Categories
Population

A New Contribution to the journal Contraception

Very seldom have I read anything in the journal Contraception about the importance of family planning to the environment. Recently they had an editorial on that subject, and I wrote a Letter to the Editor thanking her for publishing it. I hope that this is the start of a trend!

Here are the url and doi: https://www.sciencedirect.com/science/article/pii/S0010782420301591?dgcid=author

https://doi.org/10.1016/j.contraception.2020.05.011

Here is the complete text of this short LTE:

Thank you for recognizing the importance of family planning to our environment

RichardGrossman

Highlights:

Voluntary family planning has successfully slowed population growth.•

Larger population means more impact on our environment.•

Keywords

Family planning; Population growth; Environment

To the Editors:

I was delighted to read the March, 2020 Commentary, “Family planning, population growth, and the environment” by Jeffrey Jensen and Mitchell Crenin [1]. It connects the increase in human population, and our consumption, to the environmental problems, such as climate change, we are facing. Although I have been reading Contraception for almost all of its 50 years of publication, I can remember few articles in the past that makes this connection.

The Commentary celebrates the work that family planning workers have done over the past decades. Without access to contraception and abortion, our human population would be much larger than it already is, and environmental problems even worse. We tend to be most aware of and stress the importance of voluntary family planning to individuals. However, other species and the overall health of the planet also have benefitted greatly from our efforts.

Because of our services, the patients we serve are healthier—and so are their families. Empowered by our services, women are able to continue their education, live up to their potential and take leadership positions in our society. We also have made huge positive impacts on society.

I agree with the Commentary when it states: “As family planning specialists, we should devote part of our effort to educating policy leaders and the public about the importance of our work from an environmental standpoint.” Indeed, several of us have, but not enough. My contribution has been monthly essays on aspects of human population [2]. Warren Hern, another Fellow of the Society, has written on this subject for decades [3][4].

Many others have studied the interrelationship between human population and the environment, often commenting on the value of family planning. O’Neill et al. estimate the potential of family planning to decrease carbon emissions [5]. Bongaarts & O’Neill lament that the IPCC doesn’t pay more attention to population [6]. Population, health and environment programs that incorporate family planning may help to save biodiversity hotspots [7]. The Center for Biological Diversity uses Endangered Species Condoms, which it gives away, to inform people about the connection between human population and endangered species [8].

In the past some family planning providers have been shy about acknowledging the connection between family planning and the state of the environment. I performed an (unpublished) survey of the Society’s Fellows in 2014. Some of the responses recognized the importance of family planning to the environment, while others seemed to take offense at this idea.

I look forward to reading more in Contraception about the importance of voluntary family planning to the state of our environment.

References

[1]J.T. Jensen, M.D. CreininFamily planning, population growth, and the environmentContraception., 101 (3) (2020), pp. 145-147

[2]Grossman R. Population Matters-USA. www.population-matters.orgAccessed 5-2-2020.

[3]W. HernIs human culture carcinogenic for uncontrolled population growth and ecological destruction?BioScience, 43 (11) (1993), pp. 768-773, 

[4]Hern, W. Choose between candidates who understand global ecological realities, and those who don’t. The Colorado Statesman 2012; 113(9):1535. https://www.coloradopolitics.com/opinion/choose-between-candidates-who-understand-global-ecological-realities-and-those-who-don-t/article_2933b6c0-5791-5c05-889e-bc5bf0751a99.html accessed 4-30-2020. Also available at: https://tinyurl.com/yd7m5xuj.

[5]B.C. O’Neill, M. Dalton, R. Fuchs, L. Jiang, S. Pachauri, K. ZigovaGlobal demographic trends and future carbon emissionsProc Natl Acad Sci USA, 107 (41) (2010), pp. 17521-17526, 10.1073/pnas.10045

[6]J. Bongaarts, B.C. O’NeillGlobal warming policy: Is population left out in the cold?Science, 361 (6403) (2018), pp. 650-652, 10.1126/science:aat8680

[7]Blue Ventures. https://discover.blueventures.org/madagascar-health-environment/ Accessed 5-2-2020.

