Sharon Camp's blog

Report: Higher Rates of Unintended Pregnancy, Abortion Among Women of Color

2009-06-15T09:00:00-04:00

An important new report by the Kaiser Family Foundation documents persistent disparities between white women and women of color on a broad range of health indicators, including rates of diseases such as diabetes, heart disease, AIDS and cancer. The report also documents widespread disparities in access to health insurance and health screenings, and finds that there are "racial and ethnic disparities in health status and health care in every state in the nation, often disparities that are quite stark." It finds, moreover, that "there is growing evidence that social factors (e.g., income, education, occupation, neighborhoods, and housing) are associated with health behaviors, access to health care, and health outcomes."

The new report provides further strong evidence debunking claims by anti-abortion rights activists, who, ignoring all other contextual factors, have long argued that high abortion rates among minorities are the result of supposed aggressive marketing by abortion providers to minority communities. In truth, as the Guttmacher Institute has pointed out repeatedly, abortion rates among racial and ethnic minorities - especially blacks and Hispanics - are directly linked to their higher rates of unintended pregnancy, which in turn reflect pervasive health disparities more generally.

In an August 2008 opinion piece in the Philadelphia Inquirer, Guttmacher Institute Board chair Melissa Gilliam said the of high unintended pregnancy and abortion rates among African Americans: "The root causes are manifold: a long history of discrimination; lack of access to high-quality, affordable health care; too few educational and professional opportunities; unequal access to safe, clean neighborhoods; and, for some African Americans, a lingering mistrust of the medical community."

What can be done about entrenched disparities in women's health? Kaiser calls it a "formidable challenge" that will "require an ongoing investment of resources from multiple sectors that go beyond coverage and include strengthening the health care delivery system, improving health education efforts, and expanding educational and economic opportunities for women."

In the context of high abortion rates among women of color, Guttmacher has argued that the fundamental question policymakers should be asking is not why women of color have high abortion rates, but rather what can be done to help them have fewer unintended pregnancies and achieve better health outcomes more generally. Barriers to health care access, including financial and geographic hurdles, remain a significant issue. For instance, many women of color are unable to afford prescription birth control methods, such as the IUD, that are highly effective over extended time periods but have high up-front costs.

Beyond access to affordable contraceptives, however, other factors like dissatisfaction with the quality of services and the methods themselves may be at least as much an impediment to consistent and correct contraceptive use. There is increasing recognition that quality of care plays a major role in health-seeking behavior and health outcomes. Dissatisfaction with health care providers, a problem often made worse by cultural or linguistic barriers, can lead to frustration and poor follow-through on contraceptive use. Unstable life situations, in which consistent use of contraceptives is a lower priority than simply getting by, can also be a factor.

It's a complex challenge, but one thing is clear: By continuing to label abortion providers as "racists" and refusing to support expanded access to contraceptive services anti-abortion rights activists are by no means part of the solution - to high rates of unintended pregnancy and abortion among racial and ethnic minorities or to persistent and tragic disparities in health care generally.

The President's 2010 Budget: A Decidedly Mixed Bag

2009-05-11T09:00:00-04:00

On May 7, President Obama sent Congress his proposed 2010 budget recommendations. For programs and policies relating to sexual and reproductive health at home and abroad, the proposed budget contains some good news, some bad news and some news that is only okay. The most welcome development is the abolition of "abstinence-only-until-marriage" programs. The most disappointing is the failure of leadership the president displayed by sanctioning the continuation of federal bans on subsidized abortion services for U.S. women who depend on the federal government for their health care or health insurance. In reviewing the budget, it is important to remember it is just a starting point: Congress gets a crack at whether to accept, reject or modify the president's recommendations.

Abstinence-Only Out; Evidence In. In a clear victory for evidence-based policies, the proposed budget ends funding for abstinence-only-until-marriage programs that ignore or actively denigrate the effectiveness of contraceptives and safer-sex behaviors. Instead, the president recommends shifting these funds, plus an additional $15 million-a total of $178 million-to support a new teen pregnancy prevention initiative that includes a grants-to-states program and a separate community-based grant program. Seventy-five percent of the community-based funds would support "comprehensive, evidence-based programs," which have been proven to delay sexual activity, increase contraceptive use or reduce teenage pregnancy, and 25% of funds would support demonstration and research grants to test new models and approaches. Abstinence-only programs could continue to receive funding under the latter category so long as they have promise, but they would have to compete with other initiatives.

Access to Abortion: Absence of Leadership. The president had the option to assert his prochoice credentials and propose in his budget that the many abortion funding restrictions that exist throughout a range of federal health programs be deleted. The most infamous of these, the Hyde Amendment, prohibits Medicaid from paying for abortions for poor women. The president chose politics over principle on this set of issues. His budget proposal leaves almost all the abortion funding restrictions intact. The one restriction his budget does recommend changing, as a matter of home rule, is the one that bans the District of Columbia from using its own local revenues to pay for abortions for its indigent residents - the way states may do. The administration is sending an ominous signal about the priority that access to abortion services will have in the context of health care reform.

Domestic Family Planning: Modest Improvements. Given all the hoopla surrounding the president's initiative to reduce the need for abortion, his budget request is somewhat underwhelming when it comes to the quintessential middle ground - preventing unintended pregnancy. The Title X family planning program would receive a 3%, or $10 million, increase, which would bring funding to $317.5 million from the current $307.5 million. When it comes to Medicaid, the president proposes congressional action to remove barriers for states seeking to expand eligibility for family planning. This is a welcome development and a down payment on the president's promise from earlier this year to find a way (other than with the stimulus package) to win this important policy change. The president's proposed version in the budget is somewhat less robust than the version that has been pending in Congress-one that gives states the option of covering family planning for the same group of women eligible for pregnancy-related care. The administration's proposal would cap the ability of states to extend coverage to women at 200% of poverty.

