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Obstacles to Abortion and Comprehensive Reproductive Health Care

Obstacles to Abortion and Comprehensive Reproductive Health Care. Martin Donohoe, MD, FACP. Fertility. Without contraception, the chance for a successful pregnancy is: 25% within the first month 85% by the end of the first year. Contraception in the United States.

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Obstacles to Abortion and Comprehensive Reproductive Health Care

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  1. Obstacles to Abortion and Comprehensive Reproductive Health Care Martin Donohoe, MD, FACP

  2. Fertility • Without contraception, the chance for a successful pregnancy is: • 25% within the first month • 85% by the end of the first year

  3. Contraception in the United States • Whether they are married or not, 79% of women are sexually active by their early 20s • 75% of Evangelicals • 86% of mainline Protestants • 89% of Catholics

  4. Contraception in the United States • 99% of U.S. women have used birth control (89% of Catholic women, 90% of mainline Protestants, and 81% of Evangelicals who are not currently trying to conceive use birth control) • 68%, 73%, and 74%, respectively, use hormonal methods, the IUD, or sterilization

  5. Abortion in the U.S. • 30 million women have had abortions since legalization (1973) • 3 million unintended pregnancies per year in the U.S. • 1.2 million abortions in 2008 (↓ from 1.6 million in 1990, ↓27% since 1980)

  6. Abortion in the U.S. • 20 abortions/1,000 fertile women/year • Lowest rate since 1974 • 9/10 abortions are in first 12 weeks • 9/10 abortions surgical • 236 induced abortions/1,000 live births • Over 1/3 decline since early 1980s

  7. Abortion in the U.S. • 49% of all pregnancies are unintended, including more than 30% within marriage • 80% of teen pregnancies unintended • Teen pregnancy has decreased 44% since 1991 • But is still higher than in many other developed countries • IUD insertion post abortion is the best reversible method of contraception to prevent another unintended pregnancy

  8. Abortion in the U.S. • Patients: • 48% over age 25 • 14% married (67% never married) • 56% have children • 43% Protestant, 27% Catholic, 8% other, 22% no religion • Catholics, mainline Protestants, and Evangelicals all have similarly high rates of contraceptive use (compared with other religions)

  9. Abortion in the U.S. • Patients: • 59% white • African-Americans and Hispanics more likely to have abortions than Caucasians, in part due to: • Higher levels of poverty • Higher rates of unintended pregnancy • Greater proportion of conceptions that end in abortion

  10. Most Important Reason Given for Terminating an Unwanted Pregnancy • Inadequate finances - 21% • Not ready for responsibility - 21% • Woman’s life would be changed too much - 16% • Problems with relationship; unmarried - 12% • Too young; not mature enough - 11%

  11. Most Important Reason Given for Terminating an Unwanted Pregnancy • Children are grown; woman has all she wants - 8% • Fetus has possible health problem - 3% • Woman has health problem - 3% • Pregnancy caused by rape, incest - 1% • Other - 4% • Average number of reasons given = 3.7

  12. Abortion in the U.S. • When abortion was illegal, 1 million were still performed annually • By age 45, the average female will have had 1.4 unintended pregnancies • By age 45, 35% of US women will have had an induced abortion

  13. Abortion in the U.S. • 54% of women with unintended pregnancies get pregnant while using birth control • Optimum one year contraceptive failure rates: • periodic abstinence -21% • OCPs – 7% • IUD - 1-2%

  14. Abortion in the U.S.:Public Opinion Split • 2009: 42% consider themselves more “pro-choice,” 51% more “pro-life” (was 44%/50% in 2008) • Men 46% pro-choice, women 51% pro-choice • 2010: 45% pro-choice, 47% pro-life • 2010: Abortion should be “generally available” (36%), “available under strict limits” (39%), “not permitted” (2%)

  15. Abortion in the U.S.:Politics Republicans less supportive than Democrats 25-30% of members of both parties would not vote for a candidate who did not share their views on abortion

  16. Abortion in the U.S.:Public Opinion • 25-30% of American women think abortion should be legal and available in all circumstances • 17-19% think abortion should be illegal under all circumstances • The remainder would restrict abortion to cases of rape, incest, or to save a woman’s life

  17. Abortion in the U.S.:Public Opinion • Top priorities for the women’s movement • Reducing domestic violence and sexual assault 92% • Equal pay for equal work 90% • Keeping abortion legal 41% • 2/3 believe the Supreme Court will not overturn Roe v Wade • Center for the Advancement of Women surveys, 2001-2003 • Are we taking Roe v Wade for granted?

