The effects of economic conditions and access to reproductive health services on state abortion rates and birthrates

The effects that such factors as wages, welfare policies and access to physicians, family planning clinics and abortion providers have on abortion rates and birthrates are examined in analyses based on 1978-1988 state-level data and longitudinal regression techniques. The incidence of abortion is found to be lower in states where access to providers is reduced and state policies are restrictive. Calculations indicate that decreased access may have accounted for about one-quarter of the 5% decline in abortion rates between 1988 and 1992. In addition, birthrates are elevated where the costs of contraception are higher because access to obstetrician-gynecologists and family planning services is reduced. Economic resources such as higher wages for men and women and generous welfare benefits are significantly and consistently related to increased birthrates; however, even a 10% cut in public assistance benefits would result in only one birth fewer for every 212 women on welfare. Economic factors showed no consistent relationship with abortion rates.

Public perceptions about unplanned pregnancy

A nationally representative telephone survey in 1994 of 2,002 adults indicates that 60% believe that unplanned pregnancy is a very big problem in the United States, and virtually all (90%) say it is at least a somewhat big problem. Two-thirds mistakenly believe that a larger percentage of women have unplanned pregnancies now than 10 years ago. A decline in moral standards is cited by 89% of respondents as contributing very much or somewhat to the problem. Lack of education is mentioned as a significant factor by 87%, and 88% see any of three barriers to contraceptive use--knowledge about use, access or cost--as being important factors. Never-married women with children, women in general, low-income respondents, Hispanics and those aged 65 or older are the most likely to believe that barriers to contraceptive access contribute very much to unplanned pregnancy; they are especially likely to cite cost or an inability to obtain contraceptives.

The cost-effectiveness of family planning service provision

BACKGROUND

Family planning services are amongst the most highly utilized services in the National Health Service. There have, however, been few empirical studies of the cost-effectiveness of these services.

METHODS

Two measures of output were used to calculate the cost-effectiveness of family planning services. The first measure is based on the number of pregnancies averted. The second measure uses the couple year of protection as the measure of output. Accordingly, two cost-effectiveness ratios are calculated: cost per pregnancy averted and cost per couple year of protection.

RESULTS

The direct cost per pregnancy averted is between 48 pounds and 167 pounds for reversible and 18 pounds and 21 pounds for non-reversible methods. The cost per couple year of protection is between 49 pounds and 184 pounds for reversible and 17 pounds and 21 pounds for non-reversible methods. For both approaches, if averted NHS costs associated with family planning services are included these translate into resource savings to the NHS resulting from the provision of these services.

CONCLUSION

From the perspective adopted in this study, family planning services are highly cost-effective. According to calculations made in this paper, these services provide a high rate of return to the NHS and, when the resource consequences of unplanned pregnancies in the health sector as a whole are considered, result in resource savings.

Adolescent use of Norplant implants: clinic services, policies and barriers to use

INTRODUCTION

The purpose of this article is to review the experiences of family planning clinic providers in making Norplant available to adolescents. We look specifically at the proportions of women receiving the implant from these providers who are teenagers, the policies adopted regarding implant education and whether or not parental consent is required for minors. Pricing policies and the implications of high method cost for teenagers are discussed. Finally, some of the policies adopted by state agencies related to adolescent use of the implant are reviewed.

METHODS

The data come from two national surveys conducted by the Alan Guttmacher Institute (AGI). The first, a survey of family planning agencies, collected data from 616 family planning providers of clinic services (response rate 69%). The second surveyed the Medicaid, health and welfare agencies in all 51 jurisdictions about policies related to Norplant.

RESULTS

Over one-quarter of all contraceptive implants inserted by family planning agencies were provided to teenagers. Teenagers were routinely informed about the implant in about 85% of those clinics offering implant services. Few state agencies notify women about the implant. Twenty-three percent of all family planning agencies providing implant services report that parental consent must be obtained prior to implant insertion. The Medicaid program has paid for a majority of implant insertions at family planning agencies.

CONCLUSIONS

Teenagers who rely on publicly funded family planning clinics for contraceptive services face a variety of barriers in obtaining Norplant. High method cost, parental consent requirements and issues related to Medicaid eligibility are likely to deter some teenagers who might otherwise choose Norplant.