Services to New Mothers: Promising. The president proposes the creation of a new "home visitation" program for low-income parents and pregnant women to the tune of $8.6 billion over the next 10 years. It would be an entitlement program for states, which would have to apply for the money and put up their own matching funds. Although some funds would go toward testing promising newer models, the program would, like the teen pregnancy initiative, primarily fund models with a strong research evidence base. The most prominent of those models, the Denver-based Nurse-Family Partnership, is currently serving more than 16,000 women in 28 states and has been shown over more than 30 years to have numerous long-term benefits for children and families, including reductions in preterm births and improved birth-spacing.

Global Health Initiative: Moving Toward a More Integrated Approach. The president presented his recommendations for global health funding in the context of his new Global Health Initiative. "We cannot simply confront individual preventable illnesses in isolation. The world is interconnected, and that demands an integrated approach," he said. The idea is to consider the synergies among global health programs in order to seek a more comprehensive and integrated approach to fighting disease, improving health and strengthening health systems. The initiative will focus on preventing millions of new HIV infections, reducing maternal and newborn deaths, averting millions of unintended pregnancies and eliminating some neglected tropical diseases. Over the next six years (FY 2009-2014), the administration plans to spend $63 billion under the Global Health Initiative, with $51 billion allocated to global HIV/AIDS and malaria efforts and $12 billion to other global health priorities, including maternal and child health, family planning and neglected tropical diseases.

For FY 2010, the president is requesting $5.3 billion for the global HIV/AIDS programs, a slight increase over the current amount. Overall funding for maternal and child health programs would rise from $494 million to $524 million. (Maternal health efforts are not broken out separately.) Funding for international family planning and reproductive health programs would increase to $543 million-$48 million more than current levels. Additionally, the president is recommending a $50 million contribution to the United Nations Population Fund (UNFPA), the same amount as this year. The budget does propose deleting all the limitations on the U.S. contribution to UNFPA, including one that prevents any U.S. funds from being used in UNFPA's China program and another that deducts from the annual U.S. contribution the amount that UNFPA spends in China that same year. If approved by Congress, the overall amount proposed for international family planning and reproductive health programs - $593 million - would represent the highest level ever from the U.S. government.

We're Back! US Reclaims Leadership Role in International Reproductive Health

2009-04-14T08:00:00-04:00

On Friday, April 3, at the conclusion of the annual meeting of the United Nations Commission on Population and Development, the international community pledged to ramp up efforts to improve women's health and reduce poverty in the developing world. And for the first time in eight years, the United States was front and center in advocating an increased global commitment to reproductive health and rights.

Add this new U.S. stance to the recently resumed American support for the United Nations Population Fund (UNFPA), the repeal of the infamous "global gag rule" that barred overseas organizations that so much as provided abortion information from receiving U.S. family planning assistance, and Secretary of State Hilary Clinton's unequivocal endorsement of women's rights as human rights, and it is safe to say: The U.S. is back!

Or, more precisely, back on track--the policies of the past eight years have left a lot of catching up to do. Current U.S. international family planning assistance, at $545 million a year, is significantly higher than previous years, but falls far short of the $1 billion that represents the minimum U.S. share of the global commitment.

While the United States contributes more funds than any other country toward voluntary family planning services worldwide, European nations far outspend the United States in terms of the proportion of the gross domestic product allocated to foreign assistance. There is, understandably, a sense that Bush administration policies have left Europe to pick up the slack in international family planning funding and other aspects of promoting sexual and reproductive health.

The renewed U.S. commitment to international sexual and reproductive health is a timely development. The meeting also marked the 15th anniversary of the Cairo Program for Action, a 20-year plan to stabilize population growth and reduce poverty, in part by investing in women's health.

Though the vast majority of United Nations (UN) member states signed onto the Cairo Program of Action, 15 years later, most countries have fallen behind in their commitments. UNFPA estimates that, in 2008, there was a nearly $4 billion gap between actual and needed support for family planning from donor nations.

To focus attention on these gaps, the Guttmacher Institute and UNFPA convened an expert panel at last week's UN population meeting to discuss global funding priorities, especially given a more supportive U.S. administration.

Stan Bernstein, senior policy adviser at UNFPA, chaired the panel. Barbara Hendrie, counselor of development and human rights for the United Kingdom Department for International Development, heralded the change in the U.S. administration as a "major opportunity" for the European donor community and the United States to work together on reaching development goals.

Scott Radloff, director of the department of population and reproductive health at the U.S. Agency for International Development, shared new initiatives under the Obama administration, while Susan Cohen, director of government affairs at the Guttmacher Institute, represented the nongovernmental perspective.

The result was a lively debate of European versus American approaches to investing in developing countries. For example, the United Kingdom prefers to provide "basket funding" or core support, investing in developing country health systems overall and pooling funds with other European countries where there are overlaps in programs.

In contrast, U.S. funding focuses on specific programs, partly due to Congressional oversight that requires greater accountability and meeting assigned targets. Despite these differing donor philosophies, the panelists agreed that their funding initiatives could be complementary.

Both Hendrie and Radloff also spoke of the need for their countries to make programs more efficient by integrating family planning and HIV/AIDS services. And all involved expressed real optimism that with support of the current U.S. administration, these kinds of changes might finally be possible.

The social and financial return on these investments is great, added Cohen, citing Guttmacher and UNFPA evidence. Meeting targets set in the Cairo Programme for Action and in UN Millennium Development Goals will require strong commitment and increased cooperation. For this to work, the United States must maintain a clear leadership role and European donors cannot back away now just because the United States has returned to the scene.

Back Up Your Birth Control Day Gets Boost from Court Decision

2009-03-25T09:00:00-04:00

On Monday, March 23, a U.S. District Court found that the Food and Drug Administration (FDA) bowed to political pressure from the Bush administration in its 2006 decision to limit access to emergency contraception without prescription to women aged 18 and older. The court ordered the FDA to expand over-the-counter access to 17-year-olds within 30 days. It further ordered the FDA to reconsider the application to eliminate all age restrictions to over-the-counter access to emergency contraception, which is sometimes called Plan B or the "morning-after pill."

