Archive for the 'Family Planning' 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

Recognize Family Planning as a Human Right

Tuesday, May 29th, 2018

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Family planning was declared to be a basic human right fifty years ago this month. The right to family planning was included in the International Conference on Human Rights held in Tehran, May 1968.

The concept of universal human rights started after World War II with the United Nations. Its charter included the obligation “…to promote… universal respect for, and observance of, human rights and fundamental freedoms for all without discrimination….” The Tehran conference was held 23 years later to define what those rights are. One of several points states:

“The protection of the family and of the child remains the concern of the international community. Parents have a basic human right to determine freely and responsibly the number and the spacing of their children”

The 84 countries attending this Iranian conference agreed to be bound by the decisions, but the world has changed radically since then. For one thing, there are more than double that number of countries. Furthermore, global population has more than doubled from 3,600,000,000 to 7,500,000,000 people. On the good side, there are more, safer and more effective methods of contraception available. The right to family planning is supported by many programs, including FP2020 which works in many developing countries. Planned Parenthood and the federal Title X (ten) program in the USA are under jeopardy because of a proposed law limiting healthcare providers from mentioning the word “abortion”.

Unfortunately the right to family planning is being limited or taken away in many countries. Funding for many organizations working internationally has been barred by the Global Gag Rule. The GGR prevents the US from funding any foreign agency that provides abortion services anywhere—or even mentions the word “abortion”. Because of the lack of these services women will go without birth control and there will be millions of unplanned pregnancies, and thousands of women will die from complications of pregnancy—and, ironically, there will be more abortions!

The Tehran Proclamation has 9 standards to uphold the human right to family planning. These include non-discrimination, availability of information, accessibility of services and supplies, quality, autonomy of decision making, privacy and confidentiality. I am happy to report my experience has been that these standards are upheld everywhere I have worked,. 

It is difficult to envision a UN conference being held in Iran now—there have been many changes since 1968. The Shah was overthrown in 1979 and the country became an Islamic theocracy, lead by a “Supreme Leader”. A pleasant surprise came about a decade later.

High level government and university experts held a conference in 1988 to discuss Iran’s population, which was increasing rapidly at that time. Attendees agreed “…that the rate of population growth in the Islamic Republic of Iran was high and this would have a negative effect on the welfare of the people. Hence, the participants strongly urged the Government to set up a family planning programme and integrate population factors in policy-making.” (quoted from “A New Direction in Population Policy and Family Planning in the Islamic Republic of Iran”)

The High Judicial Council of Iran decided “family planning does not have any Islamic barrier” so long as abortion was not involved. New laws were passed to promote small families. Couples were required to take birth control classes before they could get a marriage license. Government clinics were set up offering a wide choice of methods, including vasectomy. In addition, the government discouraged childbearing before age 18 and after 35 and recommended that children be spaced 3 or 4 years apart. The family planning program urged couples to have no more than 3 children; government employees lost some of their benefits, such as maternity leave and food coupons, if the family had more than 3 children. 

The TFR (the average number of children that a woman bears in her lifetime) in Iran had been as high as 7.0, had decreased to 5.5 in 1988 and now is less than replacement at 1.8—the same as the USA. It doesn’t mean that population is shrinking—there are millions of children and teens whose reproductive years are still ahead of them—so it will take decades before the population stabilizes.

A dictatorship can use its influence to slow population growth. Although there are many dictators in the world today, I think Iran is the most successful in slowing its growth. That sort of heavy-handed governing wouldn’t work in the USA. Indeed, I believe that people should have the right “…to determine freely and responsibly the number and the spacing of their children.”

© 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

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