Tài liệu Obstetrics and Gynecology Clinics of North America, 2007 pdf

Foreword
Consulting Editor
This issue of the Obstetrics and Gynecology Clinics of North America, pre-
pared by Guest Editor Eve Espey, MD, deals with a very timely update on
contraception and family planning. Our specialty is influenced by social,
religious, and political forces from outside the medical community. In no
other field of medicine are these forces more obvious than in family planning.
Most fertile women prefer to avoid pregnancy, and they and their providers
are confronted continuous ly by these forces.
Women’s health care physicians must counsel and prescribe contra-
ception despite challenges such as: continual change; frequent confusion;
ignorance of legal, legislative, and judicial communities despite scientific ev-
idence; unbalanced media coverage; and health care providers themselves.
Access is not universal. Even in certain industrialized countries with more
advanced contraception technologies, women are denied easy access to family
planning services. Roadblocks for indigent women to these services are
frequently attributed to religious or political issues rather than any medical
reason.
When contraception is not used by presumably fertile partners, approxi-
mately 90% of women will conceive within 1 year. Young wom en who do
not want to become pregnant are advised to use contraception whenever
they become sexually active, regardless of their age. Women with certain
medical conditions require special consideration of contraception choice.
Contraceptive advice for the woman nearing menopause can be difficult,
because it is impossible to predict when fertility has ended. Oligomenorrhea
William F. Rayburn, MD
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doi:10.1016/j.ogc.2007.03.007 obgyn.theclinics.com
Obstet Gynecol Clin N Am
34 (2007) xiii–xiv

or increasing cycle length is associated with a diminished frequency, but not
cessation of ovulation.
Current methods of contraception include oral steroidal contraceptives,
injected or implanted steroidal contraceptives, intrauterine devices, barrier
techniques, withdrawal, sexual abstinence around the time of ovulation,
breastfeeding, and permanent sterilization. This issue also highlights more
recent forms of contraception such as the contraceptive patch, vaginal ring,
extended cycle hormonal contraceptive, transcervical sterilization, and im-
plantable contraception. Estimates of failure rates during the first year of use
are given for each technique.
Those who prescribe contraceptives must be familiar with currently avail-
able drugs and methods and their side effects. No method of fertility regu-
lation is completely effective or without side effects and danger. We must
strive to minimize these side effects and risks while appreciating that a major
risk of contraception failure is unplanned pregnancy. Effective sexual educa-
tion, as well as motivation, undoubtedly reduces the cited failure rates. This
issue addresses behind-the-counter emergency contraception and its advan-
tages and limitations. Elective abortion is not a contraceptive technique;
rather, it serves as a less-than-ideal remedy for contraceptive failure or
neglect.
It is our desire that this issue will attract the attention of providers caring
for the many women of reproductive age who need contraception. The prac-
tical information provided herein by this distinguished panel of contributors
will hopefully aid in the development and implementation of more specific
and individualized treatment plans.
William F. Rayburn, MD
Department of Obstetrics and Gynecology
University of New Mexico School of Medicine
MSC10 55801
University of New Mexico

Albuquerque, NM 87131-0001, USA
E-mail address:
xiv FOREWORD
Preface
Guest Editor
In the long run, injectable contraceptives and intrauterine devices may
prove more powerful weapons against conflict and terrorism than Abrams
tanks or F-16 war planes
dMalcolm Potts
The basic human right of self-determination is meaningless for women
who do not have the ability to control reproduction. Devoting an issue of
this journal to contraception makes sense at this time when the unintended
pregnancy rate in the United States continues to hover at 50%. Every
woman knows whether it is the right time for her to bear a child and for
her and her fami ly to commit the considerable personal and financial re-
sources necessary for raising that child. But the impact of contraception
transcends the importance of individual choice. It has dramatic implications
for the health, well-being, and survival of communities.
Contraception is a means of promoting global health. By decreasing un-
intended pregnancy, contraception reduces maternal mortality, particularly
in developing countries. Unintended pregnancy leads to abortion, which is
not only illegal but also unsafe in much of the world. Without contracep-
tion, unchecked population growth creates poverty and the desperation peo-
ple feel when they see no prospect of a fulfilling life. Poverty and despair
breed violence an d war.
As one of the wealthiest developed nations, the United States enjoys an
expanding range of approaches to family planning and methods of contra-
ception, yet access is not universal. In this issue of Obstetrics and
Eve Espey, MD, MPH
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doi:10.1016/j.ogc.2007.02.005 obgyn.theclinics.com
Obstet Gynecol Clin N Am
34 (2007) xv–xvii
Gynecology Clinics of North America, we address exciting new develop-
ments and research related to currently available contraceptives. We also
focus on the multiple social, political, public health, and medical barriers
that may deny women who most need the benefits of these developments
from accessing them.
The issue begins with two arti cles about impediments to contraceptive
access, both medical and social. Dr. Cosgrove, Dr. Ogburn, and I begin
with a review of the numerous social, public health, and political barriers
that limit access to the increasingly varied array of contraceptive options.
Dr. Leeman considers the medical roadblocks that women face in effectively
using contraceptivesdroadblocks sometimes inadvertently put in place by
physicians themselves. Dr. Yael Swica reviews two new methods , the contra-
ceptive patch and vaginal ring. Dr. Jody Steinauer and Dr. Meg Autry dis-
cuss the latest information on the increasingly popular extended-cycle
dosing regimens for hormonal contraceptives. Dr. Tony Ogburn and I ad-
dress the current status of transcervical sterilization as well as future devel-
opments. Contraceptive implants disappeared in the United States after
the removal of Norplant from the market in 2000. Dr. Michelle Isley and
Dr. Alison Edelman review implantable contraception with an emphasis
on Implanon, the newly Food and Drug Administration–approved 3-year
single-rod implant. Dr. Laura MacIsaac and I examine the evidence for ex-
panding the use of intrauterine contraception with an emphasis on recent
Food and Drug Administration label changes for the CuT380A. Dr. Stepha-
nie Teal and Dr. David Ginosar address the important task of identifying
appropriate contraception for women who have medical illnesses. Dr. Linda
Prine writes on the current status of emergency contraception and addresses
recent concerns about its effectiveness. Dr. David Turok concludes the issue