The ruling comes just two days before the eighth anniversary of the Back Up Your Birth Control Day of Action, a day devoted to increasing awareness of and access to emergency contraception. While emergency contraception can help prevent unintended pregnancy when taken up to 120 hours after unprotected sex, it is most effective the sooner it is taken. Eliminating the requirement of a prescription for women younger than 18 will reduce delays in obtaining the method - thereby helping to reduce young women's risk of an unintended pregnancy.

The typical American woman faces a daunting challenge: Given that she wants two children, she spends only a few years trying to become or being pregnant, but about three decades trying to avoid pregnancy. Recent Guttmacher research documents the difficulty women confront in using contraception consistently and correctly over a lifetime. Finding the "right" contraceptive method is not a one-time decision - rather, women make a series of choices in response to their changing life circumstances and contraceptive needs.

The study found that life changes, such as the beginning or end of a relationship, a job loss or change, moving to a new home or a personal crisis, can contribute to lapses in contraceptive use, increasing the risk of unprotected sex. That's why emergency contraception, a back-up birth control method, can play a key role in helping women ensure that a contraceptive lapse or failure does not lead to unintended pregnancy. Health care providers are especially well positioned to counsel women about the potential impact of life events on their contraceptive use. They can also help women prepare for those transitions, as well as for potential method failures (like condoms breaking during sex) by providing emergency contraception to keep at hand in case it is needed and by educating them about its benefits and availability.

Continued efforts to raise public awareness about emergency contraception are essential and should include debunking myths about the method. Many women and men still do not know that emergency contraception exists or are confused about how the method works. Emergency contraception contains the same hormones that are found in ordinary birth control pills. It will not in any way disrupt an established pregnancy. And it is not to be confused with mifepristone, sometimes called RU-486, a drug used to terminate a pregnancy that is only available and administered at clinics or doctor's offices.

Much still remains to be done to help women and their partners improve their contraceptive use overall. The more we can identify and remove barriers to consistent use-while ensuring that people know about and have access to a back-up method like emergency contraception-the better prepared women will be to avoid unintended pregnancies and plan for the children they want, when they want them.

Click here for more information on:

Back Up Your Birth Control Campaign

Achieving greater contraceptive convenience

Improving Contraceptive Use

Facts on Contraceptive Use

State Policies on Emergency Contraception

The Check's in the Mail: US Resumes UNFPA Funding Just in Time for UN Meetings

2009-03-18T08:00:00-04:00

After a seven-year hiatus from contributing to the United Nations Population Fund (UNFPA), the United States is in the process of making approximately $50 million in funding available to the organization.

In his first week in office, President Obama announced his intention to work with Congress to restore U.S. funding for UNFPA in order to "join the 180 other donor nations working collaboratively to reduce poverty, improve the health of women and children, prevent HIV/AIDS and provide family planning assistance to women in 154 countries."

Now, with the enactment of the fiscal year 2009 appropriations bill, it appears that the first U.S. contribution to UNFPA will arrive just as experts from around the world prepare to gather at the United Nations for a global review of population and development priorities. The review, an annual meeting of the Commission on Population and Development, will take place on March 30-April 3 in New York City. It is the first of several United Nations events that will mark the 15th anniversary of the International Conference on Population and Development held in Cairo in 1994.

At the conference, the United States and 178 other member states signed on to an ambitious 20-year plan for international development. The plan was guided by the principle that stabilizing population growth and fighting poverty are fundamentally interrelated goals, neither of which can be achieved without investing in the rights of women.

In 2000, an even larger group of countries, including the United States, reaffirmed this commitment by signing on to the Millennium Development Goals (MDGs). While the United States has honored parts of that pledge, largely through the efforts of the U.S. Agency for International Development, it has fallen far behind other developed countries' investments in the developing world. In fact, among developed countries, the United States is tied for last place in the percentage of gross national income it devotes to foreign assistance.

Reinstating funding for UNFPA and rescinding the anti-family planning "global gag rule" are excellent first steps by the Obama administration to make up for ground the United States has lost over the past decade. But much more remains to be done to restore U.S. leadership on global sexual and reproductive health issues. With "Cairo plus 15" as a central theme, the upcoming United Nations meeting is a prime opportunity for the United States to reassert its commitment to fulfilling the promises made in 1994.

As part of the proceedings, the Guttmacher Institute and UNFPA will convene representatives from the British, Norwegian and U.S. international aid agencies in a parallel session to discuss priorities in funding for population and development. The panelists will also explore how the donor agencies can work together to maximize investments in global sexual and reproductive health.

Click here for information on:

What the United States can do to restore its leadership in global sexual and reproductive health policy

What the Obama administration has done so far to promote global health and development

A look back at "Cairo plus five" and "Cairo plus 10"

Celebrating Roe While Promoting Prevention

2009-01-15T08:00:00-05:00

January 22, 2009, marks the 36th anniversary of Roe v. Wade, the landmark U.S. Supreme Court decision that legalized abortion nationwide. This anniversary comes two days after the inauguration of the first prochoice president in eight years and at the beginning of a new administration and a new Congress whose leaders recognize that behind almost every abortion is an unintended pregnancy.

Although the rate of abortion in the United States has fallen to its lowest level since 1974, slightly more than one in five pregnancies end in abortion, and stark disparities persist in rates of unintended pregnancy and abortion; poor and low-income women are at particularly high risk. Compared with higher income women, poor women are four times as likely to have an unplanned pregnancy, three times as likely to have an abortion and five times as likely to have an unplanned birth. Consequently, the need for publicly funded family planning services is as critical as ever.

