Obstacles to Abortion and Comprehensive Reproductive Health Care

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 • Miscarriage is common (60% of pregnancies for women in their 20’s, 97% for women in their late 40s) • Usually in first trimester • Primarily due to sporadic chromosomal abnormalities

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 • 89% 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. • Over 30 million women have had abortions since legalization (1973) • 3 million unintended pregnancies per year in the U.S. • 926,200 abortions were performed in 2014 • 1.1 million in 2011 • 1.6 million in 1990 • 1.3 million in 1980

6. Abortion in the U.S. • 926,200/yr (2014) • 15 abortions/1,000 fertile women/year • Lowest rate since 1981 (29/1,000) • Decline due to availability of contraception • 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 1/3 of those within marriage) • 42% of these end in abortion • 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; 12% teenagers • 14% married (67% never married) • 59% have had children • 30% Protestant, 24% Catholic, 38% 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: • 39% white, 28% African-American, 25% Hispanic • African-Americans and Hispanics more likely to have abortions than Caucasians, in part due to: • Higher levels of poverty/lower SES • 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% (40% contributing factor) • Not ready for responsibility - 21% • Woman’s life would be changed too much - 16% • Problems with relationship; unmarried - 12% • ½ of babies born today are to unwed mothers (1/5 in 1980)

11. Most Important Reason Given for Terminating an Unwanted Pregnancy • Too young; not mature enough - 11% • 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 20, 5% of US women will have had an induced abortion • By age 30, 19% • By age 45, 33%

13. Abortion in the U.S. • 51% of women with unintended pregnancies get pregnant while using some form of contraception • Optimum one year contraceptive failure rates: • periodic abstinence -21% • OCPs – 7% • IUD - 1-2%

14. Rape and Pregnancy • Noninvasive prenatal genetic testing through amplification of fetal alleles from maternal blood very accurate for identifying father • Can be performed at 8-14 weeks gestation • vs. amniocentesis and chorionic villus sampling (10-15 weeks, risks to mother and fetus) • May assist mother’s decision to carry vs. terminate pregnancy • IPV more common in women seeking pregnancy termination

15. Abortion in the U.S.:Public Opinion Split 2018: 48% “pro-choice”; 48% “pro-life” 2018: Abortion should be legal in all cases (34%); illegal in all cases (22%); legal under certain circumstances (37%) Men and women support equally

16. 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

17. 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

18. 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

19. Abortion in the U.S.:Public Opinion 2013: Roughly six-in-ten Americans (62%) know Roe v. Wade was a decision about abortion, but among adults under 30 years old, only 44% know Younger adults are less likely to view abortion as an important issue Are we taking Roe v Wade for granted?

20. History of Abortion in the U.S. Abortion legal and advertised from time of colonization (had been practiced for thousands of years) 1700s – 1880: Abortion allowed and widely practiced (except after quickening, when fetus was felt to be alive) Earliest efforts to govern abortions centered on concerns about poisoning, not morality, religion, or politics

21. History of Abortion in the U.S. • 19th Century: AMA led crusade to ban abortion • Procedure commonly performed by non-MD providers • Attempt to eliminate competition in health care

22. History of Abortion in the U.S. • 1873 Comstock Law: prohibited the dissemination of birth control information and services • Antifeminist crusade, • Link with “pornography” • Abortion bans also aimed at concerned that immigrants would out-populate whites • By 1900: Abortion legally restricted in almost every country

23. History of Abortion in the U.S. • By 1910: All but one state has outlawed abortion except to save woman’s life • Dangerous “back alley” abortions common • 1967-1973: 1/3 of states eliminated or liberalized abortion laws • Women’s Movement • Underground groups, including clergy, help women get safe abortions

24. History of Abortion in the U.S. • 1973: Roe v Wade (SCOTUS): • Americans’ right to privacy included the right of a woman to decide whether to have children, and the right of a woman and her doctor to make that decision without state interference

25. 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

26. Abortion Worldwide • 56 million/year • 35/1,000/yr • 27/1,000 in developed regions • 37/1,000 in developing regions • 36/1,000 for married women • 25/1,000 for unmarried women • 23 million unsafe (98% of these in developing countries) • Increasing percentage

27. Abortion Worldwide Cost of treating women for complications of botched abortions = 4 times the cost to provide contraception Countries with more liberal abortion laws have lower abortion rates

28. 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 • 7 million require hospitalization or treatment at health care facility annually • 30 infections/injuries for every one abortion death

