Archive for the 'Contraception' Category

Give Thanks

Saturday, November 24th, 2018

 

Map of Total Fertility Rates courtesy of M. Tracy Hunter

At the risk of seeming overly optimistic, I would like to make a list of good things that are happening in the world of family planning and demography. Here goes:

My perception is that people are starting to realize the advantages of having small families. Their motivation is two-fold. Many people are realizing that it is possible to be married and have a good life with just one child, or with no children at all. In the USA and in many other rich countries this is practical because we have old age benefits, but more difficult where these benefits don’t exist so people have to rely on their children. There is another, altruistic reason a few are limiting their fertility. They see that the world is already overpopulated and don’t want to contribute further to the problems we are causing.

There are better, safer and more effective contraceptive methods than 52 years ago when Gail and I got married. The number of women using highly effective methods is rising, and (thanks to some good people running altruistic organizations) some are more affordable. An example is Medicines 360 which makes the Liletta™ IUD available to nonprofit clinics for just $50.

Colorado was chosen several years ago for a 5 year experiment. Women were able to receive LARCs (Long Acting Reversible Contraceptives, such as IUDs and implants) at no cost, even if they didn’t have insurance. The result was phenomenal—the unplanned pregnancy rate in our state dropped dramatically, and so did the abortion rate. I like to think of all the young people who were able to finish high school and go on to college because of this experiment. That experiment is over, but funding has continued thanks to private and state funding.

Emergency Contraceptive pills are now available without a prescription. This medication is so safe that there are essentially no cases of serious harm from taking it. It is not the best solution, because it is used after a failure—failure of a man to respect a woman, failure of a couple to use contraception or failure of a condom. Nevertheless, EC pills have prevented thousands of unplanned pregnancies.

There is also a movement to make birth control pills available without prescription (www.freethepill.org), or with a prescription from a pharmacist. Now a woman can purchase “the pill” over the internet, and in some states (including Colorado and New Mexico) pharmacists can prescribe hormonal contraceptives by following a protocol. Planned Parenthood has been doing something similar for years. A woman can purchase pills there, if all is ok, after answering a health questionnaire and having her blood pressure checked.

Although the need for abortion is decreasing, there are still all-too-many unplanned pregnancies. Access to abortion services is being curtailed in many parts of this country, causing women to have unsafe abortions. This is similar to what happened before Roe v. Wade in the USA, and is common in countries where abortion is illegal. The good news is that mifepristone and misoprostol, the pills used for a medical abortion, are available over the internet.

There are problems with internet-aided abortions. Most of these pills come from India, are expensive, some are of low quality, and they can take weeks to arrive. Unfortunately, medical care by internet has some inherent issues that will be difficult to resolve. It lacks the personal support that is so important when making an important decision. Also, there are two possible complications. Unless a woman has an ultrasound she might not know that the pregnancy is ectopic. These medications won’t cure a tubal pregnancy, which can rupture and cause serious internal bleeding. And the medications aren’t always effective in ending a pregnancy, so follow-up pregnancy tests are important.

Many countries now have Total Fertility Rates (TFRs) below the replacement rate—the number of children needed to replace the two parents. Replacement rate is slightly more than 2 because some kids die before they reach the age of parenting. This means that the countries’ populations will eventually decrease. Don’t be fooled, however—with few exceptions, all countries have increasing populations due to population momentum and increasing longevity. Of the CIA’s list of countries, only 105 have a TFR above 2.1, and 119 are less. The average TFR for the world is 2.4. We are getting closer to slowing population growth, but still adding about 80 million people to the already overcrowded planet each year.

I’ll be attending the International Conference on Family Planning this month and hopefully will have more good news for you soon!

© Richard Grossman MD, 2018

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

 

 

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