Publicly funded family planning clinics provide contraceptive services to about seven million women each year. Without these services, unintended pregnancy rates would be nearly 50% higher for all women and about two-thirds higher among low-income women. According to recent Guttmacher research, 1.4 million unintended pregnancies, which would likely result in about 640,000 unintended births and 600,000 abortions, are averted each year because of these services. Research shows that these services save $4.3 billion in public funds. Nationally, every $1.00 invested in helping women avoid pregnancies they do not want saves $4.02 in Medicaid expenditures that otherwise would be needed-in addition to providing clear benefits to individual women and their families by helping them avoid unintended pregnancies and plan the pregnancies they do want.

Guttmacher research has also found that each $20 million increment in new funding under the Title X family planning services program alone would help women avoid another 17,200 unintended pregnancies, including 7,000 that would end in abortion. Expanding eligibility for Medicaid-covered family planning services nationwide to the same income eligibility levels used for pregnant women would yield even greater results, further reducing unintended pregnancy and abortion by 15%, while achieving an additional $1.5 billion in net savings annually.

While in the Senate, President-elect Obama cosponsored numerous bills, such as the Prevention First Act, aimed at expanding access to contraceptives, health information and preventive services to help women avoid unwanted pregnancies. Senate Majority Leader Harry Reid (NV), himself antiabortion, reintroduced the Prevention First Act in early January, and companion legislation in the House was reintroduced soon thereafter.

We know that we must put prevention front and center, so let's stop talking about it-and start doing it.

For more information, click here for:

Facts on induced abortion in the United States

A comprehensive resource on trends in abortion in the United States since 1974

State facts about abortion

Information on who has abortions in the United States and why

Parental Involvement Laws Have No Effect on Abortion Rates

2008-10-24T12:00:00-04:00

Antiabortion activists repeatedly claim that state laws requiring parental involvement (such as notification or consent) for minors to obtain abortions have been a major contributing factor to declining abortion rates among minors in the United States.

Recently, Michael New, a visiting fellow at the antiabortion advocacy organization Family Research Council, posted an analysis on the organization's Web site that he claims "demonstrates that state level parental involvement laws are effective in reducing the incidence of abortion among minors." New's analysis, which has not been published in a peer-reviewed journal, has serious methodological flaws. Like many previous studies on the subject, it is not able to substantiate the claim.

In contrast, there is strong evidence that the decline in minors' abortion rates is largely the result of fewer teen pregnancies, which, in turn, reflect better contraceptive use among adolescents. Moreover, the evidence suggests that even in the absence of parental involvement laws, some six in 10 minors involve at least one parent in their decision to have an abortion. Mandating this involvement can be harmful to some minors.

There is no strong evidence that parental involvement laws have prevented many minors from obtaining abortions

Most studies purporting to show a significant impact of such laws suffer from a range of serious methodological flaws. One common flaw of these studies (including New's) is that they track abortions by state of occurrence, not by state of residence. By failing to account for minors traveling to neighboring states to obtain an abortion, it is impossible to prove that parental involvement laws caused overall declines in minors' abortion rates, even if they may succeed in shifting the occurrence of abortions from one state to another.
Minors' abortion rates have been declining steadily for years, both in states with and without parental involvement laws. Even in states with such laws, the declines often started well before these statutes became effective.
A study published in the New England Journal of Medicine in 2006 found that in the period immediately following implementation of a Texas parental notification law, the abortion rate among teens aged 15-17 in the state fell more sharply than it did among 18-year-olds, who were not subject to the law. The authors concluded that the law was associated with reduced abortion rates among minors and an increase in the birth rate among older minors. However, given the design of this study, causality cannot be proven. If the law has had this effect, it likely reflects the fact that all states bordering Texas, with the exception of New Mexico, also have a mandatory parental involvement law, which makes it extremely difficult for Texas minors to seek an abortion elsewhere. The sheer size of the state contributes to that difficulty. Should additional states enact such laws, thus giving the minority of teens who seek abortions without involving parents fewer places to turn, these types of restrictions may begin to have a measurable impact on adolescent abortion rates.

Declines in minors' abortion rates are largely the result of declines in their pregnancy rates

Declines in minors' abortion rates reflect the fact that fewer minors are becoming pregnant in the first place. Between 1989 and 2002, the pregnancy rate among minors aged 15-17 declined 43% to a historic low.

Most (77%) of the reduction in the pregnancy rate among minors was the result of improved contraceptive use among sexually active minors; the remainder (23%) was attributable to some minors waiting longer to initiate sex.

Mandating parental involvement can be harmful

The most vulnerable and scared teens are put at greatest risk. Forcing teenagers to disclose to their parents that they are pregnant or seeking an abortion may place some teens at risk of physical violence or abuse. According to a 1992 study, about one-third of teenagers who did not tell their parents about their decision to seek an abortion had experienced violence in their family, or feared that violence would occur or that they would be forced to leave home.
Legal impediments to teens' access to abortion services can result in teens' delaying abortions until later in pregnancy, when they carry a greater risk of complications and are also more expensive to obtain.
Many medical, public health and youth-serving organizations have consistently opposed laws and policies requiring mandatory parental involvement for abortion services. These organizations-made up of professionals who study and work most closely with teens-include the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Medical Association and the Society of Adolescent Medicine, among others. They agree that health care providers have an obligation to encourage adolescents to talk to their parents about sexual activity and reproductive health care, and that they have an important role in facilitating such conversations. At the same time, however, they uniformly state that minors should not be forced to involve their parents in their decision to obtain an abortion.

Guttmacher Celebrates 40 Years of Bringing Science and Research to Reproductive Health

2008-10-22T08:00:00-04:00

This year, the Guttmacher Institute celebrates its 40th anniversary. Although the Institute has evolved in many ways over the past four decades, one thing has remained constant: the core belief that scientific evidence can and should shape public policy. Our experience has only strengthened our conviction that well-designed, rigorously conducted research, compellingly presented and systematically disseminated to the right people, can fundamentally shift the public debate and help usher in critical policy and program reforms.

