COMMENTARY

October 2002: 30 Years After "The Joy of Sex" -- Unintended Pregnancy in the United States

Ursula Snyder, PhD

Disclosures

October 09, 2002

Introduction

The United States has the unfortunate distinction among industrialized nations of being the one with the highest rate of unintended pregnancy. The most recent data we have is from 1994: Nearly half (49%) of all the 6 million pregnancies that year were unintended, and half of those were terminated by induced abortion.[1]

Although a recent study from the Centers for Disease Control and Prevention indicates a rise over the past decade in the number of adolescents who are virgins and an increase in contraceptive use among sexually active teens,[2] the United States also has the highest adolescent pregnancy rates among western industrialized nations, with about 900,000 pregnancies each year. The vast majority of these are unintended and about a third are terminated by induced abortion.[3] Compared with adolescents in Canada, France, Great Britain, and Sweden, adolescents in the United States at all socioeconomic levels have lower levels of contraceptive use and higher rates of abortion.[4]

The socioeconomic cost of adolescent pregnancy is significant and sad. The long-term prospects for a productive life are much lower, especially for the youngest mothers, and even for young mothers who come from backgrounds of higher socioeconomic status. Adolescent mothers have much lower prospects for education and employment; they have a higher risk of becoming heads of single-parent households and being dependent on social welfare. They also have shorter interpregnancy intervals.[4,5]

The widespread availability of hormonal emergency contraception could prevent an estimated 2 million unintended pregnancies and 1 million abortions each year in the United States.[6] Women in Albania, Belgium, Denmark, Finland, Israel, Morocco, Norway, Portugal, South Africa, Sweden, the United Kingdom, and parts of Canada can obtain emergency contraception over-the-counter (OTC) without prescription.[7] Not so in the United States, except in California and Washington, where it is not available OTC but pharmacists can dispense it without a prescription. The US Food and Drug Administration seems not to be able to take on the project, despite a petition last year from more than 70 organizations requesting that hormonal emergency contraception be made available OTC. However, as Medscape Ob/Gyn & Women's Health board member David A. Grimes, MD, points out in an important editorial in The New England Journal of Medicine, during the past 30 years, the FDA has managed to approve the switch of more than 700 prescription products to OTC status.[7] In a "Newsmaker Interview" with Medscape, Dr. Grimes remarks

"I don't know why there has been such a delay by the FDA in granting OTC status to EC, but an editorial in a Florida newspaper... suggests that abortion politics have stalled it, and that the present administration is squeamish about all issues that have anything to do with sex."

Given that women must still go to their physicians to get prescriptions for hormonal emergency contraception, it is imperative that women and physicians know what is available and how to use it. According to a New York Times story published last year, only 1 in 5 gynecologists told their patients about emergency contraception in advance of any need. On Medscape, you can find 2 recent highly informative articles on emergency contraception by Sanders Wanner and her colleagues and by Ellertson and her colleagues.

Decreasing the incidence of unintended pregnancy can be assisted of course by clinicians working with patients to help them choose contraception that is individually appropriate. The annual meeting of the Association of Reproductive Health Professionals in Denver, Colorado, a few weeks ago provided attendees with a basic review of what's new in contraception and medical abortion, and we just published a report from that meeting. Also on Medscape, you can find a review of ultra low-dose hormonal contraception, and new studies on contraception are often covered in our Reproductive Endocrinology and Obstetrics/Gynecology Journal Scans. The Cochrane Review Abstracts are also a valuable source of evidence-based evaluations of contraceptives. For example, a recent Cochrane review evaluates hormonally impregnated intrauterine systems vs other forms of reversible contraceptives as effective methods of preventing pregnancy.

It is well established that for most healthy women who do not smoke, the benefits of oral contraceptives outweigh any risks. In the wake of the findings of the cardiovascular and breast cancer risk of hormone therapy in postmenopausal women, recent data from the Women's Contraceptive and Reproductive Experiences is reassuring.[8] The CARE study found no association between past or present use of oral contraceptives and breast cancer. In women with a history of breast and ovarian cancer, however, there is conflicting evidence about the safety of oral contraceptives, and this is discussed in a recent article from Medscape's eJournal MedGenMed. In Medscape Women's Health eJournal, the cardiovascular risks of hormonal contraceptives were recently reviewed by Medscape Ob/Gyn & Women's Health board member Peter Kovacs, MD. Risks of oral contraceptives are also discussed in an article by well-known contraceptive researchers Crenin and Pymar from the University of Pittsburgh School of Medicine and Magee-Women's Research Institute.