with a comprehensive review of contraceptive methods currently under
development.
The control of fertility is at the root of true equity for women. If we are to
achieve equality and justice for women globally, members of the family-
planning communi ty must commit to a social agenda that promotes sexual
health by encouraging education about contraception and by providing free
access to contrac eptives as a right for all women. We have made a start in
this country. Excellent methods are available and even more are on the ho-
rizon. In recent years, laws and Medicaid waivers have improved access for
at least some women. Behind-the-counter access to emergency contraception
has finally been approved.
It is our responsibility to advocate for universal coverage and universal
access to contraception: no woman left behind. Starting here in our own
backyard and armed with injectable contraceptives and IUDs, we can fight
conflict and terrorism. And we can win.
xvi PREFACE
I would like to thank all of my fellow authors for their outstanding con-
tributions. Special thanks to Carla Holloway from Elsevier for her invalu-
able assistance in coordinating this effort.
Eve Espey, MD, MPH
Associate Professor
Department of Obstetrics and Gynecology
1 University of New Mexico, MSC10-5580
Albuquerque, NM 87131, USA
E-mail address:
xviiPREFACE
Family Planning American Style: Why
It’s So Hard to Control Birth in the US
Eve Espey, MD, MPH
a,

*
, Ellen Cosgrove, MD
b
,
Tony Ogburn, MD
a
a
Department of Obstetrics and Gynecology, MSC10-5580, 1 University of New Mexico,
Albuquerque, NM 87131, USA
b
Department of Internal Medicine, MSC10-5550, 1 University of New Mexico,
Albuquerque, NM 87131, USA
In America sex is an obsession, in other parts of the world it is a fact.
Marlene Dietrich
Life in Lubbock, Texas, taught me two things: One is that God loves you and
you’re going to burn in hell. The other is that sex is the most awful, filthy
thing on earth and you should save it for someone you love.
Butch Hancock
The United States possesses the dubious distinction of having the highest
teen pregnancy rate [1] and one of the highest overall unintended pregnancy
rates (49%) among developed countries [2]. Unintended pregnancy and
abortion disproportionately affect young, unmarried, low-income, and edu-
cationally disadvantaged women [3]. Sadly, unintended pregnancy rates are
increasing in these groups. An infectious disease epidemic on this scale
would be met with a concerted public health campaign, including personal
responsibility approaches, health protection strategies, and public policy
measures. Similar to unintended pregnancy, the US abortion rate of 21.3
per 1,000 women aged 15 to 44 compares unfavorably with rates in other
developed countries [4].
Why is it that other developed countries have managed to achieve much

lower rates of unintended pregnancy, teen pregnancy, and abortion (Fig. 1)?
Many factors create barriers to effective contraceptive usage, but certain so-
cial and public health barriers that are unique to the United States must be
recognized and removed to reduce unintended pregnancy and abortion.
These barriers include the abstinence-only approach to sex education,
* Corresponding author.
E-mail address: (E. Espey).
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doi:10.1016/j.ogc.2007.02.002 obgyn.theclinics.com
Obstet Gynecol Clin N Am
34 (2007) 1–17
acceptance of and support for teenage parenthood, reduced access to health
care because of lack of insurance or hospital mergers, and reduction of ac-
cess to family planning services from burdensome contraceptive dispensing
practices. A relatively new and ominous anticontraception sentiment also is
gaining momentum in this country, although polls demonstrate that it is an
extremist position. This article discusses each barrier and comments on
strategies for reducing each one to achieve an integrated, comprehensive,
public health approach to this complex problem.
Abstinence-only education
Content and funding of sex education
The increasing emphasis on abstinence-only education reflects the large
infusion of funding for this type of education appropriated under Title V,
Section 510 of the Welfare Reform Act of 1996. Through this and other
programs, more than $1.1 billion have been spent on abstinence-only
education over the last two decades [5]. To receive funds for sex education
under Title V, states must provide $3 in matching funds for every $4 in
federal funds. They also must comply with an eight-item definition of
Fig. 1. US teenagers have higher pregnancy, birth, and abortion rates than adolescents in other
developed countries. (From The Alan Guttmacher Institute (AGI). Teenage sexual and repro-

