Both birth control technology and its use are imperfect. As such, approximately 60% of all pregnancies in the US are unplanned and unintended, with almost 45% of all live births being the result of unintended pregnancy. More than 50% of unintended pregnancies and 33% of all pregnancies in the US end in abortion. That emergency postcoital contraception (EPC) is used only rarely in the US is one reason why unintended pregnancy rates are higher in that country relative to other developed countries. EPC is a method for managing unprotected coital exposure by the pharmacologic or mechanical inhibition of fertilization or implantation. Knowledge and easy access to EPC could prevent an estimated 2.3 million unintended pregnancies per year in the US and reduce the number of abortions by 800,000 annually. The author stresses the moral and professional responsibility which family planning providers have to provide their clients with postcoital contraception.
Oral contraceptives (OC) were first introduced in the US in the early 1960s as an efficient, convenient, and reversible method of contraception. The pill has since undergone many changes. Most OCs prescribed today contain 35 mcg of estrogen and 0.5-1 mg of progestin, approximately one-third the estrogen and one-tenth the progestin in the original OCs. Considerable scientific research, economic analysis, and social marketing have yielded invaluable data on how OCs, the most popular form of birth control in the US, have affected the lives of women, men, and society overall. Researchers have also investigated the health risks and benefits of OC use. Both truths and myths exist about the effects of OC use. A 1993 Gallup poll conducted for the American College of Obstetricians and Gynecologists found that 65% of patients believe oral pill use to be at least as dangerous as pregnancy. 58%, however, were unable to name one non-contraceptive benefit of the pill. A 1995 Harris poll conducted for the American Medical Association found that although 96% of reproductive-age women considered themselves to be knowledgeable or very knowledgeable about contraception, 56% incorrectly believed a woman periodically needs to give her body a rest from OC use. The authors discuss the benefits and risks of using OC.
In 1995, researchers developed a model to compare the effectiveness and economic costs per person of different contraceptive methods. The model addressed the direct medical costs of method use, adverse and beneficial side effects, and unintended pregnancies. Indirect costs, such as the price of travel to and from a clinic, or loss of productivity in case of hospitalization, were not measured. All costs were evaluated from the perspective of both a private and a public payer. The study assessed the effects of all sexually active women of reproductive age in the US using each method for periods of 1, 2, 3, 4, or 5 years. 15 methods were compared. The outcome measure calculated for each was the number of pregnancies avoided, defined as the difference between the number expected to occur with no method and the number expected to occur using that method. The use of any of the evaluated methods proved to be more effective and less costly than using no method at all.
Women need accurate information about the various forms of contraception from which they may choose. Findings from four recent national telephone surveys conducted among reproductive-age women in the US since 1993, however, indicate that women in the US are not well informed or are misinformed about oral and other forms of contraception. Brief summaries are presented of the following surveys: the 1993 Gallup Organization follow-up survey conducted for the American College of Obstetricians and Gynecologists of 995 women's views on contraception, the 1995 Lou Harris and Associates telephone poll conducted for the American Medical Association of US women's attitudes and perceptions about reproductive health matters, the January 1996 Kaiser Family Foundation survey of 279 women's perceptions about contraception, and the Health Benefits of Contraception, ARHP survey of 280 women. The second part of this latter survey will be completed later in 1996. The common theme in the four surveys is that women do not have enough accurate information about contraception. Reproductive health professionals need to take advantage of every opportunity to provide such information, correct misperceptions, improve their counseling skills, and spread the word about the health benefits of contraception.
The Association of Reproductive Health Professionals (ARHP) has available a multimedia educational program informing physicians, nurse practitioners, clinical staff, and patients about Depo-Provera. It is called "New Developments in Contraception: Depo-Provera". The Upjohn company partially funded the program. It consists of 4 videotapes, 2 brochures, and a reference book on clinical proceedings. "DMPA: A New Contraceptive Option" is an 18-minute videotape giving an overview of Depo-Provera for physicians and nurse practitioners. It addresses pharmokinetics, efficacy, safety, side effects, patient selection, administration, and medical management of medroxyprogesterone acetate. "DMPA: Patient Counseling and Clinical Staff Procedures" is a 15-minute video including patient counseling scenarios and discussion of usual patient questions. Clients can view the "Choosing a Birth Control Method" video to get a balanced overview of 5 reversible contraceptives. It provides graphics, discussions between patients and providers, and patients' comments on their experiences with the various methods. The fourth video is a Spanish language version of the "Choosing a Birth Control Method" video. One brochure complements the "Choosing a Birth control Method" video; the other one "Questions and Answers About Birth Control Shots", centers on Depo-Provera. ARHP plans to distribute 55,000 copies of its multimedia educational program to health care professionals and to family planning and Planned Parenthood clinics in the US. This program advances and rounds out ARHP'S National Program to Prevent Unintended Pregnancy.