Join me in looking back over the past four decades, and in noting four of Guttmacher's defining institutional achievements that are testimony to the power of science to drive human progress:

1. Helping to Create a National Network of Family Planning Clinics

In 1970, landmark federal legislation was enacted establishing a national family planning program. The purpose of the new law -- Title X of the Public Health Service Act -- was to address the unmet contraceptive needs of low-income women and narrow the wide gap between rich and poor women in unintended pregnancy. Two years before, as congressional deliberations were just getting under way, the Center for Family Planning Program Development was born. Alan F. Guttmacher, one of the country's most eminent obstetrician-gynecologists and then-president of the Planned Parenthood Federation of America, recognized the need for the Center and nurtured its development as a semiautonomous division within Planned Parenthood.

The Center was determined not just to shepherd the Title X legislation through Congress, but also to ensure that the new program would endure -- because it would be built on sound science. Throughout the 1970s, the Center's expert staff provided hands-on assistance in developing the network of clinics authorized under Title X by creating regional family planning councils; helping state agencies and community clinics make an evidence-based case for Title X funding; guiding prospective Title X grantees through the application process; and fostering best practices in family planning services, as documented by the Center's ongoing research.

In 1974, following Alan Guttmacher's death, the Center was renamed in his honor, and in 1977, it became an entirely independent agency. Meanwhile, the Title X clinic network grew to encompass more than 4,000 family planning clinics, serving more than four million low-income women and teens. By the 1990s, Guttmacher research was able to document a substantial narrowing of gaps in contraceptive use and unintended pregnancy among women in different racial, ethnic and income groups, proof of the public health benefits brought about by Title X.

Today, there are family planning clinics in nine out of every 10 U.S. counties, which together constitute a major national provider of preventive health care. According to Guttmacher data, one in four U.S. women of reproductive age who obtain a contraceptive service, one in three who obtain an STI service and one in six who obtain either a Pap test or a pelvic exam do so at a Title X family planning clinic.

While Title X funding continues to play a key role in the U.S. family planning effort, Guttmacher research has also documented a fundamental transition in financing for family planning services. Medicaid has gradually overtaken Title X as the principal source of support, accounting, by 2005, for more than 70% of all family planning public funding. This sea change came about in no small measure because of innovative income eligibility expansions first developed in a handful of states in the early 1990s. The original advocate for these programs, Guttmacher has since served as a clearinghouse for information on their operations and impact, as well as provided technical assistance to states engaged in the arduous process of obtaining the required federal approval to expand coverage.

Thanks in part to our efforts, three in four American women in need of publicly subsidized family planning now live in a state where expanded Medicaid coverage is available. In 2006, Guttmacher research showed the potential these Medicaid program expansions have to reduce unintended pregnancy and the need for abortion while saving federal and state dollars. These findings helped accelerate efforts to extend these programs nationwide and rocketed the issue to the top of the reproductive health and rights agenda.

2. Putting--and Keeping--Teenage Pregnancy on the Policy Agenda

The Institute's blockbuster report "11 Million Teenagers," published in 1976, was a wake-up call for Americans, providing the first comprehensive picture of adolescent sexual activity and its consequences. It documented that 11 million teenagers -- the overwhelming majority of whom were unmarried -- were already sexually active, and that one million of them were getting pregnant every year. The report put teen pregnancy on the policy agenda and refocused the debate in the United States, spurring the development of teen pregnancy prevention programs across the country. The incidence of teenage pregnancy, which peaked in 1991, had declined by a whopping 36% by 2005.

Unfortunately, increased support for adolescent services and sex education generated its own opposition in the form of the abstinence-only-until-marriage education movement and a wave of "junk science" claiming a key role for abstinence in recent teen pregnancy declines. Guttmacher moved quickly to counter this growing threat to evidence-based policies with a series of analyses showing that declines in teen pregnancy were due mainly to improved contraceptive use, not less sex. As federal abstinence-only programs became more hard-line, targeting not only young teens but also unmarried adults as old as 29, Guttmacher countered with research showing that 95% of Americans have sex before marriage -- and have done so for three generations.

The Institute has also expanded its focus to include teens in the developing world as well. Early this year, the Institute released the last of a dozen studies based on qualitative research and national surveys of nearly 20,000 African adolescents aged 12-19. The studies make clear that meeting their needs will be critical to preventing unintended pregnancy and halting the AIDS epidemic in Africa.

3. Achieving Contraceptive Equity in Prescription Drug Coverage

In addition to charting the path toward sexual and reproductive health coverage in the public sector, Guttmacher has played a pivotal role in the fight to increase coverage of these services by private health insurance plans. Amidst the Clinton-era uproar over health care reform, Guttmacher's 1993 study of insurance coverage for reproductive health care put the issue of contraceptive coverage on the map. It showed that coverage patterns, in the words of the study report's title, were wildly "uneven and unequal." The Institute's study galvanized broad support for change at the federal and state levels.

In 1997, a bipartisan group of members of Congress introduced legislation requiring coverage of contraceptive services and supplies in health plans nationwide. Although that bill has yet to pass, Congress did move in 1998 to require coverage in the largest employer-sponsored health insurance program in the country, the constellation of plans offered to federal employees, retirees and their dependents.

Meanwhile, even more significant progress was occurring at the state level. Beginning with California in 1994, only months after publication of the Guttmacher study, measures to require coverage of contraceptive services began to be introduced in state legislatures. Maryland was the first state to enact such a law, in 1998; eight states followed suit the next year. Today, fully 27 states mandate coverage, and 54% of women of reproductive age live in a state that requires contraceptive coverage in insurance plans that offer presecription drug coverage.

A follow-up Guttmacher study conducted in 2002 cast this progress in sharp relief. By that year, nearly nine in 10 group insurance plans purchased by employers for their employees covered a full range of prescription contraceptives-three times the proportion just a decade earlier. Moreover, the proportion of plans covering no method at all plummeted from 28% to only 2%.

4. Understanding Abortion in Women's Lives

The legalization of abortion in 1973 was an immense stride forward in self-determination for American women. Given the different levels of abortion reporting among states, however, there was no accurate count of how many women chose abortion, much less any clear picture of who they were, what kind of care they received or why they chose to terminate a pregnancy.