ductive health in developed countries: can more progress be made? New York: AGI, 2001.
Available at: Accessed Febru-
ary 7, 2007; used with permission.)
2
ESPEY et al
abstinence-only education, which specifies that the exclusive purpose of sex
education is to teach the benefits of abstaining from sexual activity, that ab-
stinence is the only certain way to avoid pregnancy and sexually transmitted
infections (STIs), that sexual activity outside marriage is likely to have
harmful psychological and physical effects, and that a mutually faithful,
monogamous relationship in the context of marriage is the expected stan-
dard of human sexuality. All states but California have accepted these
funds. No federal funds have been appropriated for comprehensive sex
education, defined as a program that includes abstinence and contraception
and STI education.
Although significant federal and state funding is available for abstinence-
only education, no federal laws or policies mandate the offering or content
of sex education. Thirty-nine states have developed their own laws or poli-
cies regarding sexuality or STI education or both. Twenty-one states require
coverage of sexuality and STIs, whereas 17 require only coverage of STI s.
Only 1 state requires sex education but not STI coverage. Eleven states leave
it entirely to the local school districts to decide what will be taught [6]. Six-
teen states, including some that have statewide mandates requiring educa-
tion on sexuality, STIs, or both, give local school districts complete
discretion over whether and how to teach abstinence and contraception.
The remaining 34 states, regardless of whether they have mandates about
sexuality and STI education, place some requirements on local school dis-
tricts about the teaching of contraception and abstinence. A national pref-
erence for abstinence education is evidenced by the fact that 34 states
require that it be taught and 25 require that it be stressed. In contrast,

only 19 states require coverage of contrac eption, and none requires that it
be stressed [6].
Support for comprehe nsive sex education
The Sexuality Information and Education Council of the United States,
a national organization that advocates for the right of all people to compre-
hensive and accurate sexuality information, reports that ‘‘89% of Americans
believe it is important to teach young people about contraception and the
prevention of STIs and that sex education programs should focus on how
to avoid unintended pregnancies and STIs, including HIV and AIDS, since
they are such pressing problems in America today’’ [7].
Comprehensive sex education is broadly supported by professional orga-
nizations, including the American College of Obstetricians and Gynecolo-
gists, the American Public Health Association, the American Academy of
Pediatrics, and the American Medical Association [8–10]. Perhaps most im-
portantly, 95% of parents of junior high school students and 93% of parents
of high school students believe that birth control and other methods of pre-
venting pregnancy are appropriate topics for sex education programs in
schools [7].
3FAMILY PLANNING AMERICAN STYLE
Despite the tremendous public support for comprehensive sex education,
the last decade has seen a major decline in formal instruction about birth
control methods. From 1995 to 2002, formal instruction about birth control
methods declined from 81% to 66% for adolescent boys and from 87% to
70% for girls [11]. Over the same time period, the number of adolescents
who received abstinence-only education increased from 9% to 24% for
boys and from 8% to 21% for girls. In 2002, only 62% of girls and 54%
of boys who were sexually experienced had received education about contra-
ceptive methods before first intercourse.
Effectiveness of sex education programs
Few studies have evaluated the effectiveness of different approaches to

sex education. Decisions to use abstinence-only versus comprehensive sex
education are based almost exclusively on opinion.
Douglas Kirby, PhD, of Education Training Research Associates is
a leading publisher of patient education, health promotion, and health edu-
cation pamphlets and other materials. He performed a comprehensive re-
view of 73 studies evaluating sex education programs [12] and found
‘‘reasonably strong’’ evidence that comprehensive sex and HIV education
programs may delay sex, increase contraceptive or condom use, or decrease
teen pregnancy. Studies included in this review met predetermined criteria to
include the most rigorously designed reports but fell short of the gold stan-
dard of randomized controlled trials. Of the 28 studies that reviewed com-
prehensive sex education, 9 found that the programs delayed initiation of
intercourse, 18 found no impact, an d 1 found an earlier age at initiation
of intercourse. Results were similar for frequency of intercourse and number
of sex partners. Dr. Kirby concluded that the outcomes of comprehensive
sex education programs are generally favorable.
By contrast, studies of abstinence-only curricula have failed to show an
impact on teen pregnancy or STI risk [12]. In a meta-analysis of five ran-
domized controlled trialsdfour evaluating abstinence-only programs and
one evaluating comprehensive sex educationdabstinence-only programs
were associated with a higher pregnancy rate in the partners of male partic-
ipants of the programs [13]. Overall, they have no effect on changing teen
sexual behavior or contraceptive use either positively or negatively.
In a report commissioned by Representative Henry Waxman (D-Califor-
nia), the Special Investigations Division of the House of Representatives ob-
tained program summaries of abstinence-only curricula from organizations
that received abstinence-only funding [14]. The division reviewed 13 curric-
ula and found that 80% contained inaccurate scientific and medical infor-
mation and distorted information about reproductive health. The report
concluded that these curricula often promote religion, reinforce traditional