The Association of Reproductive Health Professionals (ARHP) has developed a National Program to Prevent Unintended Pregnancy. A multisectoral group of 100 people attended ARHP's April 1993 consensus conference to come up with strategies to reduce unwanted pregnancies in the US. Participants agreed that health care professionals are the key in achieving this goal, but all sectors of society are needed for a integrated approach. ARHP would begin by motivating and educating health practitioners, especially nurses, physicians, and primary care givers. It would eventually like to be in a position to expand its efforts to the mass media, religious groups, schools, and community groups. ARHP's strategy is to build a working coalition of health professional associations to boost awareness of and support for the program. The second strategy includes individual health professionals increasing their own familiarity with the program and their opportunities to actively participate in prevention of unwanted pregnancy. A speaker's bureau would be part of this strategy. The third strategy involves ARHP developing a continuing medical education program on preventing unintended pregnancy. It envisions a core curriculum on contraception, family planning counseling, quality reproductive care, and sexually transmitted disease prevention using videos, print materials, and a curriculum guide. Increasing the availability of quality patient education materials which would strengthen practitioners' counseling encompasses the fourth strategy. The final strategy consists in development of undergraduate and graduate education curricula in reproductive health, including health behaviors. ARHP encourages its members to become involved to make this program a success.
With the reforms expected for US health care, the question remains as to the impact on family planning services. Although the focus is on health care finance reform, the mix of patients seen, the incentives for decision making, and the interactions between health care providers will change. Definition of key concepts is provided for universal access, managed competition, and managed care. The position of the obstetrician/gynecologist (Ob/Gyn) does not fit well within the scheme for managed health care, because Ob/Gyns are both primary care providers and specialists in women's health care. Most managed health care systems presently consider Ob/Gyn to be a specialty. Public family planning clinics, which have a client constituency of primarily uninsured women, may have to compete with traditional private sector providers. "Ambulatory health care providers" have developed a reputation for high quality, cost effective preventive health care services; this record should place providers with a range of services in a successful position. Family planning providers in a managed competition system will be at a disadvantage. 3 scenarios possible under managed competition are identified as the best case, out of the mainstream, and most likely. The best case is when primary reproductive health care services, contraception, sexually transmitted disease screening and management, and preventive services are all obtained directly from reproductive health care providers. Under managed care, this means allowing for an additional entry gatekeeper to specialized services. The benefits are to clients who prefer seeing reproductive health care providers first; reproductive services would be separated from medical services. The out of the mainstream scenario would place contraceptive services and other preventive services as outside the mandated benefits. The government would still provide Title X type programs for the indigent. The most likely scenario is one where primary care providers offer contraceptive services, and some family planning providers would expand their services to include nonreproductive health care. Abortion services are presently out of the health care mainstream, and efforts will need to be made to identify impact on reproductive and family planning practices and to advocate for specific provisions in health care reform.
The artificial dichotomy between family planning services and sexually transmitted disease (STD) treatment and control has been broken by the addition of HIV to the list of STDs. Now health care workers must operate in terms of reproductive health, educating clients about both pregnancy prevention and disease prevention, including men in the loop, and securing funds for this new focus. The continuing failures of the health care profession include the facts that 1) there is no vaccine or cure for HIV, 2) women have been neglected in HIV/AIDS research, 3) women have not been helped to protect themselves (we are just beginning to develop female-control barriers and virucides). The 1992 International AIDS conference was the first session that included information on intravaginal STD/HIV prevention technology controllable by women. The only way to affect immediate changes is to continue the education of health care providers and patients. In order to do this, health care providers must broaden their thinking about behavior and prevention.
Relevant research efforts in male contraception involve: 1) hormonal approaches to block sperm production by inhibiting the hypothalamic-pituitary-gonadal axis, 2) disruption of sperm production by drugs that act directly on the testes, 3) interruption of sperm transport, and 4) alteration of secretions of the accessory sex glands and their subsequent effect on the spermatozoa. Both agonistic and antagonistic synthetic analogs of the hypothalamic gonadotropin releasing hormone (GnRH) factor cost too much and lack an effective mode of administration. Recent studies indicate that over 90% of Chinese and Indonesian men can develop complete azoospermia following either a testosterone or a progestin and an androgen combination treatment. Vaccines that utilize GnRH and follicle stimulating hormone as the active antigens have been introduced in clinical studies in the US and India. Drugs such as sulfasalazine, pyrimethamine, nitrofurane, and bis(di-chloracytal) diamines reduce male fertility but side effects make them unacceptable. Dinitropyrroles, halopropanedils, chlorosugars, and indazole carboxylic acids have been tried in laboratory animals. Gossypol rendered men infertile in large-scale clinical studies conducted in China but synthesis of safer analogs has not succeeded. Extracts of another plant, tripterigium wilfordii, are used in China as a popular herbal medicine. Vasectomy has improved with no-scalpel vasectomy and by the novel technique of blocking the vas with cured in situ polymeric plugs. Preliminary data suggest that men prefer condoms made from polyurethane as opposed to latex rubber increasingly used to protect against AIDs and sexually transmitted diseases. The antifungal agents, imidazoles, have spermicidal activity and synthetic variants may reduce undesirable side effects. Research on male-oriented methods has intensified during the last 10-15 years, but a new product is not likely to appear in the next 5-10 years.