Another recent article of interest is "Oral Contraceptive Use and Association With Glucose, Insulin, and Diabetes in Young Adult Women: The CARDIA Study." The results of this study suggest that current oral contraceptive use may reduce the risk of diabetes in young African-American and white women. Finally, two recent studies add to the evidence that oral contraceptives reduce the risk of ovarian cancer [9] and can be used successfully to treat acne.[10]

The emergency contraceptive and abortifacient mifepristone was approved in the United States in November 2000 for use only as an abortifacient. Paul Blumenthal, MD, MPH, Editor of Medscape Women's Health eJournal and colleagues marked the approval of mifepristone and the first-year anniversary in 2 editorials published in Medscape Women's Health eJournal. On this 2nd year of its availability, however, a recent New York Times story reports that use of medical abortion is still low.[11] About 2.6 million women in the United States had abortions since the drug was available; on the order of 100,000 used mifepristone. On the basis of experience in other countries, however, a slow start is to be expected. A report from the Alan Guttmacher Institute indicates that although more than half of the early abortions in France (56%), Scotland (61%), and Sweden (51%) are now done with pills rather than surgery, it took 10 years to reach this level.[12] However, the United States may never achieve this level.

It seems that access to abortion -- medical or surgical -- may be threatened. On September 25, 2002, the US House of Representatives passed the Abortion Nondiscrimination Act, which allows any health entity, including health plans and hospitals, to decline to offer or cover abortion services without being penalized by any state or federal program. Clearly, this is going to limit women's access to abortion if the bill passes in the Senate. Moreover, 2 days later, the US Department of Health and Human Services finalized a rule defining fetuses and embryos as "unborn children" for the purpose of providing prenatal healthcare coverage to low-income pregnant women. As one women's advocacy group, National Partnership for Women and Families, suggests, the current administration may be using the bill to push an agenda to make abortion illegal:

"Comprehensive prenatal care is the ingle best way to protect the health of a fetus, and that goal is best achieved by providing health care to pregnant women -- not just their fetuses. Yet today, the Bush Administration approved a sham policy that makes fetuses eligible for the State Children's Health Insurance Program (SCHIP). The policy also indicates that the fetuses of immigrant women would be eligible for coverage. This is not a victory for pregnant women or immigrants, as the Administration claims. The policy's true goal is to make a statement about the legal status of fetuses and undermine women's legal right to reproductive choice.

This policy may look good on its face, but at its heart it is both antichoice and anti-immigrant. It fails to provide comprehensive coverage for pregnant women, instead only providing coverage for the fetus. Pregnant women may not be covered for ailments unrelated to the fetus' needs, and they would be left without critical coverage after the child is born. In fact, the rule states that postpartum care cannot be covered with SCHIP funds."[13]

That federal coverage is not extended to the mother is extraordinarily disturbing. As pointed out in my first column of this series, maternal poor physical health has strong associations with children's physical health and behavior problems. In this country, about 42.5 million people are without health insurance, including 20 million women and 5 million girls.[14] And the number of people with private health insurance fell in 2001 and the first quarter of 2002.[15] About 40 million people are covered through Medicaid and SCHIP, and many of those who lost their private insurance last year were enrolled in these programs. However, no new funds are going into SCHIP with the passing of this legislation, and with the economic downturn, those women (of all ages) and children that are covered by these programs risk losing this insurance because some states are considering cuts.[15] In fact, it has already been happening in Oklahoma: cuts in these programs will result in approximately 80,000 low-income people in Oklahoma losing healthcare coverage.[15]

One should also remember that even the many women who do have private insurance still do not have access to affordable, effective, reversible contraception. A study by the Allan Guttmacher Institute in 1994 showed that about half of fee-for-service health insurance plans do not cover any reversible contraception (as opposed to female sterilization), and only 15% cover the 5 most common prescription methods (oral contraceptives, diaphragms, DepoProvera, intrauterine devices, and Norplant). Furthermore, whereas 97% cover prescription drugs, only 33% cover the oral contraceptives.[16] Coverage for contraceptives is currently determined on a state-by-state basis; only 20 states have passed contraceptive legislation. National legislation is needed, but the US Government will not pass the Equity in Prescription Insurance and Contraceptive Coverage Act. This legislation has been introduced 3 times so far -- in 1997, 1999, and 2001. Obviously, passing this act would increase access to contraception and lower the rate of unintended pregnancies and abortions. Senator Harry Reid (D-NV), who reintroduced the bill in 2001, suggested that one of the reasons the bill has not progressed is because some Senators believe some forms of contraception are tantamount to abortion.[17] Such lack of knowledge by people in positions of power is not beneficial for women.

Dr. Alex Comfort, author of The Joy of Sex, believed that ignorance about sex made people's lives miserable.[18] As the Allan Guttmacher Institute report concludes:

Many in the United States give little support to young people as they establish sexual relationships. They consider adolescents to be developmentally incapable of making good judgements about their own behavior and of using contraceptives and condoms, effectively... Where young people receive social support, full information and positive messages about sexuality and sexual relationships, and have easy access to sexual and reproductive health services, they achieve healthier outcomes and lower rates of pregnancy, birth, abortion, and STDs.[4]

Lack of education about sex and contraception, lack of easy access to contraception, unintended pregnancy, abortion, lack of easy access to abortion, unwanted children, and unhealthy mothers make for profound misery in the United States. It makes difficult work for the country's obstetrician/gynecologists. I fear it will get worse.

Comments or concerns are welcome. Please send them to womenshealtheditor@webmd.net. If your concern is technical, however, please contact our customer support staff at medscapecustomersupport@webmd.net).

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