The contraceptive implant and the injectable: a comparison of costs

A comparison of the relative costs of the injectable contraceptive (depot medroxyprogesterone acetate) and the hormonal implant (Norplant) indicates that the implant is a less costly contraceptive option when it is used for its full five-year lifespan. Over a five-year period, the implant costs $107 annually, compared with $140 per year for the injectable. However, if a woman discontinues the implant before she has used it for at least four years, the injectable becomes the less costly option. Relatively high continuation rates--around 95% annually--are necessary to make the implant the more cost-effective contraceptive method.

The impact of condom prices on sales in social marketing programs

The issue of pricing contraceptives in family planning programs is becoming more and more important. What is the relationship between consumer prices and demand, and how can we strike the correct balance between the two? This report examines the correlation between consumer prices for condoms, expressed as a percentage of per-capita gross national product, and per-capita sales of condoms in 24 social marketing programs. The correlation that emerges is strong and negative: Even when the data are controlled for age of program and other independent variables, there is a clear negative correlation between prices and contraceptive sales in these programs. The conclusion is clear that condom prices must be set very low--well below the equivalent of 1 percent of per-capita gross national product for a year's supply--in order to achieve satisfactory prevalence for condoms in either a family-planning or an AIDS-prevention context.

Norplant contraceptive maker accused of profiteering on drug

Family planning groups and a lawmaker accused a US drug company yesterday of profiteering on Norplant, the implantable, 5-year contraceptive. The company said its $365 product is cheaper than birth-control pills. But Rep. Ron Wyden said Norplant was developed with extensive government support and sells for $23 in some Third World countries. He said its cost to Wyeth-Ayerst laboratories may be as little as $16. About 875,000 US women have had 6 match-sized hormone-dispensing rubber capsules implanted in their upper arms since 1990. Dr. Amy Pollack of the Association of Reproductive Health Professionals said 56% of the 6 million pregnancies in the US each year are unwanted. She said 1.7 million pregnancies occur among women using contraceptives. The failure rate is less than 4 per 10,000 with Norplant compared with 3 per 100 women on the pill, she said. Dr. Marc W. Deitch, Wyeth's medical director, said the company made a risky decision to bring Norplant to market in collaboration with the nonprofit Population Council. The implant costs women 20 cents a day over its 5-year life, said Dr. Deitch. The $365 cost is significantly less than the $1481 they would pay over 5 years for birth-control pills, $762 for a diaphragm and $590 for shots of Depo Provera, he said. Male condoms cost $312 and an IUD $176. Family planning advocates challenged Dr. Deitch's math. Judith DeSarno, president of the National Family Planning and Reproductive Health Association, said federally funded clinics pay only $60 for a 5-year supply of oral contraceptives. Women also must pay doctor fees--usually from $150 to $200--for inserting Norplant and eventually removing it from their upper arms.

Global update: Haiti

In a country of 6 million that is the hemisphere's poorest, an American-supported Haitian campaign against AIDS has moved beyond getting people to ask questions about the risk of disease and helped make condom use commonplace. Within a year, the program has gone from selling about 40,000 condoms a month to nearly half a million. The story of condom use in Haiti, experts say, is one of careful attention to local psychology and culture. Equally important, they say, has been the subsidized price, currently about 3 cents each. In Haiti, despite infection rates that are thought to approach 10% in urban areas, there has been strong resistance to belief in the threat posed by AIDS.

Preliminary experience with Norplant in an inner city population

Norplant, the five-year subdermal contraceptive system, is the first implantable contraceptive method approved for general use in the United States. We describe the preliminary experiences of 246 U.S. women who accepted Norplant between April, 1991 and September, 1991. Norplant was well accepted among this diverse general population. Intensive counselling about side effects, especially menstrual changes, is crucial for patient satisfaction. Although 48% of acceptors experienced menstrual cycle changes and 70% experienced at least one side effect, phone calls and unscheduled visits for problems were infrequent. Adequate counselling about side effects obviates the need for a routine follow-up visit one month after insertion.

