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Improving contraceptive technology: is it a zero-sum game?
Contraception 72 (2005) 321 – 322
Editorial
Improving contraceptive technology: is it a zero-sum game?
bFewer women using birth control. Experts see troubling spike in new numbersQ This was the headline of a story by journalist Ceci Connolly in the January 3, 2005, issue of the Washington Post. The data that prompted this article came from the National Center for Health Statistics surveys which had shown that the number of women in the United States who had sex in the previous 3 months but did not use birth control rose from 5.2% in 1995 to 7.4% in 2002, a statistically significant difference. In a country where almost half the pregnancies are already unplanned, this is a disturbing statistic as it would put at least 4.6 million sexually active women at risk of conceiving a child they had not planned. The traditional knee-jerk reaction to this news is to say that we need more and better methods of contraception that will appeal to more women and men who will use them more consistently. In short, we blame this sort of failure of men and women to use birth control on the imperfection of contraceptive technology and believe that if we could just find that perfect, or at least almost perfect, method of birth control, usage problems would diminish — or even disappear. Is this a reasonable assumption backed by evidence? Should we continue to urge governments and industry to put more effort and money into developing new and better methods of contraception with the hope that it will result in lower rates of unplanned pregnancies? To explore the answers to these questions, let us go back 40 years. According to the US Census Bureau in 1965 when the more modern and effective methods like the IUD and the pill were in their youth, 36.8% of married women in the United States did not use contraceptives. By 1995, when these methods had been improved and other methods had been added to the contraceptive cafeteria, 23.6% of married women still were not using birth control. If improved technology caused increase in usage of contraceptives, given the vast improvement in technology and methods over this period, one would expect something more than a 13% increase in use among these women. Even more discouraging are the statistics during this period for all — not just married — women ages 15– 44. In 1982, 55.7% 0010-7824/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2005.07.012
were using contraception; by 1995 the proportion had risen to 64.2%, but in 2002 it had fallen to 61.9% [1]. During the period discussed in the Washington Post article, 1995–2002, it seems paradoxical that falling usage was occurring while a spate of new or improved methods of contraception, the Nuva Ring, OrthoEvra, Lunelle, Yasmin and Mirena, to name just a few, were initially marketed in the United States. If improved technology were the answer, rates of contraceptive use should have increased rather than shown a decrease during this period. Looking at the same question, that is, relating technology to use with birth rate as the outcome measure, we find that in some countries where not all highly effective methods are available, the percentage of unwanted births is far lower than in the United States. The country where this was best demonstrated, perhaps, was in Japan. Until relatively recently, oral contraceptives were not approved for use in Japan, but the unplanned pregnancy rate was far below that of the United States. The condom and IUD were in use but less than 10% of the population had access to one of the most effective methods of birth control, oral contraceptives. Some will immediately say that the relatively low birth rate in the pre-pill day in Japan was due to a high abortion rate; however, according to the statistics reported by the Alan Guttmacher Institute [2], the abortion rate in Japan was 14/1000, while it was 26/1000 in the United States. The point is that lower birth rates were possible even when the population did not have access to the most effective methods. From this rather superficial look at the evidence, it seems that improving contraceptives technically, even though they become safer, more effective and even more user friendly with far less bobstacles to use,Q is not the only answer to increasing usage and decreasing unwanted pregnancies in any population. If improving the technology and developing with better birth control will not solve this problem, what will? The classic description of the perfect contraceptive is one that is 100% effective, safe, reversible, easy to use, has few side effects and is affordable. (It is somewhat amusing to think we are still looking forward to the perfect contraceptive when if we look backward, we might have already found it, at least according to this definition, in the chastity
322
Editorial / Contraception 72 (2005) 321 – 322