gender stereotypes, and focus on particular ideologies rather than on the
transfer of accurate information about sexuality and pregnancy prevention.
4 ESPEY et al
The large amount of school funding for abstinence-only-until-marriage
education implies that the goal of avoiding premarital sex is an achievable
one. A recent publication analyzing data from the National Survey of Fam-
ily Growth confirmed the near universality of premarital sex in the United
States [11] . Finer [11] reported that 75% of respondents had premarital
sex by age 20 and that 95% had had sex by age 44, regardless of whether
they were married. He concluded that because most Americans have sex be-
fore marriage, we should provide education and interventions that provide
skills and information necessary to prevent unintended pregnancy and STIs
regardless of marital status. By contrast, Sweden and the Netherlands, both
with much lower rates of unintended pregnancy and abortion, are known
for early and accurate sex education coupled with easy access to contracep-
tives [15] .
The future of sex education
The Responsible Education About Life (REAL) Act, introduced in Con-
gress by Representative Barbara Lee (D-California) and Senator Frank
Lautenberg (D-New Jersey), would provide federal money to support com-
prehensive sex education in schools. This education would include science-
based, medically accurat e, and age-appropriate public health information
about abstinence and contraception. In the recently convened 110
th
Con-
gress, Senate Majority Leader Harry Reid (D-Nevada) introduced the Pre-
vention First Act, which would increase access to and education about
contraception, support teen pregnancy prevention programs, and ensure
medical accuracy in sex education.
Because much of the content of sex education is determined at the local

level, providers should be aware of their community’s sex education to un-
derstand potential gaps in teens’ knowledge, inform adolescents and parents
of the importance of comprehensive sex education, and advocate for its in-
clusion in local schools.
Societal attitudes about sex and early childbearing
Influence of media on sexual behavior
A major chasm lies between the abstinence-only messages conveyed in the
formal school-based education of teenagers and the implicit societal mes-
sages about sexuality and sexual conduct embedded in media. In a commen-
tary on adolescent sexuality and the media, Strasburger [16] pointed out that
‘‘American media have arguably become the leading sex educator in the
United States.’’ Children and teenagers spend an average of 6.5 hours per
day with different media, including approximately 4 hours per day watching
television and videos/ DVDs [17]. Most media are packed full of sexual ref-
erences and innuendo. The number of sexual scenes on television has
5FAMILY PLANNING AMERICAN STYLE
increased significantly. In 1998, 56% of all shows contained sexual content,
with an average of 3.2 scenes per hour. By 2005, the percentage of shows in-
cluding sexual content increased to 70%, with an average of 5 scenes per
hour [18]. Of the top 20 teen television shows, more than 70% contain sex-
ual content (Fig. 2).
This content conveys a different meaning from the abstinence-only-until-
marriage message of school education programs. Common media messages
about sex are that ‘‘everyone is having sex,’’ sex ‘‘just happens,’’ being
‘‘swept away’’ is the natural way to have sex, and adults do not plan for
sex and do not use contraception [16]. Teen shows also typically contain
the most sexual content (Fig. 3). Only 14% of shows with sexual content
touch on the real-life risks and consequences of sex. Despite the enormous
sexual content of television programs, the networks have highly restrictive
policies about advertising for birth control. Two major networks refuse con-

dom ads, and three more accept such ads only after 9 or 11
PM. Birth control
pill ads are refused by some networks and aired on others but most often
with an emp hasis on noncontraceptive benefits, such as reduction of acne
or ease of use.
Societal norms and teen pregnancy
The level of adolescent pregnancy varies by a factor of almost 10 across
developed countries; the United States has one of the highest rates [15].In
a study that examines trends over time, teenage childbearing has decreased
across all countries over the past 25 years. The decline of 20% in teenage
fertility in the United States from 1970 to 1995 was among the smallest
56%
67%
64%
71%
77%
70%
80
70
60
50
40
30
20
10
0
1998 2002 2005
All shows
Prime-Time
Fig. 2. Percent of shows with sexual content, over time. (From Sex on TV 4, A Kaiser Family

Foundation Report–Executive Summary (#7399), The Henry J. Kaiser Family Foundation,
November 2005. This information was reprinted with permission from the Henry J. Kaiser
Family Foundation. The Kaiser Family Foundation, based in Menlo Park, CA, is a nonprofit,
private operating foundation focusing on the major health care issues facing the nation and is
not associated with Kaiser Permanente or Kaiser Industries.)
6
ESPEY et al
declines of all countries studied, whereas the decline in abortion was among
the largest (33%). Teenagers in the United States remain more likely than
teens in other countries to become pregnant and continue their pregnancies.
Despite this high teen birth rate, US teens still have more abortions than
teens in other developed countries because of the high rate of unplanned
pregnancy in US adolescents [15]. The decline in US teen unintended preg-
nancy over the last two decades is largely attributable to improvements in
contraceptive use and an increase in sexual abstinence. The percentage of
teens using condoms has increased, whereas the percentage of teens using
withdrawal and no method has declined [19]. The percentage using hor-
monal contraceptiondgenerally, methods with higher effectivenessdhas re-
mained stable and relatively low compared with other countries.
Antecedents of teen pregnancy in the United States
Cultural differences between countries may account for the increased
birth rates and abortion rates among US teens. Surveys reveal that US teens
are more likely to desire motherhood than teens in other countries [20]. De-
spite similar levels of sexual activity among teens across countries, US teens
are more likely to have an earlier age at onset of intercourse (!15 years) and
are more likely to have shorter and more sporadic sexua l relationships. Pov-
erty and social disadvantage increase the risk of early childbearing and
8
7
6