The Institute recognized that a lack of reliable data on abortion would only work to the advantage of a growing antiabortion movement. In 1974, Guttmacher helped fill in the blanks with its first of 14 periodic censuses of U.S. abortion providers. In its most recent survey of abortion providers, released in January 2008, Guttmacher documented the continuing -- if somewhat slowed -- decline in U.S. abortions. These surveys still provide the most comprehensive estimate of abortion incidence in the United States. Although abortion remains one of the most divisive issues in American politics, partisans on all sides of the abortion debate accept -- and use -- Guttmacher data.

Guttmacher's periodic counts of U.S. abortion procedures have also helped make possible accurate calculations of unintended pregnancy -- the underlying cause of nearly all abortions. In addition, the Institute's quantitative and qualitative research on U.S. abortion patients has helped put a human face on abortion, showing, for example, that fully six in 10 women seeking abortion already have one or more children and that nearly all women make the decision to terminate a pregnancy out of concerns for their responsibilities to other family members.

Recent Guttmacher studies also document the growing disparities in unintended pregnancy and abortion between rich and poor women in America. After years of declining unintended pregnancy rates among low-income women (largely a result of public support for family planning services), the gap between rich and poor is again increasing.

Women living in poverty are now four times as likely to have an unintended pregnancy, three times as likely to have an abortion and five times as likely to have an unplanned birth as are other women. Poor women seeking abortion are also more likely to have their abortions later than they want -- an average of two weeks later than nonpoor women -- because in the absence of public funding, they face multiple financial and logistical barriers to timely procedures.

Worldwide and regional abortion estimates jointly released in October 2007 by the Guttmacher Institute and the World Health Organization showed that the lowest rates of abortion are in the western European countries that place few restrictions on abortion and provide easy access to contraceptives and comprehensive sex education. The sharpest declines in abortion over the past decade occurred in neighboring eastern Europe, where access to and use of modern methods of contraception soared after the collapse of the Soviet Union. The highest rates are in Latin America and Sub-Saharan Africa, where almost all abortions are illegal. These data are crucial to informing better, evidence-based policies and interventions in countries around the world.

Visit the Guttmacher Institute's website for more information about the Institute and its work.

Congress -- Mind the Reality Gap!

2007-11-28T09:10:31-05:00

"Mind the gap" signs on Amtrak trains warn riders to be wary when they step off a train. We should likewise post "mind the gap" warnings in many of America's schools -- alerting students, parents and the public to the very real hazard posed by the huge, and growing, reality gap in U.S. sex education.

Just how cavernous is the gap between the scientific evidence and our sex-education policies? Several authoritative studies released this year show compellingly that there is no evidence base to support the massive federal investment in abstinence-only-until-marriage sex-education programs. And yet, Congress wants to authorize a $28 million funding increase for these hard-line programs, on which we have already wasted about $1.5 billion -- including $176 million this year alone.

Let's review the evidence: A recent report by the nonpartisan National Campaign to Prevent Teen and Unplanned Pregnancy finds that "[a]t present, there does not exist any strong evidence that any abstinence program delays the initiation of sex, hastens the return to abstinence, or reduces the number of sexual partners." The report concludes that "studies of abstinence programs have not produced sufficient evidence to justify their widespread dissemination." Is it unreasonable to expect, at a minimum, that such programs demonstrate a positive impact before hundreds of millions of our dollars are poured into them?

Also consider the eight-year, congressionally mandated evaluation by Mathematica Policy Research released in April, which shows that abstinence-only programs have no beneficial impact. Students who participated in a range of curricula funded through the federal Title V abstinence-only program were no more likely than non-recipients to delay sexual initiation, to have fewer partners or to use condoms when they did become sexually active. Apparently, that's what a $176 million annual investment in federally funded abstinence-only programs gets you: no positive impact whatsoever.

Recent research conducted by the Guttmacher Institute further exposes the dysfunctional, and at times outright absurd, nature of our government's approach to sex education. Even though we found that 86 percent of the recent decline in U.S. teen-pregnancy rates is the result of improved contraceptive use, the Bush administration and some members of Congress want to increase funding for abstinence-only programs that-if they mention contraception at all-are prohibited from any discussion of its effectiveness and benefits. And never mind that, as our researchers found, premarital sex is near-universal among Americans. Federal abstinence-only programs now promote abstinence not just for young teens, but are encouraged to do so for all unmarried people through age 29.

Instead, it would be more effective and responsible to provide our young people with the skills and information they really need-both to postpone the onset of sex and to be safe once they do become sexually active, which nearly everyone eventually will. This approach is bolstered by an abundance of evidence, including from the National Campaign's just-released report, showing that a substantial majority of comprehensive sex-education programs-which receive no dedicated federal funding-are effective; indeed, many succeed in delaying teens' initiation of sex, reducing their number of sexual partners, and increasing condom or contraceptive use.

Policy-makers at the state level increasingly get it. Thus far, 14 states have opted not to accept federal funds under the rigid Title V abstinence-only program -- among them New York, New Jersey and Ohio. Unshackling their students from hard-line ideology and offering them more comprehensive sex-ed programs instead not only is bolstered by a very strong body of evidence, but also is endorsed by the vast majority of Americans.

Just how overwhelming is the public's support for comprehensive sex education? Even a Zogby survey (chock-full of leading and misleading questions) commissioned by the National Abstinence Education Association (NAEA), the lobbying arm of the abstinence-only industry, found that almost 80 percent of parents agree that learning how to use condoms and other contraceptives correctly "is best for [their] child's health and future." Too bad such instruction is expressly forbidden by current federal guidelines for abstinence-only programs on whose behalf the NAEA lobbies.

In short, one would be hard-pressed to find another issue where the thrust of our policies goes so strongly against the evidence-not to mention against the interests of a generation of American youth. However, Congress now has the opportunity to redeem itself following President Bush's successful veto (on grounds that it is too expensive) of the major appropriations bill that included the increase for abstinence-only funding. As it renegotiates the spending bill, Congress should do right by America's taxpayers and youth and stop-or, at the least, scale back-the funding for ineffective abstinence-only programs.

