By Jeffrey T. Jensen, MD, MPH

Leon Speroff Professor and Vice Chair for Research, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland

Dr. Jensen reports that he is a consultant for and receives grant/research support from Bayer, Abbvie, ContraMed, and Merck; he receives grant/research support from Medicines 360, Agile, and Teva; and he is a consultant for MicroChips and Evofem.

The evidence strongly suggests that comprehensive family planning services provided under the Affordable Care Act (ACA) that include subsidized coverage for highly effective long-acting reversible contraception (LARC) have contributed to a decrease in the rate of unintended pregnancy and a sharp decline in abortions. Policy changes proposed by the Trump administration threaten to dismantle these advances by eliminating the family planning safety net by defunding Planned Parenthood (PP) and abolishing the contraception coverage mandate of the ACA. Reduced access to contraception could increase unintended pregnancy and abortion. At the same time, an attack on abortion rights threatens access to safe legal services in many parts of the United States, and the new administration has promised to work to overturn the Roe v Wade decision. As women’s healthcare providers, we should be leaders in standing up to policy changes that will endanger women and threaten our most vulnerable citizens.

Let’s review our current situation. Estimates from the U.S. Census Bureau place the world’s human population at slightly less than 7.4 billion, of which more than 1.6 billion are reproductive age women. Although fertility rates in both developed and developing countries have declined, the world population is expected to exceed 11 billion by 2100 before gradually stabilizing. This assumes that we reach an average worldwide total fertility rate (TFR) of 2.1. If half of women add in the “third child” (e.g., a TFR of 2.6), the population will increase to about 17 billion by 2100 with no leveling. Instead, if many women worldwide decided to give birth to a single child (TFR = 1.6), the population would continue to increase, peaking at around 9 billion by 2050 before poetically decreasing to end the 21st century at about 6 billion, the number of humans in 1999. (See Figure 1.) The large number of young people in the prime reproductive years explains this population momentum. (See Figure 2.) Although most of this youth population bulge exists outside of North America and Europe, these young people have the same hopes and dreams for their families that we have for our own. Many social scientists find that the large numbers of unemployed young men contribute to the increase in violence and terrorism in many regions where political violence is prevalent. In a recent cross-national, time-series study of the period 1950-2000, Urdal et al found a significant increase in conflict outbreak in the presence of youth bulges even when controlling for other factors, such as level of development, democracy, and conflict history.1 For every percentage point increase in the youth population relative to the adult population, the risk of conflict increases by more than 4%. In most developed countries, 15- to 24-year-olds average about 15% of the total adult population. In contrast, more than 40 developing countries experienced youth bulges of 35% or more. When youth make up more than 35% of the adult population, the risk of armed conflict is 150% higher than in countries with stable youth populations.1 In short, I worry about a nationalist pronatalistic agenda that turns away from family planning at home and also undermines the importance of international family planning assistance during this critical point in human history.

Figure 1: World Population Growth According to the Median Fertility Scenario

World population growth according to the median fertility scenario (Total Fertility Rate (TFR) of 2.1) with 80% (dashed) and 95% (dotted) prediction intervals. The upper and lower lines indicate TFR of ± 0.5 (e.g., TFR 2.6 and TFR 1.6).

Figure 1

SOURCE: United Nations Department of Economic and Social Affairs, Population Division (2015).

Figure 2: World Youth Population Growth According to the Median Fertility Scenario

World youth (age 0 – 24) population growth according to the median fertility scenario (Total Fertility Rate (TFR) of 2.1) with 80% (dashed) and 95% (dotted) prediction intervals. The upper and lower lines indicate TFR of ± 0.5 (e.g., TFR 2.6 and TFR 1.6).

Figure 2

SOURCE: United Nations Department of Economic and Social Affairs, Population Division (2015).