5
5.0
5.9
6.7
4
3
2
1
0
All
Programs
Prime-Time Top Teen
Programs
Fig. 3. Among shows in 2005 with sexual content, the number of sex-related scenes per hour.
(From Sex on TV 4, A Kaiser Family Foundation Report–Executive Summary (#7399), The
Henry J. Kaiser Family Foundation, November 2005. This information was reprinted with per-
mission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation, based in
Menlo Park, CA, is a nonprofit, private operating foundation focusing on the major health care
issues facing the nation and is not associated with Kaiser Permanente or Kaiser Industries.)
7
FAMILY PLANNING AMERICAN STYLE
unplanned pregnancy, but teens across the socioeconomic spectrum in the
United States are more likely to experience unplanned pregnancy than their
counterparts in other countries.
Investigators have speculated that one factor explaining decreased teen
childbearing in other countries is the strong social support for the concept
of reserving parenting for adulthood. Similarly, the acceptance of sexual ac-
tivity in young people and the pragmatic approach of making sex education
and contraceptives readily available are features of European countries that
have low unplanned pregnancy and abortion rates [20]. In the United States,

well-intentioned social supports are designed to assist young mothers. Spe-
cial schools allow young mothers to return to school, and financial aid
assists with health care and food purchases. These supports may parad-
oxically serve an enabling role and send a message that teen pregnancy is
acceptable.
Strategies to reduce teen pregnancy
Solutions to the problem of teen pregnancy and social supports for it are
complicated. As outlined in the national campaign to prevent teen preg-
nancy, ‘‘Emerging Answers,’’ research supports advocacy for evidence-
based pregnancy prevention programs [21], including programs that focus
on sexual antecedents of pregnancy, emphasizing abstinence and use of con-
traceptives and service learning programs that do not focus on sexual activ-
ity at all.
Service learning programsda form of youth developmentdultimately
may have the best results in reducing teen pregnancy. An example of such
a project, the Teen Outreach Program, consists of three components: super-
vised community service, classroom discussion of service experiences, and
activities related to the social and developmental tasks of adolescence. Out-
comes data suggest a reduced teen pregnancy rate, a reduced risk of school
suspension, and a reduced risk of course failure [22].
Insurance barriers
Financial barriers to contraceptive access
Lack of adequate insurance is a barrier to contraceptive use. Approxi-
mately 46 million Americans have no insurance and millions more are un-
derinsured [23]. Women who live in poverty rely on a patchwork quilt of
underfunded family planning programs for their reproductive health care.
It is estimated that one in five reproductive-aged wom en was uninsured in
2003, an increase of 10% over the previous 2 years [24]. Similarly, a 6% in-
crease in the number of women who depend on publicly funded family plan-
ning services occurred from 2000 to 2004, which brought total numbers to

approximately 17 million. It is estimated that half of all reproductive-aged
women who are sexually active rely on publicly funded family planning
8 ESPEY et al
services [25]. Public fundingdstate and federaldfor family planning ser-
vices falls mostly to two programs: Medicaid and Title X of the Public Ser-
vice Act. Despite the rapidly growing population segment that requires
assistance to access family planning, funding for family planning has been
reduced or remained flat in 27 states [24]. Even more worrisome is the
fact that for the first time in more than 30 years, changes to Medicaid
laws passed in February 2006 allow states to eliminate family planning
from their Medicaid coverage for some recipients [26].
Even individuals with insurance may not have coverage for contracep-
tives; many do not cover the range of US Food and Drug Administration
(FDA)–approved contraceptives. Non-use of contraceptives has a dispropor-
tionate impact on unintended pregnancy in the United States: the 7% of re-
productive-aged women who do not use any contraceptive method are
responsible for 46% of the unintended pregnancies [27]. Despite the current
epidemic of unintended pregnancy, debate continues about the appropriate-
ness of insurance coverage of contraceptives.
Federal and state contraceptive equity initiatives
A proposed federal bill, the Equity in Prescription Insurance and Contra-
ceptive Coverage Act, would have required all insurance plans that offer
prescription drug coverage to cover contraceptives equally, but it has
made little progress toward enactment. Federal law, however, does require
contraceptive coverage for federal employees and their dependents. Health
plans that participate in the Federal Employees Heal th Benefits Program
are required by law to provide coverage of all prescription contraceptives
approved by the US FDA at the same level as coverage for all other pre-
scription drugs [28]. The federal Healthy People 2010 goals include ‘‘increas-
ing the proportion of health insurance policies that cover contraceptive