In Washington, D.C. adolescents are infected with about 1/3 of all sexually transmitted diseases, and the incidence of congenital syphilis is mounting. The District of Columbia had a reported AIDS infection rate of 132.5/100,000 residents between July 1991 and June 1992 compared with 44.8 in New York. A total of 6613 cases were reported of which 6523 afflicted adults and adolescents. Only San Francisco had more cases with 12,402 cases of adults and adolescents reported. The District of Columbia's 1991 Youth Risk Behavior Survey disclosed that 78.8% of the 1275 adolescents in grades 9 and 10 had experienced sexual intercourse, and 38.8% of these were 13 years old or younger at 1st coitus. 33% of responders had had sex with 6 or more people. .53% of adolescent military recruits from the District had HIV infection, the highest rate in the nation. The District of Columbia Public Schools (DCPS) started an AIDS education program in 1987 for grades 4-12 with support from the Centers for Disease Control. During 1987-92 a 5-year HIV/AIDS Education program's activities involved formal training for all teachers; awareness seminars for school counselors and instructors; evaluation of teachers trained; student assessment of classroom training; DCPS Advisory Board with medical specialists, AIDS educators, and AIDS victims; coalition building with more than 20 organizations in the city; and distribution of literature to the 174 schools in the system. The program resulted in significant improvement in HIV/AIDS awareness at all 3 school levels, although it was more effective with elementary students and it made the least impact on senior high school students, especially on boys. Girls in junior high school showed improvement in knowledge, attitudes, and behavior concerning HIV/AIDS than boys. Future educational efforts should concentrate more on boys both in junior and senior high school.
The Association of Reproductive Health Professional (ARHP) sponsored a National Conference on Unintended Pregnancy in April 1992 to plan a Campaign for 1993. Ideas had been solicited in 1991 and early 1992. Foundation, the pharmaceutical industry, and government agency representatives attended. Presentations were given and are summarized in this article on the nature and extent of the problem, the role of medicine and politics and the media in unwanted pregnancy, the effect of religion on sexual behavior, sexuality education, new contraceptive technology, and communications and resources. A representative of the Alan Guttmacher Institute (AGI) noted among other things the 53% of unintended pregnancies occur to 10% of women not using contraception and 82% of teenage pregnancy is unintended. There is a worsening climate for dealing with reproductive issues. There is less money for family planning (FP) and clinics. Sexual responsibility is different for men versus women. The tag of being good also needs to be identified with women who choose sexual responsibility and avoid unintended pregnancy. Human sexuality needs to be taught at the earliest of ages and more time needs to be spent on providing young people with the tools to properly use the information given. There is insufficient access to medical services and information. Messages need to be targeted better to specific audiences. Many health professionals are uninvolved in the political problems. The concern about overturning Roe v. Wade and the Gag Rule has helped to activate health professionals. Physicians need to promote positive images of women and their bodily functions. Education of the medical and health professions is a top priority. Supportive services for the new mother and income loss are disincentives for childbearing. The media have not portrayed a positive female image. Sex sells. Religion can play a positive role in portraying responsible sexual behavior, supporting contraceptive research, encouraging the government to be more supportive of women and children, and providing greater participation in family planning efforts. A systematic critique of patriarchy within the Church is needed in order to be consistent with teaching about human sexuality. Sin and guilt are powerful words. More and better contraceptives are needed and new products promoted. The level of awareness of the problem should not be confused with commercial advertising. The message is it is possible to have every child a wanted one.
Long-acting steroid contraceptive technologies that have either been recently approved or are currently under study are reviewed and the status of contraceptive research in the US is noted. The benefits and drawbacks, as well as the duration and possible cost, of each method are discussed. Approved by the Food and Drug Administration on December 10, 1990, Norplant is reportedly the first new contraceptive technology available to women in the US since the 1960s. This implant delivery system, which lasts up to 5 years, is cheaper than the pill and nearly as effective as sterilization. Study is currently under way on other multiyear, nonbiodegradable and biodegradable implants. Although already used by 4 million women worldwide, the long-acting injectable Depo-Provera has yet to be approved for use in the US. 5 new types of injectables are being developed. Steroid-containing IUDs have been in the market for some time, and current research is attempting to increase their contraceptive life beyond 1 year. Contraceptive developers are also exploring transdermal delivery systems, vaginal rings, and buccal and sublingual delivery. It is considered misleading to call Norplant the first new contraceptive introduced since the pill. Over the past 20 years, virtually every contraceptive has been significantly improved, developments that have enhanced the contraceptive options of couples. Because new contraceptive technologies are increasingly complex, their development is much slower. Consequently, it is concluded that in the foreseeable future, the demand for more acceptable contraceptives will be met through improvements of currently available technologies.