By the time you read this, President Trump already may have signed legislation to make PP clinics ineligible to receive federal funds for providing healthcare services. President Obama prevented this attempt in the last Congress, citing the vital work of PP clinics. Although proponents of defunding PP argue that health departments and other federally qualified health centers (FQHCs) would fill the gaping hole torn in the family planning safety net, the evidence suggests otherwise.2 PP clinics consistently perform better than other types of publicly funded family planning providers and serve a greater share of women. In many areas, PP is the sole source of publicly funded contraceptive care. Most PP clinics also offer same-day appointments and are more likely to accommodate clients who have difficulty taking time off from work or family.2 Most importantly, PP clinics offer the full range of approved contraceptive methods (including the most effective LARC methods), while only two-thirds of health departments and only half of FQHCs have this capacity. Also, nearly all PP clinics offer same-day LARC placement, another big difference from both health departments and FQHCs. Finally, PP clinics provide on-site availability of oral contraceptives, and typically will provide a full year supply, a particular benefit for low-income women. Defunding PP clinics while reducing public funding for contraception through the ACA will reduce access for millions of low-income American women. In 2010, PP sites accounted for only 10% of all publicly funded family planning clinics but served 36% of publicly funded contraceptive clients.3 In more than 300 U.S. counties, PP acts as a primary safety-net health center for family planning. About a third of all women relying on publicly funded contraceptive services live in one of these counties. In 2014, more than 20 million U.S. women required publicly funded family planning services. This represents an increase of 1 million women since 2010.4 This need won’t go away with political rhetoric.

The ACA improved women’s lives and made communities better by ensuring access to highly effective contraception.5 The tens of millions of women who now face few cost barriers to obtaining contraception will see this benefit change with repeal of the ACA. Several studies have shown that the elimination of cost barriers between 2012 and 2014 has resulted in an increase in both use and continuation of prescription contraceptives and, in particular, LARC methods.6 Increased use of LARC methods has been associated with a decrease in the proportion of unintended pregnancies in the United States (from 51% in 2008 to 45% in 2011).7 How can a policy that benefits women and communities so directly be under attack?

Some cite opposition to abortion as reasons to defund these programs despite evidence that abortion rates have fallen dramatically as use of LARC methods has increased.7 Under the Hyde Amendment, federal law currently bans funding for abortion by all federally funded health programs, including Medicare, Medicaid, the Federal Employees Health Benefits Programs, TRICARE (military), Indian Health Service, and Bureau of Prisons. Of the roughly 7.5 million women covered by these programs, a disproportionate number (51%) are women of color.8 As a former U.S. Navy physician, my heart goes out to the more than 1.4 million military servicewomen and dependents denied abortion coverage. For more than 900,000 of these women, TRICARE is their only source of coverage. This funding ban applies equally to the undesired pregnancy at six weeks and the much desired but severely malformed and genetically abnormal fetus diagnosed at 22 weeks. I am familiar with many heartbreaking stories from active duty women denied abortion coverage for management of an abnormal fetus. More recently, several states have taken steps to restrict private insurance coverage of abortion, and 10 states currently have policies that restrict abortion coverage.8 We can only expect to see more restrictions and attempts to undermine abortion coverage under the new administration. Will these restrictions ultimately backfire as they affect more and more middle-class Americans?

My wife Robin and I attended the March for Women’s Lives event in Hilo, Hawaii, on January 21, 2017, in solidarity with millions of women and men in Washington, DC, and around the world. The event in Hilo on a stormy, rainy day attracted about 2,000 people. In my hometown of Portland, more than 100,000 marched in a pouring rain. My colleagues shared some of their favorite signs. One of the best, held by a 12-year old boy, said “What do we want?…’Evidence-based science!’…When do we want it?...’After peer-review!’”

Although we may feel sometimes that these mass events in the nation’s capital or in local communities make no difference, the prevalence of protests across the country and even in many countries around the world was heartening. As women’s healthcare clinicians, we are leaders in our communities. We need to stand up for science and educate our patients and communities. Our collective voices have great influence. Silence on these matters suggests acquiescence.

REFERENCES

  1. Urdal H. A Clash of Generations? Youth Bulges and Political Violence. International Studies Quarterly 2006;50:607-629.
  2. Hasstedt K. Understanding Planned Parenthood’s Critical Role in the Nation’s Family Planning Safety Net. Guttmacher Policy Review 2017;20:12-14.
  3. Frost JJ, Frohwirth L, Zolna MR. Contraceptive Needs and Services, 2013 Update. New York: Guttmacher Institute; 2015.
  4. Frost JJ, Zolna MR, Frohwirth L. Contraceptive Needs and Services, 2014 Update. New York: Guttmacher Institute; 2016.
  5. Sonfield A. What Is at Stake with the Federal Contraceptive Coverage Guarantee? Guttmacher Policy Review 2017;20:8-11.
  6. Carlin CS, Fertig AR, Dowd BE. Affordable Care Act’s mandate eliminating contraceptive cost sharing influenced choices of women with employer coverage. Health Affairs 2016;35:1608-1615.
  7. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med 2016;374:843-852.
  8. Donovan M. In Real Life: Federal Restrictions on Abortion Coverage and the Women They Impact. Guttmacher Policy Review 2017;20:1-7.