supplies and services’’ [29].
Twenty-six states have enacted laws that require insurers that cover pre-
scription drugs to provide coverage for the full range of US FDA-approved
contraceptives [30]. Eighteen of these states, however, allow certain em-
ployers and insurers to refuse to comply with the mandate on religious or
moral grounds. Interpreting the rules for conscience clause exemptions is
complex, and complicated state-based laws may be difficult for individuals
to navigate. Although 13 states require employees to be notified when their
health plan does not cover contraceptives and 26 states have contraceptive
coverage laws, these laws apply only to employers who purchase insurance
from a commercial insurance carrier for their employees. Approximately
half of all workers are covered under employer-sponsored self-insurance
plans. These self-insured plans, in which an employer provides medical cov-
erage but does not purchase it from an outside commercial insurance com-
pany, are typically not subject to state contraceptive coverage laws or
insurance regulations.
9FAMILY PLANNING AMERICAN STYLE
It seems that contraceptive equity laws have specifically been responsible
for a major increase in better access to contraceptives from 1993 to 2002
[31]. Compared to the scant coverage and narrow range of choices covered
in 1993, most insurers surveyed in 2002 covered a wide range of contracep-
tive choices. In 1993, only 28% of surveyed insurers covered the five leading
contraceptive methods (ie, oral contraceptives, 1- and 3-month injectables,
intrauterine device, and diap hragm) compared with 86% in 2002.
Several factors led to improved contraceptive coverage. In 2000, in a case
in which two employees sued their employers because of lack of coverage of
oral contraceptives and Depo-Provera, the US Equal Employment Oppor-
tunity Commission ruled that exclusion of contraceptives from prescription
drug c overage constituted sex discrimination under Title VII of the Civil
Rights Act as amended by the Pregnancy Discrimination Act [32].In

2001, in a highly publicized case, a district court ruled that excluding con-
traceptives from a prescription drug plan was illegal [33]. Media attention
has focused increasingly on contraceptive co verage and other matters re-
lated to contraception, such as the US FDA decision on over-the-counter
Plan B.
Contraceptive mandates were probably the most important factor in in-
creasing coverage . Most states that currently have contraceptive equity laws
adopted the legislation between 1993 and 2002. An analysis that compared
coverage of contraceptives by insurers with locally determined policies in
states with and without mandates showed that plans in nonm andate states
were significantly less likely to offer the full range of contraceptiv es (56%)
than plans in states with a mandate (90%) [31]. A federal mandate such
as Equity in Prescription Insuranc e and Contraceptive Coverage Act would
be even more helpful, expanding coverage requirements not only to
the women who currently live in states without mandates but also requiring
coverage for the women who are currently covered by employers with self-
insured plans.
Out-of-pocket costs for contraceptives
Coverage of contraceptives by insurance companies is an important but
not sufficient condition to improve access to and effectiveness of contra-
ceptives. Current coverage policies may be a major factor in noncompli-
ance: high out-of-pocket costs in the form of copays and deductibles
and insurance plans with limited dispensing regulations are barriers to bet-
ter usage. A study using an Agency for Healthcare Research and Quality
database (the Medical Expenditure Panel Survey) examined two important
factors related to ability to comply with oral contraceptive regimens: out-
of-pocket costs for the pills and number of packs obtained with each
pharmacy purchase [34]. In this sample of approximately 500 users, the
average out-of-pocket cost per pill pack was $14. The survey took place
at a time when the average retail price for lower priced oral contraceptive

10 ESPEY et al
pills was approximately $15. Privately insured women without drug cover-
age and uninsured women paid the most for oral contraceptives. Forty-six
percent of women paid $15 or more per pill pack. Overall, women paid
a substantial amount of the costs of oral contraceptives. Even women
with private insurance paid approximately 60% of the total cost of the
pill, compared with typical out-of-pocket costs for noncontraceptive drugs
of only 33%.
Insurance regulations limit dispensing more than one month
of contraceptives
Equally concerning for compliance with oral contraceptives, this same
study revealed that 73% of the women received only one pack of pills per
pharmacy visit. Although many providers prescribe 3 months of pills at
a time, insurance regulations often limit the number obtained at the phar-
macy to a single pack. Individuals who paid more for pills (O$15) were
more likely to obtain only one pack per visit. This study emphasized that
contraceptive equity laws are only partially effective in improving access
to contraceptives. A recent publication confirms that dispensing a year’s
supply of oral contraceptives is not only more cost effective but also im-
proves continuation of the method compared with dispensing 3 months at
a time [35].
Ample evidence documents the cost savings of contraceptive use in the
private and public sectors [36,37]. An analysis examining teenage contracep-
tive use confirms the reduction in costs from the use of various contraceptive
methods [38]. Ironically, public and private insurance almost universally
covers the medical costs of continuing an unintended pregnancy, costs
that are substantially higher than the cost of a contraceptive insurance
benefit.
Strategies to reduce insurance barriers
One program that has shown benefi t is the Medicaid waiver program.

This program allows states to develop and implement plans that extend
Medicaid family planning coverage to certain groups of individuals as
long as the program is budget neutral or results in an overall cost savings.
As of January 2007, 25 states had used the waiver program to extend family
planning services to persons who otherwise would not be eligible. Most
states provide services to individuals based on income requirements, typi-
cally set at or near 200% of poverty level. Other states have extended cov-
erage to other groups, such as all postpartum women, women who lost their
Medicaid coverage for any reason, and even men [39]. A study of waiver
programs in 2004 found that they increase the number of family planning
providers, increase family planning accessibility, decrease unintended preg-
nancy rates, and provide overall cost savings [40].
11FAMILY PLANNING AMERICAN STYLE
Mergers
A systems level barrier to reducing unintended pregnancy is the negative
impact on reproductive health services that occurs when nonsectarian hos-
pitals merge with religious, particularly Catholic, hospitals. More than 100
such mergers occurred in the 1990s as hospitals sought to reduce costs and
compete for managed care contracts [41]. Religious health care facilities,
particularly Roman Catholic institutions, play a major role in the delivery
of health care in the Un ited States. The 615 Catholic hospitals represent
12.5% of community hospitals in the United States and more than 15.5%
of all US hospital admissions [42]. The threat to reproductive health services
from Catholic mergers has been considered the most concerning because of
the explicit requirements embodied in the Ethical and Religious Directives
for Catholic Health Care Services [43] . These directives explicitly oppose
abortion, family planning, sterilization of men and women, emergency con-
traception, and HIV counseling that includes information about condom
use.
Countering these directives are various state and federal laws that re-