[8]Endangered Species Condoms. https://www.endangeredspeciescondoms.com Accessed 5-2-2020.

Categories
Population

Follow the Progress of IUDs

Image from Medical Gallery of Blausen

            After our first son was born my wife, Gail, wore a Lippes loop IUD for 3 years. It worked well; our second son was born about 9 months after its removal.

            In the 1950s IUDs were controversial. Fortunately, one doctor had the gumption to develop the first widely-used model. Dr. Jack Lippes was a professor of OB-GYN at the University of Buffalo when he invented the Lippes loop in the 1960s. Loops were used from 1965 until 1986 with a remarkable record of safety and effectiveness. Lippes himself is still actively working on family planning technology at age 94!

            Current IntraUterine Devices are small, T-shaped pieces of flexible plastic with a monofilament string for removal attached to the long arm. All IUDs in the USA now are better than 99% effective due to something added to the plastic. Four are enhanced with a hormone and one uses copper.

            There are several thoughts about how IUDs work; it seems as though most of the action is on sperm. Levonorgestrel, the hormone, makes cervical mucus tacky so sperm cannot swim into the uterus. Hormonal IUDs usually make periods less unpleasant for women who have heavy bleeding or bad cramps. 

            The copper in the Paragard® is toxic to sperm, and it also makes the lining of the uterus less hospitable. Some women want to know if IUDs work by causing an abortion. To me, that is more of a philosophical question than a medical one. It depends on when you consider life starts, as well as other factors that are more philosophical than medical. However, my feeling is that if one were to define the action of an IUD as being an abortifacient, it is so only rarely and very early in pregnancy.

            The best way to lower the abortion rate is with good contraception. The teen abortion rate dropped by 60% and the number of teen births by almost that much when free IUDs, and all birth control, were made available in Colorado. Yes, it is safe for teens to us IUDs!

            How long are IUDs effective? Again, that gets into the realm of philosophy. For two IUDs the Food and Drug Administration says one thing and good research says another. The FDA states that the Paragard® is effective for 10 years, but studies have shown that it is very effective for up to 12 years. Therefore, Planned Parenthood recommends that a Paragard® can be used for a dozen years so long as it is not causing problems and the woman still wants contraception. Extending the duration is an “off-label” use.

            Another off-label use of the Paragard® is for emergency contraception. In case of rape, condom failure or poor planning, a Paragard is the most effective means of preventing pregnancy if inserted within 5 days of unprotected intercourse. The insertion can be the beginning of 10 (or 12) years of highly effective contraception.

            IUDs went through a bad era in the early 1970s. Women suffered because the Dalkon Shield IUD was brought to the market without sufficient testing. Some women wearing Shields had unplanned pregnancies. Some of these pregnancies became infected causing at least 4 maternal deaths. Some women even required a hysterectomy for a severe pelvic infection due to the Shield. Many other women had infections caused by Shields that made them infertile. Even though Shields were taken off the market in 1974, IUDs’ reputation suffered. 

            The effectiveness, safety and other advantages of current IUDs have led to high acceptance. The chief disadvantage of this means of birth control is expense. Fortunately, Obama Care and most insurance will pay for the woman’s choice of contraception, but cost can be a deterrent for uninsured women. Studies, including one here in Colorado, have shown that many women will choose an IUD (one type of Long Acting Reversable Contraception) if price is not an issue. This is reflected by the percentage of American contracepting women using IUDs—about 12% now, up from 1% in 1970.

            In a recent symposium on IUDs, two issues received the most attention. One was how women can safely get IUDs during the pandemic. Telemedicine for counseling is a solution to decrease risk.

            The other issue was IUD removal. Remember the string mentioned above? Usually removal is a simple procedure for a practitioner to grasp the string and pull out the IUD. However, one study found that the average charge for this is more than $250 and some providers charged over $1000! Women can remove their own IUDs, as two of my patients demonstrated. One told me she laid down and used her fingers to find the strings and tugged. The other succeeded in getting her IUD out, but with bad consequences. She removed her device in the shower, fainted and fell through the glass door! I don’t recommend that technique.

© Richard Grossman MD, 2019