Health is a key issue in the approaching U.S. elections, and the voters' choices will impact future policies both domestically and internationally. This is a critical time to think about the policies needed to improve the health of women in the U.S. and around the globe. Women's health is often compromised by discriminatory practices and policies that neglect women's needs or impede their economic and social opportunities.

Objectives: Extensive data from clinical trials document mifepristone's safety and efficacy for induced abortion, but less information is available about its safety in routine clinical use. Methods: Data on mifepristone abortion use from the Planned Parenthood Federation of America, the largest provider of mifepristone abortion in the United States, from 2001 through the first quarter of 2004 were collected using a centralized reporting system. Over the study period, 95,163 mifepristone abortions were provided. Reportable events are complications requiring inpatient or outpatient hospital treatment. Results: Overall, 2.2 per 1000 women (95% CI 1.9-2.5) experienced a complication, most commonly, heavy bleeding. Mifepristone abortion mortality is estimated to be 1.1 per 100,000 based on one death (95% CI 0.3-5.9). Conclusions: The safety of mifepristone is high; few serious medical complications occur in routine clinical use.

CONTEXT:California's Reproductive Health Privacy Act, which became law in January 2003, clarified that advanced practice clinicians could legally provide medical abortion. Little is known about the characteristics associated with nonphysician clinicians' interest in receiving medical abortion training or their perceptions of barriers to medical abortion provision.METHODS:In early 2003, a total of 1,176 licensed advanced practice clinicians in California-nurse practitioners, physician assistants and certified nurse-midwives-completed a mail-in survey assessing their personal characteristics, beliefs and clinical practices. Weighted univariate and bivariate analyses were conducted to describe the respondents, their interest in receiving medical abortion training and their perceptions of barriers to providing such care.RESULTS:One-quarter of respondents desired training in medical abortion. A higher proportion of nurse-midwives than of nurse practitioners or physician assistants desired training (42% vs. 24% and 23%, respectively). The proportion of respondents desiring training also was elevated among clinicians who have prochoice attitudes, those who are familiar with medical abortion and those who spend at least one-third of their time providing care to women of reproductive age. Lack of training opportunities, legal uncertainties and clinical facility constraints were the most frequently reported perceived barriers to provision of medical abortion.CONCLUSIONS:Considerable proportions of advanced practice clinicians-especially of nurse-midwives-may be interested in receiving medical abortion training. Perceived barriers to providing medical abortion are amenable to change. Policies and programs are needed to ensure that interested, committed clinicians can overcome barriers to providing medical abortion for their patients.

OBJECTIVES:Extensive data from clinical trials document mifepristone's safety and efficacy for induced abortion, but less information is available about its safety in routine clinical use. METHODS:Data on mifepristone abortion use from the Planned Parenthood Federation of America, the largest provider of mifepristone abortion in the United States, from 2001 through the first quarter of 2004 were collected using a centralized reporting system. Over the study period, 95,163 mifepristone abortions were provided. Reportable events are complications requiring inpatient or outpatient hospital treatment. RESULTS:Overall, 2.2 per 1000 women (95% CI 1.9-2.5) experienced a complication, most commonly, heavy bleeding. Mifepristone abortion mortality is estimated to be 1.1 per 100,000 based on one death (95% CI 0.3-5.9). CONCLUSIONS:The safety of mifepristone is high; few serious medical complications occur in routine clinical use.

In Brief Mifepristone’s approval in September 2000 gave women a new option for early pregnancy termination. In the 3 years since receiving FDA approval, mifepristone has proven to be even safer and more effective than previously demonstrated.

With record deficits, it may seem counter-intuitive to suggest that it makes sense now, more than ever, to establish full funding for family planning in the United States and internationally. There is good evidence, however, that family planning programs are not just cost-effective, but cost-saving: these programs save money in both the short- and long-term and thus remain a key priority, even in times of budget deficit. Programs to improve health, well being, and social and economic development around the globe are also important investments for long-term security and international stability. In tight financial times, however, expenditures that do not have good evidence of effectiveness—such as abstinence-only programs—are unwise and can even be harmful, particularly if they draw funding away from proven, effective measures.

As human beings, our perception and understanding of risk are heavily influenced by contextual factors, as well as by how risk is described: •Are you more likely to agree to a treatment with a 97% chance of survival, or a 3% probability of dying? •Would you take a medication that had bothersome side effects if it decreased your risk of dying in the next 5 years by 20%? What if not taking the medicine increased your risk of death by 16%? •Does a medication that lowers the risk of stroke from 5 per 1,000 people to 3 per 1,000 seem like a valuable innovation? What about a medication that is reported to reduce the risk of stroke by 40%?

