An Open and Fruitful Discussion

Hi All,
First off, kudos to Iris, Shayne and Yeshika for coordinating a terrific session last night. Also kudos to our panelists - Matt, Emily, Mo, Mike, Sarah, Drs Foster and Harris. Lastly, kudos to all the students who contributed to a terrific turn out for our discussion!
So, here's what I heard around which we had consensus:
  *We can gather together having different points of view and have a robust discussion about making a difference with our patients.
  *Docs should be skilled to deliver effective health and sex education to their patients (and parents.)
  *In ways small and large, there is a great interest in helping promote safety of children so that they have as many options available to them.
  *Lives of our patients may be very different than our own, so imposing our attitudes and expectations may not be a 'best fit.'
   *Patient autonomy and respect are important.
   *We can be respectful of difference in opinions but facts and opinions are two very different things and excellent clinicians based actions on evidence.
   *Free condoms never hurt!
   *Women's reproductive choices play an important part of their lives and are never a trivial matter.
Regrettably, we weren't able to 'solve' the healthcare delivery and finance problem in the time provided. We did have an engaging discussion about divergent opinions and varied viewpoints.

So from a least to most about getting involved or learning more - here's some after-care sites to check out:

THE NUMBERS: Numbers and trends of abortion
*Abortion is one of the most frequently performed procedures in the U.S. Abortion rates have steadily declined since the procedure was legalized in 1974; however, the rate of decline has been slowing down since 2000.

*Of the 49% of unplanned pregnancies (2001), 24% ended in abortion (this number excludes miscarriages)
*This 24% consisted of 16% of currently married, 16% formerly married and 67% never-married women.
*61% of abortions were obtained by women who have one or more child
*The majority of women who obtained an abortion (54%) were using some type of contraceptive method (that failed due to inconsistent or incorrect use) 13-14% (pill vs condom) uses reported correct use and method failure.


References Finer LB, Henshaw SK. Estimates of U.S. Abortion Incidence, 2001–2003. Guttmacher Institute. August 3, 2006. Available at http://www.guttmacher.org/pubs/2006/08/03/ab_incidence.pdf. Accessed September 09, 2006.; Jones RK, Darroch JE, Henshaw SK. Patterns in the socioeconomic characteristics of women obtaining abortions in 2000–2001. Perspectives in Sexual and Reproductive Health. September/October 2002; 34(5):226–235. ; Jones RK, Finer LB and Singh S, Characteristics of U.S. Abortion Patients, 2008, New York: Guttmacher Institute, 2010.; Jones RK, Darroch JE and Henshaw SK, Contraceptive use among U.S. women having abortions in 2000–2001, Perspectives on Sexual and Reproductive Health, 2002, 34(6):294–303.
*ABOUT 1/3 - An estimated 35% of women will have at least 1 abortion by the time they are 45 years old.
Reference  Boonstra HD, Gold RB, Richards CL, Finer LB. Abortion in Women’s Lives. New York, NY: Guttmacher Institute; 2006.

OVERALL DOWN TRENDING RATES

References 
Finer LB and Zolna MR, Unintended pregnancy in the United States: incidence and disparities, 2006, Contraception, 2011, doi: 10.1016/j.contraception.2011.07.013.

Jones RK and Kooistra, K., Abortion incidence and access to services in the United States, 2008, Perspectives on Sexual and Reproductive Health, 2011, 43(1):41-50.
*Abortion rates are trending downward - The CDC reported a 2% drop in rates (see here)
A number of factors contribute to the overall decline in abortion rates in the US:   1. More and better contraceptive options; 2. Increased and improved contraceptive use, particularly of long-term contraceptives;     3. Decreased access because of fewer providers and/or anti-choice harassment and stigmatization         (This study did not delineate differences in age, income levels or other factors)
References  Finer LB, Henshaw SK. Abortion incidence and services in the United States in 2000. Perspectives on Sexual and Reproductive Health. January/February 2003; 35(1):6–15.

*AGE RANGE FOR HIGHEST RATES: 56.9% of abortions occurred in women ages 20-29 (29.4 abortions per 1,000 women aged 20--24 years and 21.4 abortions per 1,000 women aged 25--29 years).

TEEN DATA
Eighteen percent of U.S. women obtaining abortions are teenagers; those aged 15–17 obtain 6% of all abortions, teens aged 18–19 obtain 11%, and teens younger than age 15 obtain 0.4%
In contrast to the overall unintended pregnancy rate of 49%, teens unintended pregnancy rate is 82% with 40% of these ending in abortion.
Reference   Jones RK, Finer LB and Singh S, Characteristics of U.S. Abortion Patients, 2008, New York: Guttmacher Institute, 2010; Finer LB, Henshaw SK. Disparities in Rates of Unintended Pregnancy In the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health. 2006; 38(2):90–96.

PARENTAL NOTIFICATION AND IMPACT - Fear is a health hazard for teens

Parental notification laws have a negative impact on adolescents’ access to reproductive health care.


According to the American Medical Association and the Society for Adolescent Medicine, the primary reason that adolescents often do not get the health care they need is that they fear disclosure of confidential information to their parents or guardians.

A regional survey of suburban adolescents found that less than 20% would seek care related to birth control or STDs if parental notice was mandated.