belt!) Technology has brought us close to meeting these metrics, but the data cited above indicate that we are still not reaching our goals of increasing contraceptive use and reducing unplanned and often unwanted pregnancies in the United States. Methods may be perfect, but people are not. While we have relentlessly pursued improving the technology of the method, we have been less successful, particularly in the United States, in making these excellent methods widely accessible and acceptable. The rate-limiting step for contraceptive use in the US as in many other areas of the world is accessibility. From countries whose economy is largely rural and agricultural, and the population is difficult to reach, to the United States where, although many forms of highly effective contraception are available, too many women seek methods they cannot afford, the effectiveness of the method in reducing unplanned pregnancy in either case is restricted by the delivery system. Accessibility, whether financial, geographic or cultural, is the real problem that limits contraceptive effectiveness in a population. In the overall picture, whether the effectiveness of a method is 80% or 95% is of little consequence to a man or woman for whom it is 100% inaccessible. It remains important that we continue seeking better methods of contraception that are more effective and safer, simply because they are better and safer. If we truly want to decrease the rate of unplanned pregnancy, scientists and physicians must stop spending so much time tweaking the technology and become more involved in the wider world in which contraception is delivered. In many nations where the unintended pregnancy rate is low, reproductive health including contraception is part of the overall health coverage, which is available to all citizens of the country. In the United States, millions of people have no health care insurance because they make too much money to qualify for government assistance but not enough to pay for health care, and less than half of the states require insurance
companies to cover prescription methods of contraception for those who do have health care. Countries without the economic benefits of the US provide better overall health and wellness care to their citizens. Many governments have made it a focus of health care to provide access to birth control for women and families, and thus to decrease the number of unplanned births. Technology has taken us as far as it can, but it is not far enough. To paraphrase Shakespeare’s famous line, bThe fault, dear Brutus, lies not in our stars, but in ourselvesQ; the fault lies not with the imperfection of the contraceptive technology, but in the world in which it exists. To decrease the number of unintended pregnancies in the United States or any other nation, perhaps the time has come for those involved in reproductive health care to stop trying to change the technology and start trying to change the world in which it exists. Lee Lee Doyle College of Medicine University of Arkansas for Medical Sciences Little Rock, AR 72205-7199, USA Wayne C. Shields President and CEO Association of Reproductive Health Professionals Washington, DC 20037, USA E-mail address: [email protected]
References [1] Mosher WD, Martinez GM, Chandra A, Abma JC, Willson SJ. CDC Division of Vital Statistics. Use of contraception and use of family planning services in the United States: 1982–2002. CDC Advance Data #350, December 10, 2004. [2] Sharing responsibility. Women, society, and abortion worldwide. New York7 The Alan Guttmacher Foundation; 1999.
Editorial
Improving contraceptive technology: is it a zero-sum game?
bFewer women using birth control. Experts see troubling spike in new numbersQ This was the headline of a story by journalist Ceci Connolly in the January 3, 2005, issue of the Washington Post. The data that prompted this article came from the National Center for Health Statistics surveys which had shown that the number of women in the United States who had sex in the previous 3 months but did not use birth control rose from 5.2% in 1995 to 7.4% in 2002, a statistically significant difference. In a country where almost half the pregnancies are already unplanned, this is a disturbing statistic as it would put at least 4.6 million sexually active women at risk of conceiving a child they had not planned. The traditional knee-jerk reaction to this news is to say that we need more and better methods of contraception that will appeal to more women and men who will use them more consistently. In short, we blame this sort of failure of men and women to use birth control on the imperfection of contraceptive technology and believe that if we could just find that perfect, or at least almost perfect, method of birth control, usage problems would diminish — or even disappear. Is this a reasonable assumption backed by evidence? Should we continue to urge governments and industry to put more effort and money into developing new and better methods of contraception with the hope that it will result in lower rates of unplanned pregnancies? To explore the answers to these questions, let us go back 40 years. According to the US Census Bureau in 1965 when the more modern and effective methods like the IUD and the pill were in their youth, 36.8% of married women in the United States did not use contraceptives. By 1995, when these methods had been improved and other methods had been added to the contraceptive cafeteria, 23.6% of married women still were not using birth control. If improved technology caused increase in usage of contraceptives, given the vast improvement in technology and methods over this period, one would expect something more than a 13% increase in use among these women. Even more discouraging are the statistics during this period for all — not just married — women ages 15– 44. In 1982, 55.7% 0010-7824/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2005.07.012
