Category: Reproductive Health

A recent Durango Herald article detailed the “New Year’s resolutions” of three Southwest Colorado lawmakers. There is an important issue that was not mentioned in this article, and Rep. Coram may have part of its solution.
Let me start by trying to summarize what is on each of the legislators has said. State Senator Ellen Roberts is focusing on rural healthcare costs—for good reason! Although we in the USA spend the most per capita of any country in the world, our health statistics lag behind many other countries. Senator Roberts is also concerned about problems brought up by the Gold King Mine spill. I am confident that her excellent legal mind can help pass a “good Samaritan” law for mine mitigation, and decrease barriers between states in dealing with emergencies. Finally, she is concerned about the monstrous wildfires we have experienced recently.
J. Paul Brown, our Representative in the Colorado House, rightly picks transportation and water as key issues for the legislative session that has just begun. He and I probably disagree about transportation because I support public transportation as well as highway improvement. But we definitely agree about water! J. Paul’s website states: “Water is the most precious resource on Colorado’s West Slope…. As your State Legislator, I will work tirelessly to protect our water.” Globally, water is the most precious resource.
Don Coram represents people a bit to the north and west of La Plata County, nevertheless he was included in this article. The only issue mentioned is voter registration, but I admire him for another topic. In 2015 he was one of the sponsors of a bill to provide safe, effective contraception to low-income women. A Republican, the bill had a Democratic cosponsor. Unfortunately, the bill failed. Fortunately, however, a coalition of private donors has temporarily picked up part of the slack.
You probably recall that a foundation funded provision of Long Acting, Reversible Contraceptives (LARCs) here in Colorado. LARCs consist of IUDs and a hormonal implant, all of which are safe and appreciated by women, but are usually out of the price range of those who don’t have insurance. They are much more effective than over-the-counter methods such as condoms, and are even 20 times as successful at preventing pregnancy as “the pill”. That grant was for a 5-year period which ended in 2015. This funding had a remarkable effect! There were fewer abortions in Colorado, and our teen pregnancy rate dropped by 40%.
Despite Representative Coram’s best efforts, the legislature would not approve funding to continue the program. The reason given for disapproval by other legislators was that IUDs sometimes cause abortions. The best medical knowledge is that IUDs do not cause abortions—but it is well known that unplanned pregnancies often end up being aborted.
Public health sources state that each dollar spent on family planning saves from 4 to 7 healthcare dollars. This is a better return on investment than just about anything else! Personal benefits, such as allowing a young woman to finish college are of even greater value. Other advantages, however, go beyond the obvious. The cost of insurance is lower if there are fewer unplanned pregnancies, Senator Roberts. Some of the highest healthcare costs are those associated with premature birth. The pregnancies that LARCs prevented in this study would have likely been to the women most likely to give birth prematurely—young and poor.
What is causing those terrible wildfires that we are having trouble paying for? Climate change is a major factor. What is the least expensive way to slow greenhouse gas emissions? You guessed it—family planning! Fewer people mean fewer emissions. LARCs won’t provide a short-term solution for either climate change or wildfires, but they can help in the long term.
Representative Brown, please remember that the more people who drive on our highways, the more costly they are to maintain. Likewise, the more people there are in Colorado, the greater the need for water. Most of the growth is on our state’s Eastern Slope. As its population increases, the pressure for them to get our Western Slope water will increase. Again, LARCs won’t solve transportation or water problems right away, but funding them can reduce the size of the problems that our children and grandchildren have to deal with.
Thank you for your courageous stand, Representative Coram. I am sorry that I cannot vote for you, but hope that you will find new allies in support of another bill to pay for LARCs.

© Richard Grossman MD, 2016

Image courtesy of Pathfinder International

The London Summit on Family Planning in 2012 was the start of a new focus on family planning (FP). The last time FP had received so much attention was the Cairo conference in 1994.

Several factors had turned attention away from FP. The HIV/AIDS epidemic received a huge amount of attention and funding. Donor fatigue was another factor, since FP programs are expensive and the results can be difficult to measure. Perhaps abuse was the most important reason that people lost interest in FP programs. For instance, it became clear that people in many countries, including our own, had been sterilized without informed consent.

Long ago I assisted with infertility surgery on a woman who had had 3 cesareans in Texas and was unable to conceive a fourth child. We found that her Fallopian tubes had been surgically interrupted without her knowledge or consent. Apparently her doctor in Texas didn’t think she should have any more children and had tied her tubes.

The darkest chapter in the history of FP was eugenics, the practice of trying to improve human genetics. In some cases eugenicists mandated sterilization of “undesirable” people—people of color, people with birth defects or learning disabilities, and people with mental problems. Often the eugenics movement was allied with political goals; the enemies were labeled as “undesirables”. My personal experience is that some of my favorite patients might have fallen into an “undesirable” category.

A number of women in California prisons were sterilized without following proper legal procedure—and probably without respect for the women’s human and reproductive rights. There are also stories of widespread abuse from India and Peru among other countries. It is unforgivable that people have been taken advantage of, but that is no reason to halt all FP programs.

Last month I wrote about the women who died in India after tubal ligation surgery. The press has focused on the terrible conditions where the surgery was performed. Also disturbing is how the women were treated before the surgery—they were not given a choice of temporary contraceptive methods nor told about the risks of the surgery.

225 million women worldwide want to avoid pregnancy but don’t have access to modern contraception. How can services to these people be delivered without abuse?

The goal of the London Summit is monumental, but attainable: to reach 120 million new users of FP by the year 2020. This effort is nicknamed FP2020. The memory of past abuses triggered concerns that such an ambitious goal could lead to new abuses. One of the first steps FP2020 took was to consult social scientists about ways to decrease the chances of coercion. In their report they asked: “How can we ensure public health programs oriented toward increasing voluntary family planning… respect, protect and fulfill rights in the way they are designed, implemented, and evaluated?”

In response they developed an innovative plan. Instead of focusing on getting people to adopt FP, they recommend working from a basis of human rights. That is correct: family planning should be based on human rights.

Although this seemed revolutionary to me at first, I realized that a major reason I became interested in FP is to further human rights. On the individual scale the lives of parents are improved if they have the right to choose how large their family will be. Of course their children benefit, too! On a global scale people’s rights may be trammeled as population density increases.

The authors of the report define reproductive rights as reproductive self-determination; access to reproductive health services, supplies and information; and nondiscrimination. Self-determination is the key—people must be able to choose what method of family planning (if any) they use. Both information and supplies need to be readily available for this to succeed. In most of the world, including the USA, lower-income folks are less able to access FP, but this discrimination must stop.

How can policies be made so rights are more important than quotas? Standards will be made and enforced to deliver quality care. Supplies are often a problem in developing countries, but that problem can be solved with technology. Production should be judged not by the numbers of patients served but by how well they are served. For instance, clients can be given questionnaires before they leave a clinic to be sure that they were given information about all available FP methods.

So far, this is theoretical; it remains to be seen if reproductive and human rights can be honored consistently. Next month I’ll report on FP2020 in action.

© Richard Grossman MD, 2015