This article was originally published in the November 20 edition of the Philadelphia Inquirer.

A 12-Step Program to Tell Good Science from Bad

2007-02-27T08:00:00-05:00

Sharon Camp is the President and CEO of the Guttmacher Institute.

The very complexity of scientific studies can make them their own worst enemy. Valuable research is too often communicated in technical language and rigid formats that make it difficult for non-experts to interpret and evaluate the findings. Worse, some groups deliberately use outdated, incomplete, misleading and outright false information to further an ideological or religious agenda. This creates an environment in which it is increasingly difficult for the public and legislators to distinguish scientifically sound studies from agenda-driven junk science.

It needn't be that way. Social science research, with its focus on human behaviors, relationships and social institutions, can be a rich source of material for journalists, policymakers and program administrators. Indeed, social science findings have their greatest impact when they are useful to—and used by—groups that channel research into practice to improve people's lives.

The questions below (drawn from Guttmacher's "Interpreting Research Studies") are intended to help demystify social science research for those who could make use of the findings but lack specialized training in research methods. It identifies the key questions to ask when evaluating a research report and explains why the answers matter.

What makes the study important?
A study's importance or newsworthiness depends on how it contributes to what we already know. Does the study answer a previously unaddressed question? Does it address an old question in a new way or with surprising results? Reading through the abstract or executive summary with these questions in mind can help you evaluate the study's relevance even before you review the full publication.

Do the findings make sense?
Do study's key "findings" or "results" make sense, given what you already know about the subject? And are they rooted in the existing body of research? A scientific report should be properly referenced, with original sources for all factual statements and data from other research clearly cited.

Who conducted the research and wrote the report?
It is important to consider whether the study results could be influenced by a researcher's conflict of interest. Are the authors well regarded in the scientific community? What are their professional credentials? Could their work have been influenced by those who employed or funded them? Any potential conflict of interest should be identified up front. That said, good researchers committed to a political or social agenda can still conduct unbiased, trustworthy studies that can withstand independent evaluation, provided they follow practices designed to protect the quality and integrity of research.

Who published the report?
An article published in a peer-reviewed journal has been evaluated by experts in the field to help ensure that it meets high scientific standards. The prestige of the journal is one indication of a study's quality. While studies from sources other than journals (including reports that research institutions publish themselves) may also contain solid, useful information, if an external review process is not mentioned, you should be more cautious about accepting the study's conclusions.

Did the researcher select an appropriate group for study?
A social scientist's work is about people. In practical terms a study often focuses on a subset, or sample, of the larger population. This sample must be selected carefully to ensure that the study results are applicable to the relevant general population. Using a representative sample is the best way to ensure that findings can be generalized to all members of the target population. Other common approaches are acceptable and—with appropriate statistical adjustments for weighting—can produce valid and representative results. Sometimes, however, a researcher may have good reasons to select the target population in a different way. When they do, they should explain their reasons, and you should consider the extent to which their findings are applicable to other groups.

If comparison groups are used, how similar are they?
If a study compares two or more groups (to evaluate the effects of an intervention, for example), the results will be valid only if the groups are similar in all ways other than their exposure to the intervention being studied. Any preexisting differences between the groups could account for different outcomes. In the best study designs, participants are randomly assigned to the study groups. But when differences do exist between the groups, researchers can use statistical techniques to control for differences. Experience and common sense can help determine whether the differences among them are important for the study.

What has changed since the information was collected?
Ideally, the data used in a study will have been collected recently so that the information reflects the current situation. However, because national-level surveys can be quite expensive and time consuming, data may not become public for several years and special analyses may require additional time. For example, data from the large National Survey of Family Growth, which was conducted in 2002, became public only in late 2004, and analyses are still ongoing. It is important to consider how any changes that have occurred in the intervening period, such as new policies, could affect the outcomes today.

Are the methods appropriate to the research purpose?
Social science studies can rely on either qualitative or quantitative methods or a combination of the two. As a rule, quantitative techniques (collecting and analyzing measurements such as whether a person is currently using a contraceptive method, etc.) are best for answering questions such as "How much?" "How many?" "How often?" or "When?" Quantitative studies can also indicate important relationships, such as whether poor women are more likely than better-off women to have more children than they want. Qualitative research (recording and analyzing interactions with people through techniques such as in-depth interviews or focus groups) may be more useful in obtaining a better understanding of complex contextual, attitudinal or behavioral issues or documenting a process.

Does the study establish causation?
Often, the goal of a study is to determine the effect of something: for example, a program, medication or policy. However, it is usually difficult to isolate the effects of one discrete factor from all the other things going on in people's lives. Even if the study shows that a particular outcome occurred after a program got under way, it can be difficult to prove that this intervention caused the outcome. In general, studies can prove only that an outcome is "associated with" or "correlated with" (rather than "caused by") an intervention. Be alert to researchers who make claims about cause and effect that seem dubious or who ignore other possible explanations for their findings.

Is the time frame long enough to identify an impact?
Studies can either follow their subjects over time, checking in with them at various intervals (a longitudinal study), or take a "snapshot" of subjects at a single moment in time (a cross-sectional study). A cross-sectional study is good for comparing groups, while a series of cross-sectional studies conducted within the same general population (but selecting a different group of people each time) can also provide information on trends over time, as long as the groups sampled are truly comparable. Because a longitudinal study follows the same group of individuals over time, it can be better for examining the effects of a particular intervention, as long as it allows enough time for adequate follow-up and is able to retain a sufficient number of participants.

Could the data be biased as a result of poor research design?
The wording and order of questions in a poll or survey can affect the answers participants provide. In addition, a low response rate (say, fewer than 70% of those selected), suggests that the results may be biased because the people who participated are not representative of the target group as a whole. Studies of sexual and reproductive behavior face another hurdle. Participants do not always answer sensitive questions truthfully. For example, adolescent boys tend to overreport sexual activity, while adolescent girls tend to underreport it.