Another study found that 59% of sexually active adolescent girls would stop, delay, or discontinue using specific sexual health care services if parental notification were legislated.
References   Lieberman D, Feierman J. Legal issues in the reproductive health care of adolescents. J Am Med Womens Assoc. Summer 1999; 54(3):109–114.; Marks A, Malizio J, Hoch J, Brody R, Fisher M. Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population. J Pediatr. March 1983; 102(3):456–460.; Reddy DM, Raymond F, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health services. JAMA. August 14, 2000; 288(6):710–714


HEALTH CARE DELIVERY RE-INTEGRATION - A FOCUS OF CHANGES TO SUPPORT OPTIONS? "Most of the difficulties in providing and obtaining access to abortion services would disappear if abortion were integrated with other health care for women" 
Reference  Henshaw SK. Factors hindering access to abortion services. Family Planning Perspectives. March/April 1995; 27(2):54–59, 87.

This is a procedure that is part of comprehensive women’s health care - Perhaps the health care delivey change is putting it back into comprehensive care practice?

SAFETY ISSUES AND ABORTION - a complete listing of information is available from the Guttmacher Institute located here  Highlights include: highly safe procedure; no evidence of association between abortions and risk for any types of cancer; no hazard for mental health.

SOCIOCULTURAL DETERMINANTS OF HEALTH AND INEQUITIES
Poverty compounds sexual health educational understanding, resources and choices - abortion rates decrease across all racial/ethnic groups as income levels increase. (So maybe better educational systems and better jobs are one solution!)
Although women who are White have the lowest abortion rates, they also have the lowest pregnancy rates.
Reference  Jones RK, Darroch JE, Henshaw SK. Patterns in the socioeconomic characteristics of women obtaining abortions in 2000–2001. Perspectives in Sexual and Reproductive Health. September/October 2002; 34(5):226–235

CAUSES: So if we consider that we want to address root causes (the why) rather than the symptoms (the abortion) - what is in the literature about the causes and what can we do to address them?
TOP THREE
1- (74%) Not ready for parenthood and make changes involved (including employment and educational opportunities put at risk) and overall increase in responsibility
2- (73%) Can't afford a child - lack of economic support for a child (or another child)
3- (48%) Don't want to be a single parent or relationship problems (not in one, not want to marry or continue with parnter or he won't/can't marry or support her)
Additional reasons:
Does not want anyone to know she has had sex or is pregnant

Too young or immature to be a parent or carry the pregnancy to term
Does not want any more children; may feel overwhelmed and overworked
Partner, man involved in the pregnancy, or parents want her to have an abortion
The fetus has health problems or genetic abnormalities

Victim of interpersonal violence/sexual coercion, including rape or incest
Pregnancy may pose risk to the woman’s health

References Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Reasons U.S. Women Have Abortions: Quantitative and Qualitative Perspectives. Perspectives on Sexual and Reproductive Health. Sep 2005; 37(3).; Planned Parenthood. Choosing Abortion. New York, NY: 2006. Available at http://www.plannedparenthood.org/birth-control-pregnancy/abortion/choosing-abortion.htm. Accessed November 14, 2006.

So look at that list - what do you think needs to be in place to address the root causes?
If you go to an area school that has no books and are unable, even at graduation to read, what type of job can you obtain?
You may be saying that as a future physician - reading or public education isn't on your 'to-do list' - but maybe your voice can mobilize action and change.
What do you need to be doing to educate boys and men about what it means to be a man in our society?
How can you support economic empowerment so that individuals can garner a living wage and be able to support a family?
What messages do we need to be better at conveying about self-esteem? About protection of children from sexual assault? How can we provide meaningful information about real-world options to prevent the legacy of teen motherhood?
We need your ideas - your innovation - your time understanding the people who are disconnected from being as healthy as they can be. If we had the answers, in theory, we'd be done - we aren't. So....

So these all seem huge and daunting, I'm sure.
Here's some baby steps to take (from little to more :>)
1. BE INFORMED: Subscribe to, add to an RSS feed or regularly check out Kaiser Family Foundation Women's Health Policy located here ; CDC data here; Preventing Teen Pregnancy here  Read about What Can Be Done here

2. IDENTIFY USEFUL RESOURCES: Check out the CDC Adolescent Health site here; There is an amazing library of resources at CORE (Curricula Organizer for Reproductive Health Education) located here; A Philadelphia based awesome resource, Women's Law Project located here

3. FIND OUT WHAT YOUR FUTURE FIELD IS DOING IN THIS AREA - APA (Peds); SGIM (General Medicine); APGO (Ob/Gyn); AAFP/STFM (Family) all have information. Check it out and see how you can be involved.


4. FIND OUT OTHER ORGANIZATIONS like the Association of Reproductive Health Professional (click here) ; the Guttmacher Institute (click here); Our local family planning council has a wonderful list of resources here. Here's a site that's mission is to use the law to advance reproductive freedom as a human right (click here ); APHA and reproductive rights (policy statement here); Association of Clinicians for the Underserved (click here)

5. VOLUNTEER to get a better idea of the lives, circumstances and challenges (as well as strengths) of our patients (and future patients) Reflect on the causes noted above. Consider what interventions or changes you could create to make a difference.

6. MAKE TIME FOR LOBBYING TRAINING AND VISIT PEOPLE (Harrisburg, Washington, local offices, attend a town hall of someone running for election/re-election, your hometown...)




Together, we can come up with ideas and solutions that respect our patients and help them have more options in their lives while living healthier!