quire the provision of some of these services. Federal Medicaid, for exam-
ple, requires that enrollees have access to family planning services. Some
states have required private insurers to cover the cost of contraceptives,
and some states have passed laws requiring the provision of emergency
contraception available to rape victims. Making the equation even more
complicated are state and federal conscience clause statutes that have ex-
panded since 1997. These statutes cover various entitiesdfrom religious in-
stitutions and payers to individual health care professionalsdprotecting
persons who object to providing reproductive health services, including
contraception.
The fact remains that mergers between nonsectarian and Catholic hospi-
tals may result in the elimination or severe restriction of reproductive health
services. In a survey of 57 hosp ital mergers conducted by Catholics for
a Free Choi ce in 1995, 10 mergers resulted in exclus ion of all reproductive
health services, 6 preserved services in a free-standing clinic, 12 preserved ac-
cess to all services except abortion, and 19 declined to complete the survey
[43]. In contrast, of the 12 mergers that occurred in 2001, none resulted in
the complete discontinuation of reproductive health services. The preserva-
tion of services occurred in large part because of pressure from local and na-
tional groups with an increased awareness of the potential negative impact
of mergers [44].
Activism to limit the impact of hospital mergers on reproductive
health care services can be a successful strategy [45]. Activists use various
methods including media campaigns and education (Fig. 4). Community
involvement and physician resistance to mergers have successfully
blocked transactions or promoted a compromise solution that preserves
services.
12 ESPEY et al
Anticontraception politics
A major barrier to effective family planning in the United States derives

from political and ideologic opposition to contraception. A New York Times
article brought attention to a view of contraception that could prove a major
threat to improved access and use [46]. The position held by a small but vo-
cal minority is that contraception promotes several societal problems, such
as promiscuity, an anti-child attitude, and the undermining of male-female
relationships.
Until recently, most expert s agreed that improved contraceptive use was
a major part of the solution to the high rate of unintended pregnancy and
abortion in the United States. A more radical view, articulat ed by the pres-
ident of the Pro-Life Action League, Joseph Sc heidler, is that ‘‘contracep-
tion is more the root cause of abortion than anything else’’ [47]. They
hold that ‘‘contraception ushered in widespread promiscuity, divorce, sexu-
ally transmitted diseases, single parent households and abortion.’’ This
fringe view, increasingly articulated by religious social conservatives, has re-
framed the debate around abortion. With scientific misinformation about
the ‘‘abortifacient’’ action of many common contraceptives, the right wing
opposition to abortion is evolving to include a strong opposition to contra-
ception. Conservatives who hold this view are open about the underlying
principle on which their opposition to contraception is based: the immoral-
ity of any sexual activity that occurs outside of marriage and is not intended
for pro creation.
Fortunately, access to contraception is protected by rulings of the US
Supreme Court. The case that decriminalized contraception was Griswold
v Connecticut (381 U.S 479 (1965), in which a law prohibiting use of any
drug or article for prevention of pregnancy was found unconstitutional
based on a right to marital privacy [48]. The reasoning and language of
Fig. 4. A billboard commissioned by Save Our Services (Rhinebeck, NY), Preserve Medical
Secularity (Cottekill, NY), and MergerWatch (New York, NY). (Courtesy of the MergerWatch
Project, New York, NY, with permission.)
13

FAMILY PLANNING AMERICAN STYLE
Griswold was cited in support of the Court’s decision in Roe v Wade, 410
U.S. 113 (1973), which extended the ‘‘right of privacy’’ to cover abortion.
A restrictive atmosphere currently permeates most policy-making and
regulatory bodies. The US FDA has issued black box warn ings for Depo-
Provera and Ortho-Evra, both of which have had a chilling impact on the
acceptability of these methods to patients and providers. Many family plan-
ning experts believe these warnings were not based on high-quality evidence.
Similarly, the pro longed delay in approval of Plan B for ‘‘behind (not over)
the counter’’ status despite overwhelming supporting scientific evidence
smacked of conservative political influence. The appointments of ‘‘non-ex-
pert’’ and ideologically conservative individuals for posts critically impor-
tant to reproductive health are particularly concerning.
It is impossible to underestimate the impact of politics on reproductive
health. Because politicians have a major say in the prioritization of public
health goals, individuals who are unfriendly to the expansion of access to
contraception may cripple progress by cutting funding (eg, Title X), refusing
to appropriate funding (eg, comprehensive sex education), and withholding
support of helpful legislation.
In June 2006, a letter from the US Department of Health and Human Ser-
vices on behalf of the President was sent to the members of Congress conveying
the administration’s support for ‘‘the availability of safe and effective products
and services to assist responsible adults in making decisions about preventing
or delaying conception’’ [49]. Such a paternalistic attitudedmaking cont-
raception available only to ‘‘responsible adults’’dfrom the most powerful
policy makers in our country undermines the stated goal of reducing the abor-
tion rate.
Summary
The twin problems of unintended pregnancy and a high abortion rate can
be addressed successfully with a systems ap proach that focuses on opportu-