  18. Abortion Worldwide • 44 million/year • 23 million unsafe (98% of these in developing countries) • Cost of treating women for complications of botched abortions = $19 million/yr (vs. $4.8 million to provide contraception) • Countries with more liberal abortion laws have lower abortion rates

  19. Abortion Worldwide • 70,000 annual deaths (7/hour) • 13% of all maternal deaths (i.e., 13% of 585,000) each year • 1/4 - 1/2 of maternal deaths in Latin America • 5 million hospitalizations annually • 30 infections/injuries for every one abortion death

  20. Abortion Worldwide • 220,000 children orphaned each year by poorly performed abortions • Legal restrictions have no effect on abortion incidence • Use of mid-level providers can decrease complications and deaths

  21. Maternal Mortality • 1/2100 in U.S. • 3X higher in black than white women • 1/31 in sub-Saharan Africa • Cause: Lack of access to comprehensive reproductive health care/obstetrical care

  22. Common Grounds on Which Abortion is Permitted Worldwide • To save woman’s life – 98% • To preserve physical health – 63% • To preserve mental health – 62% • Rape or incest – 43% • Fetal impairment – 39% • Economic or social reasons – 33% • On request – 27%

  23. Worldwide, every minute • 380 women become pregnant • 190 women face unplanned or unwanted pregnancies • 110 women experience pregnancy-related complications • 40 women have unsafe abortions • 1 woman dies

  24. Historical and Contemporary Methods of Unsafe Abortion • Many used for millennia • Examples: • Toxic solutions taken orally or intra-vaginally: e.g., turpentine, bleach, mercury, acid, detergents, etc. • Uterine stimulant drugs • Foreign bodies placed in the cervix/uterus – e.g., sticks, wires, coat hangers, air blown from pump • Direct/indirect trauma

  25. Teenage Sexual Activity • 46% of teenage boys and girls are sexually active (decreasing) • Contraception use among teens increasing • 80% condom with first intercourse • 16% in combination with hormonal method

  26. Barriers to Abortion:Misconceptions about Sex and Contraception • Common among adolescents and physicians • 40% of children age 13-17 who had intercourse did so before any parental discussion of STDs and birth control • Duration of oral contraceptive use not a factor

  27. Barriers to Abortion:Misconceptions about Sex and Contraception 20% of 18-29 yr olds say they never had school-based sex education 63% acknowledge “little to no knowledge” about contraception pills 30% for condoms 28% of men think wearing two condoms at once better (actually promotes condom breakage) - National Campaign to Prevent Teen Pregnancy, 2009

  28. Common misconceptions about OCPs • They cause weight gain (reality = 30% gain 1-2kg from fluid retention) • They cause acne and hirsutism (reality = less acne, no hirsutism) • They cause breast cancer (reality = minimal, if any, effect) • They impair future reproduction (reality = not true)

  29. Common misconceptions about OCPs: Lack of awareness of benefits re … • Decreased risk of ovarian and endometrial cancer • Regulation of cycles, prevention of dysmenorrhea and iron deficiency anemia • Decreased prevalence of PID and ensuing salpingitis and infertility • Increased bone density

  30. Barriers to Abortion:Availability of Contraception • Limited access to health care and lack of coverage • Only 27 states require health insurance policies that cover other prescription drugs to include contraceptives • Until recently, Oregon Medicaid covered Viagra but not oral contraceptives • Planned Parenthood, other sliding scale clinics

  31. Barriers to Abortion:Availability of Contraception • OTC status for OCPs would improve access, is considered safe • Would not increase sexual risk-taking behavior • IOM considers contraception preventive care

  32. Barriers to Abortion:Availability of Contraception • Equity in Prescription Insurance and Contraceptive Coverage Act • Introduced in Congress in 1997; still not passed • Would require health insurers to pay for birth control as they pay for prescription drugs • Obama plan (PPACA) requires insurers to pay full cost of contraception (including EC)

  33. Barriers to Abortion:Availability of Contraception • Savings (from averted pregnancy-related costs) for various methods of contraception, per $1 spent (2007 study): • Contraceptive implant/IUD: $7.00 • Injectable contraceptives: $5.60 • Oral contraceptives: $4.07 • Contraceptive patch: $2.99 • Vaginal ring: $2.55 • Barrier methods: $1.34

  34. Barriers to Abortion:Legal Viability • Roe vs. Wade (1973): Abortion legalized up to “point of viability” (currently 24 weeks) • After viability, states can ban abortion except when necessary to protect the woman’s life or health • Gestational limits (fetus < 500g or < 20 weeks gestational age)

