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© 2004 American Public Health Association
EDITORIAL |
The author chairs the board of directors of Physicians for Reproductive Choice and Health.
Correspondence: Requests for reprints should be sent to Wendy Chavkin, MD, MPH, Heilbrunn Center for Population and Family Health, Mailman School of Public Health, 60 Haven Ave, B-2, New York, NY 10032 (e-mail: wc9{at}columbia.edu).
It would be useful to be writing about ways to move forward creatively to tackle the daunting reproductive health problems that trouble the world. In the United States, these include rapidly rising rates of sexually transmitted HIV infection among young women and striking disparities between the many women experiencing unwanted pregnancies and those desperately pursuing quasi-experimental assisted reproductive technologies to achieve pregnancy. The developing world also confronts high rates of HIV and unwanted pregnancy, with the latter too often leading to deaths from illegal abortion. Lack of access to modern obstetric technology in parts of the developing world makes pregnancy a high-risk venture and contributes to maternal mortality rates at premodern levels. Yet here in the United States we are forced to keep our attention turned backward, to continue defending earlier advances from the unrelenting assault of the Bush administration on access to and correct information about abortion, contraception, and HIV prevention.
The articles in this issue of the Journal by Zavodny,1 Ness et al.,2 Kurth et al.,3 Goldman et al.,4 and Greene Foster et al.5 underscore the need for vigilance and suggest some new angles of approach. Early in the American AIDS epidemic, condoms were identified as critically useful in preventing sexually transmitted infections. There were many creative efforts to promote their use by gay men and to persuade heterosexual couples that they were a necessary complement to nonbarrier contraceptive methods. Gratifyingly, these efforts showed success, and condom use rose in both groups.6 However, such efforts were immediately challenged by those who asserted that such education served to promote promiscuity—despite numerous studies demonstrating that condom promotion did not encourage people to become sexually active but rather encouraged them to use condoms if they were already active.7 The critics then turned to disparaging the efficacy of condoms and embarked on a series of misinformation campaigns claiming that condoms did not protect against sexually transmitted infections.8,9
It is in this context that the study by Ness et al. is so important. Ness and colleagues report on the relationship between condom use and pelvic inflammatory disease (PID)–related morbidity in a large multisite longitudinal study. The majority of women with PID were considered to be at high risk for adverse outcomes as they were young, poor, of minority status, and not well educated and, by definition, already had a sexually acquired infection. Use of condoms reduced risks for all the major sequelae of PID: recurrence, chronic pelvic pain, and infertility. Until we develop something new and easy to use that can simultaneously protect against pregnancy and infection, condoms remain a girl’s best friend.
The efficacy and morality of other contraceptive methods have also been questioned. Recent efforts have been directed against requiring insurance companies to cover the cost of contraceptives and against ready access to emergency contraception over the counter and in emergency rooms for rape victims. Yet 2 studies reported in this issue demonstrate both the estimated public health impact of ready access and public appreciation of the import of contraception.
Greene Foster et al. used pharmacy and clinician claims and medical records to estimate contraceptive use and the number of pregnancies averted by California’s Family PACT (Planning, Access, Care and Treatment) Program. They concluded that in the first year of this program, which was designed to provide family planning to low-income uninsured Californians, more than 100 000 unintended pregnancies were averted that would have resulted in 50 000 unintended births and 41 000 abortions. Kurth et al. surveyed a random sample of adults in the neighboring state of Washington and found that both men and women valued contraceptives highly and thought that insurance should cover them. In contrast to stereotypical predictions, both those past reproductive age and low-income men supported coverage of contraceptives.
The many-pronged attacks on abortion since its legalization in the United States 30 years ago have led to a grievously contracted provider pool, as institutional medicine has failed to embrace this service and abortion providers have endured marginalization, stigma, harassment, and murder. One response has been to widen the potential provider pool beyond obstetrician-gynecologists and to enlist family practitioners and midlevel clinicians, such as advanced practice nurses, midwives, and physician assistants. Goldman et al. compared complication rates after surgical abortions performed by physician assistants with rates after abortions performed by physicians and found them to be similarly low. This study confirms previous work demonstrating the safety and efficacy of surgical abortion and offers reassurance that recruitment of midlevel clinicians as providers does not compromise this high level of performance.10 Midlevel clinicians have been participating in provision of medical abortion since the Food and Drug Administration (FDA) approved the use of the medical abortifacient mifepristone in 2000.
The FDA’s approval of mifepristone was unusually cumbersome, which makes prescribing it onerous even in comparison with known teratogens such as retinoic acid.11 Nevertheless, mifepristone use has risen steadily in the United States. It is widely used throughout the world, with several million woman-years of experience in Europe and Asia.12 While the advantage of medical abortion in the developing world is ease of administration in situations where technological resources are scarce, its significant advantage in the United States is the promise of privacy. Medical abortion can be provided by clinicians of varying backgrounds (as long as they undergo training and have obstetrical-gynecological backup) and within a regular office practice setting, as no equipment is necessary (although ultrasound is desirable). Therefore, potentially, an expanded pool of providers could integrate this service into the care they provide and patients could avoid the picketers and threats of violence currently obstructing their access to identifiable abortion clinics.
