Archive for the 'Family Planning' 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; 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

Ask Young Women One Key Question

Sunday, July 23rd, 2017

What can health-care providers, friends and parents do to help young women focus on their reproductive goals? Ask “one key question,” which is: “Would you like to become pregnant in the next year?”

Obviously this takes a special relationship with the women. That relationship is assumed with a doctor or other health-care provider, but may not be practical with some other relationships. However, if you do have such a relationship with a young woman, asking this question may help her clarify her goals.

One advantage of this question is that it is nonjudgmental. Furthermore, it doesn’t ask about the distant future, but only asks about the next 12 months. These are both reasons that it is a well-accepted way of opening an important conversation.

How have women responded? Apparently many women already have a pregnancy plan and know what their reproductive goals are for the next year. If the woman wishes to conceive, the discussion can then go toward having a healthy baby. Among other actions, she should start on prenatal vitamins, eat a healthy diet and avoid tobacco, alcohol and drugs.

If the woman responds that she does not want to become pregnant in the next year, or if she is unsure, there is a follow-up question: “Are you currently using a contraceptive method that you are satisfied with?” When the reply is, yes, she is happy with her birth control method, she is reminded about emergency contraception (EC). However, if a woman answers that she is not pleased with her contraceptive method, or is not using any birth control, this is a perfect time for contraceptive counseling—including a reminder about EC.

EC pills such as Plan B are now available without prescription and are safe, although not 100% effective. They are good up to 3 days after unprotected sex, and work best if taken within 12 hours of exposure. There is a relatively new EC pill, ella® (ulipristal); it has the advantage of being more effective (especially for heavy women), and works up to 5 days after sex. Neither of these will cause an abortion if a pregnancy is already established.

Most effective is an IUD which contains copper, such as the Paragard®. It works as EC for up to 5 days after sex—and can provide protection against pregnancy for as long as a decade.

Now you can now purchase Plan B and Ella® on the Internet! Go to and you will find both of these are available (they sell a generic equivalent of Plan B). In addition, women can get “the pill” through this same website. The world of reproductive health is changing!

The yearly Pap smear is a thing of the past. Now women can go several years without seeing a provider for reproductive health care, if ever. Although this saves the embarrassment of a pelvic exam and saves money, it also means that women may not have the opportunity to update their knowledge about contraception. In addition, birth control pills are available without a provider visit, including at Planned Parenthood, through and in some states.

Both Oregon and California have passed laws that allow women to purchase oral contraceptives (if they are in good health) just by speaking with a pharmacist. Do you remember when ibuprofen was only available with a prescription? Fortunately there is a way to petition to make a prescription medication available “over the counter”. This is what happened to Plan B as well as ibuprofen. Oral contraceptives are so safe that there is pressure on the FDA to make them available without prescription in all 50 states.

As the barriers to family planning are overcome it is important to be certain that women are aware of the method that is best for them. This is why the “one key question” is important. In Oregon, where this campaign got started, it is recommended that all family practice doctors and other practitioners who care for women of reproductive ages routinely inquire if they plan to conceive in the next year.

The birth rate in the USA is dropping, but still almost half of the pregnancies conceived are unplanned. This one key question could help to decrease the numbers of unintended pregnancies, and of abortions.

Recently a reader was kind enough to suggest that I write about “one key question”, and I am happy to follow up on the suggestion. I welcome feedback from readers, whether you like what I have written or hate it. My email address is:; please remember the hyphen!

             © Richard Grossman MD, 2017

Stay Current on International Family Planning

Thursday, December 29th, 2016


 A sign in Ethiopia showing the positive effects of having only 2 children. (Escape from poverty, health, a better housing, a fertile surrounding with trees, a better education) Picture by Maurice Chédel

“All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so.”                         United Nations, 1994


Although reproductive rights may be in jeopardy in this country, there is reason for optimism both here and abroad.

India has the world’s second largest population—about a billion and a third people. Thanks to family planning programs, family size there has been decreasing slowly through the years. Unfortunately there have been some bad bumps on the road. For instance, decades ago both men and women were sterilized without really understanding their surgery. The government put pressure on family planners to meet quotas and they, in turn, pressured patients to have surgery. Recently several women died after shoddy surgery in tubal ligation “camps”. It turned out that these unfortunate women wanted family planning, but weren’t given the option of temporary contraceptive methods nor adequately told of the risks of the surgery.

Sterilization, condoms, “the pill” and IUDs have been the mainstays in India, but the government has just added contraceptive injections to the short list of methods available to women without cost. The “Depo” shot has the advantages of lasting 3 months, of being very effective and lacking the serious side effects of contraceptives with estrogen. Therefore women who cannot use “the pill” can use it. Worldwide, “Depo” has been prescribed for birth control for over 40 years.

Although the USA has some of the most stringent rules for approving medications, I find it interesting that some other countries have limited access to birth control that we take for granted. Depo in India is one example, and birth control pills in Japan are another. For years Japanese women were not able to get “the pill” and couples mainly relied on condoms for contraception. The rationale was that condoms prevented the transmission of disease and could prevent problems if there was marital infidelity. It was only in 1999 that this policy was changed.

In many parts of Africa women needed a physical examination and blood tests before they could get a prescription for “the pill”. Few could afford these luxuries, driving up the number of unplanned pregnancies. In much of Latin America, on the other hand, a woman can walk into a “farmacia” and purchase whichever brand she would like.

Emergency contraceptive pills are easily available throughout much of the world. Plan B and other brands are now available in pharmacies in this country without prescription. They have been shown to be amazingly safe, although not as effective as having an IUD inserted. Of course EC should only be used in case of an emergency, such as rape or a broken condom, and it provides no protection against infection.

Price gouging for medications exists outside the USA. In England, for instance, the cost for EC could be more than US$40—while the same medication in France would cost less than US$10. There is an eye-catching British campaign suggesting that a woman in need could save money by taking the bus to Paris to get her pills!

Although millions more women in the USA have access to free family planning thanks to “Obamacare”, unfortunately there are still limitations. Some 20 million women in the USA live in “contraceptive deserts”. These are areas without reasonable access to publically funded clinics that offer the full range of contraceptive methods. Despite this, the teen-pregnancy rate has fallen precipitously in the past 25 years—a big reason for celebration!

Globally there is mixed news from the immense attempt to provide family planning services in some of the most difficult to reach and poorest parts of the world. The Family Planning 2020 campaign is now about halfway through its tenure, which started in 2012 and goes until 2020. Its goal is to reach 120 additional women with family planning services in 8 years. They have reached 30 million new users of contraception, which is an amazing achievement—but short of their interim goal by 20 million. It is incredibly difficult to deliver health services in areas where this campaign is working; I wish them luck.

Speaking of luck, last month I was hit by a car while crossing Main Avenue in a crosswalk. Fortunately I have no serious injury except for a broken ankle. It is also fortunate that I am totally retired from the practice of medicine—but plan to continue writing these columns. Happy Holidays to readers of Population Matters!

© Richard Grossman, 2016

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