Refocus the Media’s Concern about Births

Teen Birth Rates

U.S. birth rates are declining. This trend is cause for concern, because an aging population puts a strain on the economy.” Kimberly Amadeo, in “The Balance”, 4/29/2021

            The CDC reported that the birth rate in the USA dropped in 2020, with much lamentation in the press. Instead, we should be applauding this decrease in births, especially among one group of people.

            The general fertility rate (the number of live births each year, per 1000 women aged 15 to 44) has been decreasing since a small peak in 2014. In 2019 it was 58.3, and in 2020 it dropped to 55.8. Not a huge decline, but newsworthy. Please note that this is the number of births, not the number of babies born. The number of babies is actually about 3% higher because of twins, triplets etc.

            Did people decide to postpone childbearing because of covid-19? Due to the timing of the births in 2020, we can figure that most of the conceptions actually happened before the pandemic. Births were down most sharply at the end of the year, however, when babies conceived at the start of the pandemic would have been born. Very preliminary information suggests that the birth rate for 2021 will show a slight rise. That figure may increase as the year goes on since September is the month when the most babies are born.

Recently, many women are waiting to start their families. I am the second and last child of my parents. My parents married in 1928 and my sister Clara was born in 1939. I was born 4 years later, when my mother was 40 years old. This was an unusual pattern of childbearing in the 1940s but is much more common now as women are entering the workforce and postpone childbearing.

The birth rate of women in the 40-to-44-year cohort has been rising 3% each year for the past 35 years. The oldest women I helped give birth was Sarah, who was 52 when she delivered her second child. Her history is unusual. She retired from a professional career and then married for the first time. Despite being postmenopausal, modern reproductive technology allowed her to bear and raise 2 healthy children.

Several countries offer financial incentives for childbearing. The USA has tax breaks to help parents with the financial expenses of raising children. However, incentives are not very effective in motivating people when it comes to family size. 

Unfortunately, the media have not focused on the good demographic news. With fewer births we can expect eventually to have less impact on our environment, including slowing of climate chaos. With smaller families, each child benefits from more time with their parents and more financial resources. The best part of the CDC’s report is the number of babies born to teens. That rate has been declining much faster than the overall births. We in Colorado can be especially proud of this decline since we have been one of the leaders in the country.

Our teen birth rate declined 76% between 1991 and 2019! Free contraception for uninsured women, paid for by a large grant starting in 2009, helped this decrease. For example, one morning I inserted 6 IUDs as a volunteer at the public health clinic; the women paid nothing. Although started by the Susan Thompson Buffett Foundation, this wonderful program was continued with private and state funds. The impact on the abortion rate was noted immediately, with a steep downturn starting in 2009. Who knows how many unplanned pregnancies were prevented, and how many young women’s lives were improved by that generosity!

 Other programs have also helped to keep the teen pregnancy rate low in Colorado. Pharmacists are allowed to prescribe birth control pills, allowing healthy young women to get started on effective contraception easily and inexpensively. Furthermore, “Obamacare”, will pay for reliable contraception for people who meet eligibility standards.

It is fortunate for many reasons that people are choosing to have fewer children. Sadly, the media stressed the short-term economic problems this downturn may cause.

© Richard Grossman MD, 2021


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