Access to the basic components of reproductive health care discussed in these articles—contraception, condoms for prevention of sexually transmitted infections as well as pregnancies, and legal abortion—remains limited and contested in many parts of the globe. In the United States, even as we move forward with medical abortion and emergency contraception and the widening of the provider pool, we spend too much of our time fighting rearguard actions, defending the basic premises of scientific inquiry and doctor–patient confidentiality.
Although the scientific advisory committee of the FDA overwhelmingly (23 to 4) supported changing emergency contraception from prescription-only to over-the-counter status, the commissioner has refused to do so.13 Doctors are challenging the "partial birth abortion" ban, claiming that it is unconstitutional because it does not provide for exceptions for the woman’s health and thus violates the framework established by Roe v Wade, which specifies the primacy of maternal health throughout pregnancy. The US attorney general, when preparing to defend the ban against this legal challenge, requested individual patient charts and demanded that the plaintiff physicians identify all those they had trained to perform this illdefined procedure, as well as colleagues who perform it.14 Thus in one move, the attorney general tried to turn doctors into informants against their colleagues as well as their patients and to violate the confidentiality guarantees governing medical care. Violations of these principles and of the scientific process have implications beyond the specifics of abortion and contraception that threaten the entire medical and public health enterprise.
The scientific evidence reported in these articles should lead us to refine treatments and policies so as to improve reproductive health. In reality, however, these data will contribute to improved health only if the public health community joins the effort to create a policy environment in which science and human need prevail over ideology.
Accepted for publication April 10, 2004.
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1. Zavodny M.Fertility and parental consent for minors to receive contraceptives. Am J Public Health. 2004;94:1347–1351.
2. Ness RB, Randall H, Richter HE, et al. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. Am J Public Health. 2004;94:1327–1329.
3. Kurth A, Weaver M, Lockhart D, Bielinski L. The benefit of health insurance coverage of contraceptives in a population-based sample. Am J Public Health. 2004;94:1330–1332.
4. Goldman MB, Occhiuto JS, Peterson LE, Zapka JG, Palmer RH. Physician assistants as providers of surgically induced abortion services. Am J Public Health. 2004;94:1352–1357.
5. Foster GD, Klaisle CM, Blum M, Bradsberry ME, Brindis CD, Stewart FH. Expanded state-funded family planning services: estimating pregnancies averted by the Family PACT Program in California, 1997–1998. Am J Public Health. 2004;94:1341–1346.
6. Piccinino L, Mosher W. Trends in contraceptive use in the United States: 1982–1995. Fam Plann Perspect. 1998;30:4–10.[Web of Science][Medline]
7. World Health Organization, Department of Reproductive Health and Research. Communicating family planning in reproductive health. 1997. Available at: http://www.who.int/reproductive-health/publications/fpp_97_33/fpp_97_33_2.en.html. Accessed April 22, 2004.
8. Union of Concerned Scientists. Scientific integrity in policymaking: an investigation into the Bush administration’s misuse of science. 2004. Available at: http://www.ucsusa.org/global_environment/rsi/page.cfm?pageID=1322. Accessed April 22, 2004.
9. Politics and science: investigating the state of science under the Bush administration. Presented by Henry Waxman, ranking member, Committee on Government Reform, US House of Representatives. August 2003. Available at: http://www.house.gov/reform/min/politicsandscience/report.htm (PDF file). Accessed April 22, 2004.
10. Schirmer JT. Physician assistant as abortion provider: lessons from vermont, New York, and Montana. Hastings Law J. 1997;49:253–288.[Medline]
11. Mifeprex prescriber’s agreement. Available at: http://www.fda.gov/cder/drug/infopage/mifepristone/prescriberagreement.pdf (PDF file). Accessed May 28, 2004.
12. FDA approves mifepristone for early termination of pregnancy. FDA Consumer Magazine. November–December 2000. Available at: http://www.fda.gov/fdac/features/2000/600_ru486.html. Accessed April 22, 2004.
13. FDA chooses politics over science, delays decision on emergency contraception; data show plan B meets FDA criteria for OTC. US Newswire. February 13, 2004. Available at: http://releases.usnewswire.com/GetRelease.asp?id=138-02132004. Accessed April 22, 2004.
14. Lerner S. Attorney general demands patients’ private abortion records: Ashcroft terrorizes New York doctors. Village Voice. March 10–16, 2004. Available at: http://www.villagevoice.com/issues/0410/lerner.php. Accessed April 22, 2004.
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