Friday, February 19, 2016
Timing is everything
Quick: Which US state has the highest rate of unintended pregnancy?
I'll reveal below, but I learned the answer and several other surprising facts in an interview with Mark Edwards, the co-founder of Upstream USA, a non-profit advocacy organization that provides technical assistance to health enterprises (medical practices, clinics, public health departments) in the use of long-acting, reversible contraceptives (known in the trade as LARC).
LARC consists of two options: IUDs (intrauterine devices) and implants, which are small, match-sized, plastic rods that deliver a slow, steady dose of hormone to prevent pregnancy. They are planted in the upper arm of women to provide another form of hassle-free contraception.
Both of these methods can be discontinued at any time, at which point fertility returns—faster, I'm told, than in the case of oral contraceptives.
Here's a fact that surprised me about oral contraceptives (aka “The Pill”): Though when taken reliably their ‘success rate’ as a means of preventing unwanted pregnancy is considered to be 99%, over a 10 year use period, due to the challenging nature of remembering to take a daily pill, it's likely that 61% of those taking the pill exclusively for birth control will become pregnant. Most definitely not the intended outcome. (Source: here.)
Big picture: every year in the U.S., there are about 6.6 million pregnancies. Of those, 3.4 million, or slightly more than half, are accidental: either altogether unwanted or “significantly mistimed,” what we in the health care business describe as a pregnancy occurring 2 or more years before desired. The vast majority of these accidental pregnancies occur in women in their 20s (though teen pregnancy is a concern, only 20% of unplanned pregnancies are in teens, and the vast majority of those are in women 18-19 years old. In fact, the teen pregnancy rate has fallen significantly in the last 25 years).
That's why, regardless of your politics, offering LARC to any woman of childbearing age is crucial. At the very first visit. As a primary care doc myself, I know that “family planning” often falls down the list of concerns for patients that I see because there are so many other issues people wish to bring up in our short office visits. Thus, opportunities to provide women with LARC often fall through the cracks.
Upstream USA's methodology includes technical assistance: training staff up to ask every woman that comes in a simple question: “Do you intend to get pregnant in the next year?”
If “yes,” proceed on to other matters. If “no,” offer LARC right then and there. And the provider (doctor, nurse practitioner, or physician assistant) is trained up to put in an IUD or implant on the spot. No waiting until next time.
Why is this so important? Women with unplanned pregnancies are at greater risk for staying or falling into poverty. Their opportunity to advance in their education is diminished. Children should be brought into the world wanted, with parents that are prepared, and with the maturity and resources to succeed.
It's a fundamental choice for a woman to decide if and when she wants to have children. Of course, fewer unplanned pregnancies also means less need for abortion.
So what Upstream USA is offering is win-win-win. It's bipartisan—a rare area that people on all sides of the political spectrum can agree upon. Upstream USA's first big success was in none other than Texas. The organization also has partnerships in a number of other Red and Blue states.
The state with the highest rate of unplanned pregnancy? Surprisingly, Delaware. Upstream USA is there, too. And going big across the whole state.
This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
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