  35. Barriers to Abortion:Cost • Cost: approx. $350-$450 (1st trimester); $750-$1800 (2nd trimester) • ¾ of patients pay out of pocket • only 1/3 of patients have private insurance coverage; only 1/3 of private insurance companies cover (after deductible met) • 5 states restrict abortion coverage by private insurance plans (ID, KY, MO, ND, OK) • most insured patients reluctant to file due to confidentiality concerns

  36. Barriers to Abortion:Coverage • Medicaid: • Hyde Amendment (1978) prohibits federal Medicaid dollars from being spent on abortion, except to preserve the woman’s life or in cases of rape or incest • But, 17 states allocate Medicaid funding to cover most abortions

  37. Barriers to Abortion:Coverage • Medicaid: • Between 18% and 35% of Medicaid-eligible women who would have had abortions instead continue their pregnancies if public funding is unavailable

  38. Barriers to Abortion:Coverage • Medicare: • Hyde Amendment applied to Medicare in 1998 • Bans federal funding for abortions for disabled women except in cases of life endangerment, rape, or incest • No state funding of Medicare to make up the gap

  39. Barriers to Abortion:Coverage • Title X Family Planning Clinics: • Cover women from low income households at over 4500 family planning clinics • Ethnic minority women disproportionately represented • Funding has not kept up with inflation • Prohibited from using federal and non-federal funds for all abortions • “Gag rule” – 1981 to 1993

  40. Barriers to Abortion:Coverage • Indian Health Service: • Covers 1.5 million American Indians and Alaska Natives • Subject to Hyde Amendment restrictions

  41. Barriers to Abortion:Coverage • Military Personnel: • TRICARE (funded by Defense Dept.) covers 8.3 million uniformed personnel and their families • Permanent ban on abortion except where the life of the women is endangered (Senate Armed Services Committee voted to lift ban in mid 2010, bill pending)

  42. Barriers to Abortion:Military Hospital Abortions Ban • Military women serving abroad, and their dependents, are prohibited from obtaining abortions at military hospitals, even if they pay with personal funds • EC not available at all military treatment facilities • Alternatives: • Travel long distances for abortion – expensive and requires permission from commander to take leave • Have abortion locally – unsafe in certain countries (e.g., in Middle East)

  43. Barriers to Abortion:Coverage • Federal Employees Health Benefits Program (FEHBP) • Covers over 8.5 million federal employees, their dependents, and retirees; 45% women • Since 1983 (except for 1994), abortion coverage permitted only in cases of life endangerment, rape, or incest

  44. Barriers to Abortion:Coverage • Peace Corps • 7300 volunteers; 61% women • Funds cannot be used for abortions, even when the woman’s life is endangered

  45. Barriers to Abortion:Coverage • Federal Prisons • 11,250 women • From 1987-present (except for 1994), ban on funding abortions except when woman’s life endangered or the pregnancy the result of rape

  46. Obama Health Care Plan Executive Order states that federal funds cannot be used for abortion (except in cases of rape or incest or when the life of the woman is endangered) Prohibits discrimination against health care facilities and providers because of unwilliness to provide or refer for abortions

  47. Obama Health Care Plan • Bans tax credits and federal subsidies for people required to purchase private insurance from being used to pay for abortion (except in cases of rape or incest or when the life of the woman is endangered) • Means most policies will require two separate monthly premiums • Will discourage plans from offering abortion • Will exclude poor

  48. Barriers to Abortion:Funding Cuts • Under Bush II, U.S. opposed language in the Cairo Action Plan, such as “reproductive health care,” stating that this is a proxy for abortion • This halted U.S. participation in global efforts to prevent unintended pregnancies and control the spread of STDs, including HIV • Domestic family planning budget cuts under Bush II

  49. Barriers to Abortion:Limits on Availability of Emergency Contraception • EC available in 102 countries • Available OTC in parts of Canada and in S. Africa, UK, France, other European countries • Cost: $25-$50 • Less expensive options involving OCPs • $1.43 cost savings (from averted pregnancy-related costs) for every $1 spent • 2009 Utah study demonstrates association between increasing rates of EC use and decreasing abortion rates

  50. Barriers to Abortion:Limits on Availability of Emergency Contraception • French study showed that only 15% of EC pill use instances were reported by women using no contraception (in 45% of cases, women had been taking OCPs; in 35% of cases, partner(s) had been wearing condoms)

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