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 • At least 1/5 pregnancies ends in miscarriage • 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. • 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. • 17 abortions/1,000 fertile women/year • Lowest rate since 1973 • 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. • 51% of all pregnancies are unintended, including more than 31% within marriage • 80% of teen pregnancies unintended • Teen pregnancy has decreased 44% since 1991 (1 birth/32 girls/yr) • But 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/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 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. 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 • 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%)

16. Abortion in the U.S.:Public Opinion Split 2011: 41% “pro-choice”; 50% “pro-life” 2011: Abortion should be legal in all cases (25%); illegal in all cases (20%); legal under certain circumstances (52%)

17. 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

18. 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

19. 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?

20. Abortion Worldwide • 44 million/year • 28/1,000/yr • 23 million unsafe (98% of these in developing countries) • Percent increase from 1995 (44%) to 2008 (49%)

21. Abortion Worldwide 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

22. 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

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

24. 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

25. Maternal Mortality • 1/3800 in U.S. • 3X higher in black than white women • 1/39 in sub-Saharan Africa; 1/290 in SE Asia • 287,000 maternal deaths worldwide each year (most avoidable) • Death rate decreasing • Cause: Lack of access to comprehensive reproductive health care/obstetrical care

26. 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%

27. 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

28. 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

29. Teenage Sexual Activity • 46% of teenage boys and girls have had sexual intercourse (decreasing) • Teen birth rate (2011) = 31/1,000/yr (lowest since mid 1940s) • Hispanics 49/1000/yr • African-Americans = 47/1,000/yr • Whites = 22/1,000/yr • Asians = 10/1,000/yr

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

31. Teenage Sexual Activity • STD rates high, testing/treatment/followup poor, long-term risks include PID, infertility • HPV vaccine uptake low • No increased sexual activity with HPV • Inadequate sex education and limited access to reproductive health care likely increases morbidity, mortality

32. 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

33. 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

34. 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

35. 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)

36. 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

37. Barriers to Abortion:Availability of Contraception • Limited access to health care and lack of coverage • 2012: Only 28 states require health insurance policies that cover other prescription drugs to include contraceptives • Until recently, Oregon Medicaid covered Viagra but not oral contraceptives • Obama plan (PPACA) now requires insurers to pay full cost of contraception (including EC)

38. 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] • Worldwide contraceptive use averts almost 230 million births each year

39. Barriers to Abortion:Availability of Contraception • OTC status for OCPs would improve access, is considered safe • Would not increase sexual risk-taking behavior • ACOG and AAP support (regardless of age) • IOM considers contraception preventive care

40. Barriers to Abortion:Availability of Contraception • 1 year failure rates of contraceptives with typical use (women overestimate effectiveness): • Condoms - 20% • OCPs – 9% • IUD – 0.05% (recommended first line option, ACOG) • No increased risk of PID • No effect on later fertility • Higher up front costs, but greater net savings • Nearly 100% effective in preventing pregnancy when placed within 5 days of unprotected sex

41. 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

42. Barriers to Abortion:Availability of Contraception • Sterilization (tubal ligation) effective • Most common birth control method in developing world • Project Prevention: • Pays women $300 to get a tubal ligation or IUD, implant or Depo-Provera shots • Pays men for vasectomies • 4,097 individuals “treated” by mid 2012; 72 men • Controversial

43. 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) • Survival very rare before 24 weeks

44. 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

45. 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

46. 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

47. 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

48. 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

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

50. 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)