Insurance coverage for contraception in the United States remains spotty. An estimated 34.5 million women need contraceptive services and supplies [ [1] Alan Guttmacher Institute. Contraception counts (2004 fact sheet). Available at: http://www.guttmacher.org/pubs/state_data/index.html. Accessed July 12, 2004. Google Scholar ]. To obtain this care, women may utilize health insurance, turn to publicly funded or subsidized services or pay out of their own pockets. Women aged 1544 years pay 68% more than men for their health care, in part because some of the reproductive health care services that only women use are frequently excluded by insurance plans [ [2] Women's Research and Education Institute Women's health insurance costs and experiences. WREI, Washington (DC)1994 Google Scholar ]. To ensure that all women have access to the contraceptive care they need, the magnitude of for contraceptives through both private health plans and public programs must be improved.

Family planning has long been acknowledged as an effective public health intervention. In recent years, however, family planning has come under increased scrutiny from conservative politicians and constituents. National US policies instituted since 2001 are resulting in cutbacks in family planning programs worldwide. In the long run, these conservative initiatives may set back several decades of progress in reproductive health and reproductive rights. In promoting an ideologically driven approach to sexual and reproductive health, the recent policy developments threaten to subvert ethical standards of medical care and the principle of evidence-based policy.

As a new year begins, it is a natural time to reflect on the past 12 months and to prepare for the next. For all of us concerned about reproductive health, 2003 was a challenging year. Current United States international reproductive health policies—such as the global gag rule—are jeopardizing the health of the world's poorest women. Domestic policies—such as the emphasis on “abstinence-only” sex education—mean that we are funding programs that lack evidence of effectiveness, and that may even be harmful. The legal basis for access to safe abortion care hangs in the balance while more and more state restrictions limit services for our most vulnerable populations. Given the current national and state budget deficits, maintaining funding for reproductive health care and research is likely to become more difficult. Furthermore, core values essential for progress in scientific research and public health are threatened by the substitution of ideological precepts in place of evidence as a basis for decision-making. Such setbacks are discouraging, but are powerful reminders about what is at stake in 2004 and what efforts are needed.

In December 2003, the U.S. Food and Drug Administration's Advisory Committee for Reproductive Health Drugs reviewed research and development of a birth control pill containing folic acid. Adequate folic acid intake prior to and early in pregnancy lowers the risk of neural tube defects in a developing fetus and may also reduce the risk for cardiac malformation [ [1] Green N. Folic acid supplementation and prevention of birth defects. J Nutr. 2002; 132: 2356S-2360S Google Scholar ]. ARHP testified to the FDA that a folic acid-oral contraceptive combination could be of benefit to women who become pregnant unintentionally while taking an oral contraceptive or shortly after discontinuing it. By bringing attention to the importance of preparations for pregnancy, the combination product will remind clinicians and women about other recommendations that can help contribute to a healthy pregnancy.

Family planning services and supplies belong on the “essential” list for national and international security. Emergency contraceptives already are on the World Health Organization (WHO) emergency list, because rape and other risks for exposure to unprotected intercourse are so common in times of catastrophe, and obstetrical risks are very high. But ordinary family planning, too, plays a vital role in the task of establishing real security. Family planning helps assure the human capital and effective social systems that are necessary for enduring strength. Family planning also is an essential ingredient for social justice in our society, and helps build the strong families and cohesive communities that are capable of mutual support in times of crisis or need.

The tangible value of research is in the application of discoveries to alleviate human suffering and to enhance our lives and well-being. Scientific institutions and training are adept at identifying and exploring the frontiers of knowledge producing a wealth of information about basic clinical and social sciences. The scientific enterprise is less effective when it comes to the critical step of translating research findings into practical use. As a result the task of understanding how new knowledge can best be applied proceeds slowly. The reciprocal task of identifying practical problems that could benefit from scientific investigation can be even slower. The result is an often lengthy delay between discovery and implementation: significant advances in medical knowledge may take over a decade to be disseminated and adopted. (excerpt)

Few of us can grasp the scope of the AIDS pandemic. Since the first diagnosis in 1981 over 20 million people have died from this disease. Almost 38 million people worldwide more than the entire population of California the most populous state in the United States are infected with HIV according to estimates by the Joint United Nations Programme on HIV/AIDS (UNAIDS). In Botswana and Swaziland one in three adults is infected. In seven sub- Saharan countries life expectancy has fallen to just 49 years. Even though the force and devastation of HIV/AIDS have long been recognized the global response to the disease and its devastation remains sluggish and inadequate. From the beginning of the epidemic the U.S. government response has been late half-hearted and far too small for the scope of the disease. In recent years efforts to address the disease have been further compromised by unfulfilled promises of funding and misguided policies and ideologies that undercut program effectiveness. (excerpt)

In the wake of warnings that researchers who study AIDS and other sexually transmitted diseases may face special scrutiny complying with instructions from staff at the National Institutes of Health (NIH) to cleanse grant application abstracts of potentially controversial terms appears a prudent course of action. After all a quick document scan and a few minor wording changes seem like harmless compromises— but are they? (excerpt)