29. Abortion Worldwide • 220,000 children orphaned each year by poorly performed abortions • Legal restrictions have no effect on abortion incidence

30. Non-physicians performing abortions • Use of mid-level providers can decrease deaths • No difference in complication rates • CA allows NPs, CNMs, and PAs with special training to perform

31. Maternal Mortality • 1/3800 in U.S. (77th worldwide) • 3X higher in black than white women • 1/39 in sub-Saharan Africa; 1/290 in SE Asia • 275,000 maternal deaths worldwide each year (most avoidable) • Death rate decreasing • Cause: Lack of access to comprehensive reproductive health care/obstetrical care

32. 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%

33. 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 giving birth • 6 die per hour from unsafe abortion

34. Teenage Sexual Activity • 43%/39% of teenage boys/girls have had sexual intercourse (decreasing) (2016); overall rate down from 48% in 2007 to 40% in 2017 • Teen birth rate (2016) = 22/1,000/yr • Lowest since mid 1940s • Down from high of 96/1,000/yr in 1957) • Hispanics and African-Americans = 2X higher than Whites = 2X higher than Asians

35. Teen Pregnancy • Teen birth rate 22/1,000 (2016): lowest since 1991 (down 62% since then) • Teen pregnancy has decreased 64% since 1991 • But still higher than any other developed country (and highest rates of STDs) • 75% of teen pregnancies unintended

36. Teenage Sexual Activity • 50% of pregnant teens were not using any form of contraception when pregnancy occurred • 31% of these did not believe they could get pregnant • Contraception use among teens increasing • 80% condom with first intercourse, 59% with most recent intercourse • 16% in combination with hormonal method

37. Teenage Sexual Activity • STD rates high, testing/treatment/followup poor, long-term risks include PID, infertility • HPV vaccine uptake low, despite effectiveness • No increased sexual activity among HPV vaccinees • Inadequate sex education and limited access to reproductive health care likely increases morbidity, mortality • Health care providers frequently fail to conduct sexual risk assessment

38. Reproductive and Sexual Health Morbidity in the U.S. • Far worse than other developed nations • Adverse health outcomes/yr • 20 million STDs • 50,000 new HIV infections • 3 million unintended pregnancies • At least 1 million rapes

39. Reproductive and Sexual Health Morbidity in the U.S. • Annual costs: • STDs (including HIV) - $16 billion • Rape and other sexual assaults - $12 billion • Teen childbearing - $11 billion

40. 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

41. Barriers to Abortion:Misconceptions about Sex and Contraception 20% of 18-29 yr olds say they never had school-based sex education 1/3 of U.S. adolescents get no sexual counseling during their annual doctor visits

42. Barriers to Abortion:Misconceptions about Sex and Contraception 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

43. 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)

44. 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

45. Barriers to Abortion:Availability of Contraception • Use of some form of contraception increasing (approximately 80%) • Male sperm counts also decreasing (50% over last 4 decades): • may have both short- and long-term consequences for our species • Infertility rates climbing • 1/6 U.S. couples trying to conceive fail to do so over the course of 1 yr of unprotected sex

46. Barriers to Abortion:Availability of Contraception • Limited access to health care • Lack of insurance • School-based health centers (< ½ dispense, many require parental consent) • 2012: Only 28 states required health insurance policies that cover other prescription drugs to include contraceptives • Until recently, Oregon Medicaid covered Viagra but not oral contraceptives • Changed under PPACA – see later slides

47. Barriers to Abortion:Availability of Contraception Expense (e.g., IUD post-delivery, OCPs) Provider/pharmacist refusal (“conscience clauses”) OCPs available OTC in 3 states, but in 106 countries worldwide (safe, does not increase sexual risk-taking behavior)

48. Barriers to Abortion:Availability of Contraception PPACA (ObamaCare) requires insurers to pay full cost of contraception (but plans can exclude coverage or require cost-sharing for out-of-network services/supplies)

49. Barriers to Abortion:Availability of Contraception SCOTUS allows religious exceptions in Hobby Lobby case (2014), citing Religious Freedom Restoration Act of 1993 Zubik v. Burwell (2016): SCOTUS sends similar lawsuits back to states

50. Barriers to Abortion:Availability of Contraception • 2012: 40% of school-based health centers are allow to dispense contraception • Requirements for parental consent vary • When free contraceptives offered for 3 yrs, abortion rates fell by 70% (and teen pregnancies dropped dramatically) [Obst and Gynecol 10/4/12]