Contraceptive delivery in the developing world

A strong demand for family planning exists in most developing countries and family size is falling rapidly in many of them. Effective family planning programmes offer a world-wide range of choices (including voluntary sterilisation and abortion) through a variety of distribution channels. Universal access to voluntary family planning can be achieved easily and cheaply by the turn of the century, but only if conservative medical policies are overcome and funding is greatly expanded. The international community faces a genuine choice: if it responds to current opportunities the global population will stabilize at approximately 10 billion or fewer; if it fails, population may grow to 14 billion or more. The difference between these two projections (approximately equal to the present world population of 5.4 billion) may well determine the future of the planet.

Characteristics and attitudes of early contraceptive implant acceptors in Texas

In 1991, shortly after Norplant became available in the United States, 678 women who had received the implant from 17 providers in Texas were surveyed. Forty-five percent of these women were under 21 years old. The majority (56%) had tried the implant because they were dissatisfied with their previous contraceptive method. Forty-four percent of the sample indicated that the implant was one of the first contraceptive methods they had used and that they had only recently decided to prevent unplanned pregnancy. The average number of children per woman was 1.2, and one-third of the sample had had at least one abortion. While 37% of the women said they wanted no more children, 63% said they were using the implant as a spacing method. The reasons for choosing the implant and concerns about it varied according to the user's age, educational level and race or ethnic group.

The induction of amenorrhoea

A survey has shown that many women favour eliminating menstruation and it has been suggested that therapeutic induction of amenorrhoea might be an advantage in female personnel mobilised for war. The traditional method has been to take the oral contraceptive pill continuously. This produces weight gain and other side-effects; spotting and breakthrough bleeding can be a problem initially. The method is however cheap. The Gonadotrophin Releasing Hormone (GnRH) analogue, goserelin, is extremely effective, produces less side-effects, but it is very expensive. Two synthetic steroids, danazol and gestrinone, are moderately effective, have a variety of prominent side-effects and are also quite expensive. With all these drugs normal menstruation resumes in the cycle after they are discontinued. Although goserelin has many advantages over the continuously taken contraceptive pill, its cost precludes it from consideration as a means of eliminating menstruation.

Family planning clinics: facing higher costs and sicker patients

Family planning clinics throughout the United States are facing a variety of obstacles that threaten their ability to provide necessary contraceptive services to low-income women and teenagers, according to interviews with clinic administrators. In the last few years, the proportion of patients coming to family planning agencies in need of screening or treatment for sexually transmitted diseases (STDs) has increased dramatically. Many providers report that 10-15 percent of their clients are infected with chlamydia, the most prevalent STD. The increasing costs of Pap tests and contraceptives are also major problems: As a result of recent federal legislation, the price of Pap tests has risen substantially, and that of contraceptives is beginning to increase steeply. Finally, Title X funding for family planning services has decreased 66 percent over the last decade if both cuts and inflation are taken into account. As a result of the squeeze between increased costs and decreased public funding, clinics have been forced to charge higher fees, maintain long waiting lists for appointments and curtail community outreach. In addition, growth of the family planning patient population has slowed dramatically, and even declined, in some places.

Contraceptive use and fertility in Honduras, 1981-84

This paper presents data on contraceptive use and fertility in Honduras obtained from a household survey conducted in 1984, and compares these data with similar information obtained from surveys carried out in 1981 and 1983. About half of the increase that has taken place in contraceptive use in Honduras is accounted for by sterilization. In 1981, 27 percent of women in union aged 15-49 years were practicing contraception; in 1984, the percentage of those 15-44 was 35 percent. The increase in urban areas was smaller (from 47 percent to 51 percent) than in rural areas (from 16 percent to 24 percent). Also, fertility remained almost unchanged in urban areas while declining in rural areas. Information from questions on place of purchase, price, and brand of contraceptive (for orals) was used to determine source of supply. The use of multiple questions to determine source results in a higher percentage of contraceptive use attributed to the Honduran Family Planning Association as compared with answers to a single question. The duration of breastfeeding in Honduras has increased, with the greatest changes occurring among women in urban areas and women with the highest levels of education. Efforts have been made to promote breastfeeding in urban areas and these results suggest that the efforts have been successful.