Durango Herald Population

Delight in Children

It is easy to become antinatalist if you are concerned about overpopulation. I think this is shortsighted.
Let’s face it—the best reason to care about our growing population is concern for future generations. People a generation or two from now will experience increasing effects of crowding and resource depletion. We should be concerned for our children and grandchildren, who will know a world very different from ours.
Most of us will be part of the problem by having our own children. We need to raise our kids to be conscious of population and environmental issues. The most important step we can take is to minimize our impact by having small families, or by not reproducing at all.
You might think that there is not much difference between a family of two children and one with three. There is a large disparity, however, after a few generations. If each of your three children has three kids, and so on, you will have 27 great grandchildren. In five generations there will be 243 progeny. If there had only been two per couple, there would only be 8 great grandchildren, and 32 great, great, great grandchildren. So at the end of five generations we compare 243 with 32; the difference is over seven fold!
People used to believe that a single child would be spoiled and would not prosper, but recent studies have shown that this is not true. In fact, an only child is likely to be a high achiever and to be well adjusted. Some recent information about only kids can be found in Bill McKibben’s book Maybe One.
If you are concerned that an only child would suffer from the lack of siblings, there are ways to ensure the advantages of socializing with other kids. If you parent a single child, try not to focus all of your attention on her. Have her spend time with cousins. Choose a neighborhood that has children of compatible ages. Find activities for your child to do with other children; a good preschool is an excellent way to get children together. You might trade cooperative “sitting”, or be a day-care provider.
For those of us who choose not to bear children, congratulations! There is a support group for you: Childfree By Choice. You can find them on the web at If you are unsure about having kids, they have material for people who are still trying to make up their minds about being parents, and even a bunch of jokes about childlessness. More and more people are choosing the option to forego children. Now about one in five women will not bear any child, while a few years ago it was only one in six.
Happily, there are alternatives to giving birth. For those who want to participate in child rearing but not bear their own, and for those who enjoy a big family but don’t want to contribute to overpopulation, there are several possibilities.
Adoption is one way to go. Those who are able to make a long-term commitment deserve congratulations. So many kids need love and stability, and many demand special care. They have physical or mental problems, and require mature or experienced parents with many resources.
Not ready to make the commitment for adoption? Consider being a foster parent. There are kids of all ages who need a short-term home. Some are newborns who need a cradle for a few days while awaiting permanent adoption. Others are teenagers who are in trouble, and are farmed out to people who can provide nurture and discipline. Foster parenting can be especially challenging.
There are other, less extensive ways of being involved. For instance, Big Brothers/Big Sisters is a nationwide agency that involves adults in the short-term care of kids. If you volunteer, you only need to spend a few hours a week with your child. Coaching, helping in a classroom, working with Scouts or a church group all allow you to help kids grow.
Here is a paradox. The reason we have children is for the sake of the future. But if we have too many progeny, the future will be ruined. The solution is for people to have the right number of children—fewer than in the past. It also means that some people will forgo passing on their genes. Instead, they have the opportunity to pass on their wisdom and culture to future generations.

© Richard Grossman MD, 2006

Durango Herald Medical Population Public Health

Pick Mirena

If you were designing a perfect family planning method, what characteristics should it have? Certainly, the method would be highly effective and safe. Probably it should be designed for women, since they are usually more interested than men in controlling fertility. It would be nice if the method also had some beneficial side effects such as making periods lighter and less painful. Fortunately such a method is now available!
I have known about Mirena® for several years. Doctors in other countries, who have many years’ experience with it, have raved about it. The FDA finally approved it for use in the United States in 2000. It is wonderful to have another option for American women. As effective as tubal ligation, it is temporary and can be removed easily if a woman wishes to conceive.
Mirena® is made out of soft plastic in the shape of a “T”. The stem is filled with levonorgestrel, a potent form of progesterone—the hormone of pregnancy. A tiny amount of the hormone passes continually through the plastic into the uterus. It contains enough to last five years. Fortunately, although the levonorgestrel has a direct effect on the uterine lining, very little gets into the woman’s blood stream. Most women have no generalized symptoms from the hormone.
But isn’t this an Intrauterine Device (IUD)? Aren’t IUDs dangerous? Well, one IUD—the Dalkon Shield—was a disaster. Many years ago it was rushed to market before they had sufficient time to test it well. It made women vulnerable to serious infections, and some became infertile from the Dalkon Shield.
Two IUDs are now available in the United States, and both are amazingly safe. A woman who is in a mutually monogamous relationship is the best candidate for an IUD. Furthermore, IUDs work best for women who have given birth, since pregnancy stretches the uterus a bit. A potential user should be well informed about IUDs, and she should learn how to check that it is in the proper position. The device must be inserted skillfully by a qualified doctor or nurse.
How does Mirena® function? The levonorgestrel makes it more effective than other IUDs. Because the hormone causes the uterine muscle to relax, it also decreases cramps. The hormone prevents pregnancy in at least two ways. The principal way that it works is that it makes cervical mucus thick and sticky so that sperm cannot pass through. It also thins out the lining of the uterus. If a sperm got past the inhospitable cervical mucus and an egg did get fertilized, it would be unlikely to implant. This thinning effect also makes bleeding lighter or stops it completely.
One way of looking at Mirena® is that it is a means of getting the hormone where it can work most effectively. Because the hormone is released inside the target organ, only a tiny amount is needed, and side effects are minimized. One advantage of any IUD is that the user is constantly protected against pregnancy without having to do anything on a regular basis.
Levonorgestrel can cause a few annoying side effects. Certain women complain of increased acne or headaches, and rarely they will have breast tenderness or nausea. Some women stop having periods entirely, which is normal for a Mirena® user, as long as the device is in place. Fortunately, it does not cause weight gain.
Mirena® is small and flexible, which makes it well tolerated even by women who haven’t had a baby. The other popular IUD, Paragard®, is a bit larger and stiffer. Although Paragard® lasts longer than Mirena®—ten years versus five—women do not tolerate it as well if they haven’t started their family yet. In fact, young, childless women have requested many of the Mirenas® that I have placed so far.
Mirena® is called an IntraUterine System (IUS). I think that this is a marketing ploy to distinguish it from other IUDs. It is also possible that the manufacturer is preparing to market it for other indications. In many countries it has been used to help women who suffer from excessive bleeding or bad menstrual cramps. In addition, it prevents abnormalities of the lining of the uterus (including cancer), especially in menopausal women on estrogen. Although the FDA hasn’t approved Mirena® by for noncontraceptive uses, women welcome it for help with these problems.
At last we have an IUD that has a very low failure rate, few side effects and many benefits. Mirena® has great potential to help women control their fertility and deal with other problems.
© Richard Grossman MD, 2005