths, illegal abortion and maternal mortality. Often these women are the poorest of the poor, have little schooling and are subservient to men. Many of these women live grim lives.

A very high percentage of people in wealthy countries already use family planning (FP); indeed, that is part of how we became wealthy. It is time to share that knowledge and technology with our less fortunate brothers and sisters. Unfortunately where access to FP is limited, infrastructure is also challenging—transportation, sanitation and communication are often poor. Reaching these people will be difficult.

Providing full reproductive health care for every woman in the world who does not currently have access to those services would cost a whopping 40 billion dollars annually—about the same amount as the US military spends in a month. The lives saved by such an investment would make that money very well spent, however. Reaching all people in developing countries with FP and with maternal and newborn care would prevent 79,000 maternal deaths, 26 million abortions and 21 million unplanned births each year.

The cost of providing just FP services for these people would be about nine billion dollars a year. Because moms will be healthier, improved birth spacing alone would prevent over a million infant deaths globally each year!

Funding is a major challenge for FP2020. The programs are jointly supported by developing countries and by donor (wealthy) countries. In addition, generous funding has come from foundations; the Bill and Melinda Gates Foundation is a major source of financial support as well as being a prime mover. Assistance also comes from the UN and the US Agency for International Development, among many other organizations.

One of the FP2020 programs is in the Democratic Republic of the Congo. This beleaguered country has had a miserable history of colonialism, dictators and civil war. Average income there is less than two dollars per day. Only 53 % women are literate, and only one in twenty married women uses a modern method of contraception. Indeed, a 1933 law makes contraception illegal! The average woman bears over 6 children in her lifetime and the country will double in population every 23 years—exacerbating many of its economic and political problems.

Despite these challenges, FP2020 is seeing successes in DRCongo. One project was to map existing FP resources, using a sophisticated system of data collection with cell phones. They now know where there are trained FP personnel and which pharmacies have pills or injectable birth control. Fortunately, all sites offer condoms.

Women in DRCongo have been relying on traditional methods of FP for years, with too many unintended pregnancies—more than a million in 2013. Contraceptive implants (such as Nexplanon®) were introduced in 2014 with great success. So far, the program has recruited almost 200,000 new users of modern contraception.

What FP2020 has meant to women in DRCongo is telling. More than 300,000 unintended pregnancies were averted in 2013. Calculations suggest that 1481 women’s lives were saved, and 76,000 unsafe abortions were prevented by the use of modern contraception.

FP2020 offers hope for the future, especially for people in countries such as DRCongo. I am optimistic that FP2020 can help women and families lead healthier and happier lives and will be a model for the future of family planning. And I expect it and future programs will be built on respect for the people that they serve.

© Richard Grossman MD, 2015

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Thank you! Richard Grossman MD, MPH  richard@population-matters.org

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