nities and barriers. Clearly, the ability to make real progress depends on
making family planning services available to all. Availability is ineffective
without education, however, and education alone is insufficient without pol-
icy change.
Of the 98 state laws enacted in 2005, 22 were designed to expand access to
contraception [50]. Continued grass roots efforts at the local level can shift
the dynamic toward more balanced education approaches by tempering the
American ambivalence toward sex exemplified in the Butch Hancock quote
with American pragmatism. Answering the question ‘‘What works?’’ with
the evidence of efficacy and outcomes offers a promising approach. Compre-
hensive sex educati on coupled with ready availability of contraception has
worked in other developed nations to reduce unintended pregnancy and
abortion. It is time to apply this proven public health strategy here.
14 ESPEY et al
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17
FAMILY PLANNING AMERICAN STYLE
Medical Barriers to Effective
Contraception
Lawrence Leeman, MD, MPH
Department of Obstetrics and Gynecology, and Department of Family and Community
Medicine, University of New Mexico, 2400 Tucker NE, Albuquerque, NM 87131, USA
It would be a service to mankind if the pill were available in slot machines
and the cigarette were placed on prescription.
dMalcolm Potts, MD
Fires and unintended pregnancies are important causes of morbidity,
mortality, and financial loss in the United States. Home fire extinguishers
and emergency contraception are both effective preventive interventions.
The disparity between access to fire extinguishers and emergency contra-
ception is irrational and indirectly hurts women’s health.
dDavid A. Grimes [1]
Medical barriers to the effective use of contraception are a major c ause of
unwanted pregnancy. In 2001, 49% of pregnancies in the United States were
unintended [1a] and about half of the unintended pregnancies occurred
among the 11% of sexually active women who were not using contraception

[2,3]. Medical barriers have been defined by Shelton and colleagues [4] as
‘‘practices, derive d at least partly from a medical rationale, that result in
a scientifically unjustifiable impediment to, or denial of, contraception.’’
The barriers include delayed initiation based on a perceived need to have
had a recent menses, pelvic examination, or sexually transmitted infection
screen before using contraception, inappropriate ‘‘contraindications,’’ limi-
tations on the ability of medical providers to initiate contraceptive methods ,
provision of contraceptive misinformation to patients by medical providers,
and regulatory or financial barriers limiting contraceptive dissemination to
certain populations such as adolescents or undocumented immigrants.
Delayed initiation
The perceived need to delay initiation of contraception to ‘‘rule out
pregnancy’’ can result in high rates of unwanted pregnancy when sexually
E-mail address:
0889-8545/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ogc.2007.01.003 obgyn.theclinics.com
Obstet Gynecol Clin N Am
34 (2007) 19–29
active women wait for their next menses or a prolonged period of absti-
nence before initiating hormonal contraception. These practice patterns of-
ten stem from provider misconceptions regarding the potential for
teratogenicity or adverse fetal effects if hormonal contraception is initiated
during the luteal phase of a cycle in which a woman has conceived. A
meta-analysis has demon strated that oral contraceptives are not terato-
genic [5]. Current World Health Organization (WHO) recommendations
support starting oral contraceptives, hormonal patch, vaginal ring, or in-
jectable medroxyprogesterone within the first 5 days after each menses
without need for additional contraceptive backup (eg, condoms) during
that cycle [6]. WHO supports starting these hormonal methods later in
the cycle if the clinician is ‘‘reasonably certain’’ (Box 1) that a woman is

not pregnant, with a recommendation to abstain from intercourse or use
a contraceptive backup for 7 days [6]. If these criteria are not met the
woman is not eligible for hormonal initiation until the next menstrual cy-
cle per WHO recommendations.
The Quick Start method of initiating oral co ntraceptives (OCs) is an al-
ternative to the traditional approach of starting combined OCs on the
Sunday after a menses [7]. The Quick Start approach was designed to ad-
dress two problems: conception occurring during the delay in initiation re-
quired by the conventional approach and the realization that many wom en
never initiated their prescribed contraceptives [8]. In the Quick Start
method women may start OCs any time during their cycle as long as
they have a negative urine pregnancy test. The initial pill is taken in the
clinic and the woman is instructed in use of a backup contraceptive for
the first 7 days. In a randomized controlled trial, short-term follow-up
Box 1. WHO criteria for ‘‘reasonable certainty’’ a woman
is not pregnant*
Reasonable certainty that a woman is not pregnant is based on
any of the following:
 Fully or nearly fully breastfeeding within 6 months of delivery
and not having returned to menses
 Abstinence from intercourse since the last menses
 Within the first 4 postpartu m weeks
 Menses, miscarriage, or abortion within the last 7 days
 Using a reliable contraceptive method correctly
* WHO Department of Reproductive Health and Research. Selected Practice
Recommendations for Contraceptive Use. 2nd ed. Geneva (Switzerland): World
Health Organization; 2004.
20
LEEMAN