Monday, August 31, 2015

Some Good News About Family Planning, and Some Bad News

The U.S. has one of the highest rates of teenage pregnancy in the developed world, with more than 600,000 teens becoming pregnant each year.  Recent efforts to make contraception available, accessible and cost-free have made progress.  A program launched by Washington University School of Medicine in St. Louis, Contraceptive CHOICE, enrolled over 1400 girls ages 14-19 who were sexually active, and followed them from 2007-2011.  Teens were told about all methods of family planning, and instructed that long-acting reversible methods were the most effective.  These methods were contraceptive implants, chosen most often by younger teens, and IUDs, preferred by teens ages 17-19.  The program was free of charge.  Findings were that the teenage pregnancy rate among girls in the study was 34/1000 teens, compared to 159/1000 teens nationally.  The abortion rate of girls in the study was 9.7/ 1000 teens, compared to 41.5/1000 nationally. 

Despite the success of the CHOICE program, there is hesitancy on the part of some parents and family planning providers, who fear that greater access to more effective contraception will encourage young people to have sex.  Similar fears exist with respect to sex education in schools.  Many studies have shown that this is not true.  Other fears are based on the belief that long acting contraception such as IUDs and hormonal implants will cause infertility, which is also not shown to be the case.  In the current political climate in the US, finding federal funding for family planning will be difficult.  Private foundations funded the St Louis project.   However, since contraception is provided free of charge in Obamacare, regional efforts to prevent teenage pregnancy with long-acting, reversible methods are underway. Family planning clinicians will need training for insertion and removal of contraceptive implants in the upper arm.

Legal Abortion in Latin America
 Cuba, Puerto Rico and Guyana allow abortion upon request.   Many Caribbean countries have liberal policies. Since 2008, first trimester abortions have been legal in Mexico City, where they are provided free of charge at public health centers and hospitals.  Abortions are also available for a fee from private clinics.  However, some Mexican states still have very restrictive laws and have jailed women for seeking or obtaining abortions. According to the United Nations, more than 500,000 Mexican women seek illegal abortions every year, with more than 2000 dying from unsafe procedures. Poverty and difficulty in getting to Mexico City plays a role in this situation.    Uruguay legalized abortion in 2012.  Prior to legalization, the punishment for having an abortion was 3-12 months in prison, while performing an abortion could lead to 6-24 months in prison.  The new law, passed in 2012, legalizes abortion within the first 12 weeks, provided it is discussed with a panel of social workers and doctors, who will advise the woman on risks.  The woman must then wait 5 days to ponder her options, and the last word is hers.  The procedure is paid for by the country’s universal health care.
Colombia has also made abortion legal under certain circumstances – rape, incest, mental health of the woman, and serious fetal malformations, but the procedure is very difficult to obtain and most women still go the illegal route in that country.  Latin America is home to 5 of the 7 countries in the world where abortion is banned in all instances, even when the life of the mother is at risk: Chile, Nicaragua, El Salvador, Honduras and the Dominican Republic.  (The 2 countries outside Latin America are the Vatican City and Malta. )

Currently, in the U.S., many states are passing or planning to pass laws restricting access to abortion.  Planned Parenthood is under attack for accepting money for the costs of providing fetal tissue to universities for stem cell research, and may completely lose its funding from Congress. This makes up about 40% of its yearly income. It should be noted that federal funding for Planned Parenthood is not for abortion care but for contraception, and testing for sexually transmitted diseases and breast and cervical cancer.  What will happen as a result of this is the subject for another article.  Look for a substantial increase in the use of  misoprostol  for do-it-yourself abortions. While this method is much safer than the coat-hanger abortions of the past, it is a tragic and infuriating development in the land of the free.
Sadja Greenwood, MD, MPH  past issues on this blog



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