In contraception, the U.S. is far behind the developing world

A woman needing help would do better in India than in Baltimore

September 26, 2010|By Amy Tsui

Today, on World Contraception Day, the Surya clinic in Patna city in the Indian state of Bihar will, as always, be full of women, their children and their travel companions, waiting to see the doctors for family planning services. The female doctors are young, many recent graduates of the medical colleges, and sometimes pairing up to counsel clients on contraceptive methods. The government of India has accredited this private clinic run by the Janani network so that women opting for birth control pills, a 10-year IUD, or a three-month injectable contraceptive pay nothing. The government reimburses private clinics offering these services.

If a woman wants condoms, she can select among a range of provocatively illustrated packages at a local pharmacy and purchase them for 4 cents apiece. She can also purchase, without prescription, a cycle of Apsara birth control pills for 11 cents, or a packet of two emergency contraception pills for the same amount. If she opts for the injectable or the IUD, she will pay just over $1. Sterilizations, popular among Indian women and some men who have finished their childbearing, involve a one-time cost of $22.22, again subsidized by the government in their own or accredited private clinics.

Here in Baltimore, where the rate of teenage pregnancy is among the highest nationally, the waiting rooms at the local Planned Parenthood clinic are also busy. But here a woman obtaining birth control faces costs of $30 to $36 for a one-month cycle of pills, $70 to $210 for the same long-term IUD dispensed in India, and $8 to $50 for a DepoProvera shot (or $32 to $200 over a year). She can purchase condoms in pharmacies for approximately $1 apiece. The U.S. government is not there to subsidize her costs, and health insurers have been elusive if not obstructionist.

India, with a per-capita income one-fifth the U.S. level, has seen fit to cover the birth control costs for its 102 million contraceptive users, whether at a public health clinics or a private clinic. In the U.S., 38.2 million contraceptive users bear the full financial burdens. Except for Medicaid-eligible clients, the financial costs are subject to the vagaries of health insurance plans. Ironically, medication for erectile dysfunction of an American man is covered by health insurance.

This summer, under health care reform efforts, the federal government has begun to offer to cover 90 percent of states' costs of expanded Medicaid family planning programs, including services for vasectomies, sexually transmitted infection testing and Pap smears, for states — like Maryland — that opt in. But even this choice has seen political pushback in some states.

There are 62 million American women between ages 15 and 44, and three-fifths of them use birth control. Family planning has become as much as part of healthy living as clean water, child immunization, nutritious food and workplace safety. In fact, 10 years ago the U.S. Centers for Disease Control and Prevention declared family planning one of the 10 great public health achievements of the 20th century. The national mindset — even under health care reform — does not seem to agree or care.

Contraception, which enables partners to plan their family sizes and time births, also separates coitus from conception. Partners do not to have to overcome passion and abstain but can enjoy sex without the worry of an accidental conception. Avoided also are the moral dilemmas of managing an unplanned pregnancy. Conceptions that used to happen to older women no longer pose life threatening risks. Better protection means that intervals before the next pregnancy are longer and increase the number of infants born full term and of appropriate birthweight. Mothers are healthier, retaining their nutritional and energy stores better between pregnancies and also able to return to work and contribute to the family income. Unfortunately, pharmaceutical companies are wary of investing further in contraceptive R&D, despite the steady consumer base. Today's birth control options, while improved, are essentially based on those prepared for our parents' use.

In 2005, the latest year with available national data, there were 4.14 million births in the U.S. and 1.21 million induced abortions. Contraception has mistakenly become tainted by the stigmatization around induced abortion. Instead of encouraging and facilitating the responsible practice of contraception by sexually active individuals, we are forcing women and men to build their birth control habits through trial and error.

Although Sept. 26 is observed as World Contraception Day, avoiding accidental pregnancies is a concern for every day. We should be energetically working to assure insurance coverage and streamlining reimbursement procedures, liberalizing over-the-counter access to birth control pills, and providing good counseling about contraceptive options to prevent misinformation and misconceptions.

Amy Tsui is a professor in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health and director of the Bill & Melinda Gates Institute of Population & Reproductive Health. Her e-mail is atsui@jhsph.edu.

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