Archive for the 'Family Planning' Category

Stay Current on International Family Planning

Thursday, December 29th, 2016

family-planning-sign-in-ethiopia-by-maurice-chedel

 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

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

Don’t Get Pregnant

Wednesday, March 2nd, 2016

Microcephaly-comparison-500px

Image courtesy of the CDC

“The Zika virus provides a glimpse into a future we should do everything possible to avoid, a terrifying reminder why the fight for a stable physical planet is the fight of our time.” Bill McKibben

“Don’t get pregnant until 2018” is the advice given women in El Salvador. Yet only two thirds of married women there are using modern contraception.

The Zika virus, declared “public health emergency of international concern”, is the cause of the Salvadorian government’s warning against pregnancy. “We’d like to suggest to all the women of fertile age that they take steps to plan their pregnancies, and avoid getting pregnant between this year and next….” This quote from Deputy Health Minister Eduardo Espinoza is frightening.

Although it hasn’t caused an epidemic in Africa where it was first identified, it is raising havoc in the Americas. Zika virus symptoms are usually mild: eye inflammation, fever, rash and joint irritation—but the majority of infected people have no symptoms at all. There is no treatment for Zika disease. Mosquitoes of the Aedes genus spread Zika, dengue and other diseases, and it may also be spread by sex.

The best way to avoid getting Zika is to avoid being bitten by mosquitoes—insect repellant, dress appropriately and avoid areas where mosquitoes live. So far Colorado is safe from Aedes.

Climate change has recently increased the range of Aedes mosquitoes. Air travel has allowed the virus to spread like lightning. Humans have destabilized the planet, as McKibben states.

The Zika story in the Americas is still being written, but began last year. Brazilian doctors noticed a huge increase in the incidence of babies born with small heads—microcephaly. They found an association with the mothers having had Zika virus infection early in pregnancy.

I am terrified that brain scans of affected babies show other serious abnormalities usually associated with profoundly impairment. There are dozens of causes of microcephaly, but most of them are associated with cognitive and other problems.

The CDC recommends avoiding Zika when a woman is, or could become, pregnant. If the mother could have been exposed to the virus during pregnancy, it recommends ultrasounds to monitor fetal head growth.

What is so concerning is that where Zika is found, family planning services may be spotty. Fortunately El Salvador, where women are supposed to abstain from pregnancy for the next 2 years, has had a pretty successful reproductive health program. It is regrettable, however, that El Salvador is one of only 6 countries worldwide that outlaw abortion for any reason.

Beloved Pope Francis recently gave Catholic women who are at risk of Zika virus permission to use “artificial” contraception. This is great news for the millions of women where Zika is a threat, and will hopefully encourage governments in those areas to make contraception easily available.

One of the reasons that the U.S.A. liberalized of our abortion laws was that we had a viral epidemic that caused severe fetal damage. Fortunately, immunization has made rubella a disease of the past.

What happens if a woman is infected with Zika in pregnancy and ultrasound shows that her fetus has microcephaly? The Salvadorian punishment for having an abortion is 2 to 8 years in prison for the woman and up to 12 years for the doctor. Nevertheless hundreds of women risk having an illegal abortion. Often they cause their own abortions by thrusting a knitting needle or piece of wood into their uterus. Tragically, suicide is not uncommon among pregnant women in El Salvador.

Here is a hypothetical situation. Luisa, a Salvadoran campesina, has two healthy children. She was taking birth control pills, but her clinic ran out. Shortly after conceiving her third pregnancy she had what she thought was a cold with a mild red rash. During a routine ultrasound at 5 months the doctor said everything was ok except the fetus’s head seemed small, and she could see calcifications in the brain. What can Luisa do? If this baby’s brain was severely damaged she couldn’t afford to take care of it, and her other two children would suffer because of the family’s very limited resources.

What is wrong with a society that puts women in such a difficult bind? Rape is common in El Salvador, yet a woman who has been raped or is carrying a terribly compromised fetus has no legal recourse. Climate change and international travel make it more important that women everywhere have access to family planning and safe abortion services.

© Richard Grossman MD, 2016

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