were using contraception; by 1995 the proportion had risen to 64.2%, but in 2002 it had fallen to 61.9% [1]. During the period discussed in the Washington Post article, 1995–2002, it seems paradoxical that falling usage was occurring while a spate of new or improved methods of contraception, the Nuva Ring, OrthoEvra, Lunelle, Yasmin and Mirena, to name just a few, were initially marketed in the United States. If improved technology were the answer, rates of contraceptive use should have increased rather than shown a decrease during this period. Looking at the same question, that is, relating technology to use with birth rate as the outcome measure, we find that in some countries where not all highly effective methods are available, the percentage of unwanted births is far lower than in the United States. The country where this was best demonstrated, perhaps, was in Japan. Until relatively recently, oral contraceptives were not approved for use in Japan, but the unplanned pregnancy rate was far below that of the United States. The condom and IUD were in use but less than 10% of the population had access to one of the most effective methods of birth control, oral contraceptives. Some will immediately say that the relatively low birth rate in the pre-pill day in Japan was due to a high abortion rate; however, according to the statistics reported by the Alan Guttmacher Institute [2], the abortion rate in Japan was 14/1000, while it was 26/1000 in the United States. The point is that lower birth rates were possible even when the population did not have access to the most effective methods. From this rather superficial look at the evidence, it seems that improving contraceptives technically, even though they become safer, more effective and even more user friendly with far less bobstacles to use,Q is not the only answer to increasing usage and decreasing unwanted pregnancies in any population. If improving the technology and developing with better birth control will not solve this problem, what will? The classic description of the perfect contraceptive is one that is 100% effective, safe, reversible, easy to use, has few side effects and is affordable. (It is somewhat amusing to think we are still looking forward to the perfect contraceptive when if we look backward, we might have already found it, at least according to this definition, in the chastity
322
Editorial / Contraception 72 (2005) 321 – 322
belt!) Technology has brought us close to meeting these metrics, but the data cited above indicate that we are still not reaching our goals of increasing contraceptive use and reducing unplanned and often unwanted pregnancies in the United States. Methods may be perfect, but people are not. While we have relentlessly pursued improving the technology of the method, we have been less successful, particularly in the United States, in making these excellent methods widely accessible and acceptable. The rate-limiting step for contraceptive use in the US as in many other areas of the world is accessibility. From countries whose economy is largely rural and agricultural, and the population is difficult to reach, to the United States where, although many forms of highly effective contraception are available, too many women seek methods they cannot afford, the effectiveness of the method in reducing unplanned pregnancy in either case is restricted by the delivery system. Accessibility, whether financial, geographic or cultural, is the real problem that limits contraceptive effectiveness in a population. In the overall picture, whether the effectiveness of a method is 80% or 95% is of little consequence to a man or woman for whom it is 100% inaccessible. It remains important that we continue seeking better methods of contraception that are more effective and safer, simply because they are better and safer. If we truly want to decrease the rate of unplanned pregnancy, scientists and physicians must stop spending so much time tweaking the technology and become more involved in the wider world in which contraception is delivered. In many nations where the unintended pregnancy rate is low, reproductive health including contraception is part of the overall health coverage, which is available to all citizens of the country. In the United States, millions of people have no health care insurance because they make too much money to qualify for government assistance but not enough to pay for health care, and less than half of the states require insurance
companies to cover prescription methods of contraception for those who do have health care. Countries without the economic benefits of the US provide better overall health and wellness care to their citizens. Many governments have made it a focus of health care to provide access to birth control for women and families, and thus to decrease the number of unplanned births. Technology has taken us as far as it can, but it is not far enough. To paraphrase Shakespeare’s famous line, bThe fault, dear Brutus, lies not in our stars, but in ourselvesQ; the fault lies not with the imperfection of the contraceptive technology, but in the world in which it exists. To decrease the number of unintended pregnancies in the United States or any other nation, perhaps the time has come for those involved in reproductive health care to stop trying to change the technology and start trying to change the world in which it exists. Lee Lee Doyle College of Medicine University of Arkansas for Medical Sciences Little Rock, AR 72205-7199, USA Wayne C. Shields President and CEO Association of Reproductive Health Professionals Washington, DC 20037, USA E-mail address: [email protected]
References [1] Mosher WD, Martinez GM, Chandra A, Abma JC, Willson SJ. CDC Division of Vital Statistics. Use of contraception and use of family planning services in the United States: 1982–2002. CDC Advance Data #350, December 10, 2004. [2] Sharing responsibility. Women, society, and abortion worldwide. New York7 The Alan Guttmacher Foundation; 1999.