Are the results statistically significant?
When a quantitative study uses a sample, it is important to determine mathematically that there is little probability the result could have occurred by chance—that is, that a different sample could have produced other results. In the social sciences, a study finding is generally considered statistically significant if there is no more than a 5% probability that it could have occurred by chance (often expressed as a "p-value" of 0.05 or less). Statistical significance alone is not enough to prove cause and effect, but it lends credibility to an argument.

The answers to these 12 questions should help you evaluate and interpret reports of research findings. Of course, a study may be flawlessly designed, conducted without bias, appropriately analyzed and statistically significant, yet convey nothing important to you. But if the findings are something that you care about, and you believe that the research is sound, you are in a position to play a critical role in social science research—interpreting the findings and transmitting them to the wider world to have a greater impact.

"Interpreting Research Studies," on which this blog post is based, was written by Jennifer Nadeau and Sharon Camp and shaped by the valuable input of many Guttmacher colleagues and partners.

Keeping Our Promise to the World’s Youth

2006-12-01T07:57:07-05:00

Sharon Camp, Ph.D., is the President and CEO of the Guttmacher Institute.

The theme of this year's World AIDS Day on December 1 is accountability: Stop AIDS, Keep the Promise.

When it was first discovered in 1981, the virus that causes AIDS threatened to wreak havoc on the lives of millions worldwide, and today - with 40 million living with the virus and four million new infections this year - the virus has kept its dire promise.

On the other hand, the global community has fallen short of its promise to provide adequate funding for prevention, treatment and care. Our failure holds grave consequences for the world's youth. We promised to take care of our future generations, but do today's adolescents - tomorrow's adults - have the knowledge, skills and resources to have healthy relationships and protect themselves against diseases such as HIV/AIDS?

Not quite.

Recent studies by the Guttmacher Institute and colleagues provide a good yardstick by which to measure our progress in the fight against HIV/AIDS in Sub-Saharan Africa, where the virus has hit the hardest. The findings are clear and troubling: Adolescents in Ghana, Uganda, Burkina Faso and Malawi are not getting the information they need to protect themselves from HIV.

Awareness of AIDS is widespread, but knowledge of how to prevent HIV is not: Fewer than one in three adolescents in these four countries can both correctly identify ways of preventing HIV and reject major misconceptions about HIV.

Fewer than three in 10 adolescents use any kind of contraceptive the first time they have sex. Most say they didn't use a condom because they "felt safe" or didn't have one.

One of the best ways to reach young people before they become sexually active - school-based sex education - remains underutilized: Fewer than half of young women and fewer than 40% of young men ever attended sex education classes.

But the main message from our research is not pessimism, but hope. Young people are working hard to achieve their dreams. More than seven in 10 adolescents in Ghana, Uganda and Malawi expect to complete their education, and many young people aspire to good jobs that will allow them to support themselves and their families. Witness this exchange with one Ghanaian adolescent:

I: Now tell me what you will like your life to be like in the next five years.

R: I want to be at a teacher training college.

I: What could make this more or less likely to happen?

R: If I learn hard I can reach where I want to go.

I: But what do you think will not allow you to get to the training college by five years time?

R: If I become pregnant or infected with HIV/AIDS.

This World AIDS Day, young people from around the world are speaking up to draw attention to the need for well-funded, focused and sustained prevention efforts. We owe it to the next generation to support their dreams by promoting sound programs and policies and by opening our pocketbooks to invest in their futures and rid the world of this scourge.

According to a new report, AIDS is now promising to become the third leading cause of death worldwide. AIDS has a pretty good track record for keeping its promises. Will we?

Click here to learn more about HIV and young people

Losing Ground on Abortion

2006-10-27T09:00:00-04:00

Sharon L. Camp is President and CEO of the Guttmacher Institute.

The recent decision by the Food and Drug Administration to allow women 18 and older to buy the emergency contraceptive Plan B at pharmacies without a prescription is very welcome news. But Plan B alone will not be enough to overcome our nation's stalled progress in reducing unintended pregnancy and the need for abortion.

The latest data on abortion, published by the Guttmacher Institute in early August, should make no one happy - not the anti-abortion activists who have successfully lobbied for a raft of new abortion restrictions (and who opposed over-the-counter sales of Plan B) and not those of us who want to keep abortion safe, legal and available.

The new numbers strongly suggest that a decades-long decline in U.S. abortion rates is stalling out. In each year from 2000 to 2003, the abortion rate (the number of abortions per 1,000 women of childbearing age) barely budged. There is no reason to expect 2004, 2005 or 2006 will look any better. Indeed, they might look a good deal worse.

A decade ago, abortion rates were dropping significantly every year, as all groups of women benefited from improving contraceptive use. Today, abortion rates are declining only for better-off women. Rates for poor women are actually going up. This is very bad news, regardless of which side of the abortion divide you are on.

Given this latest evidence, anti-abortion activists may want to rethink their plan of action. Imagine what we could achieve if we could re-channel all the energy state and federal legislators now spend making it harder for women to get abortions into efforts to make it easier for them to avoid unwanted pregnancies in the first place?

The typical American woman who wants two children spends about five years of her life pregnant, post-partum or trying to get pregnant. But in order to avoid an unplanned pregnancy, she will need to use contraception correctly and consistently for 30 years. This is no mean feat in the American context, where contraceptives are relatively expensive (compared to other countries), increasing numbers of young women lack health insurance, and even those who have insurance may not have coverage for contraceptives.

Indeed, a surprising number of American women-17 million, according to new Guttmacher Institute estimates-need help to cover annual cost of prescription contraceptives and the medical services associated with them. This total grew by a million women between 2000 and 2004.

But in much of the country, public subsidies for family planning services failed to keep pace, with funding flat or declining in about half the states. Meanwhile, the cost to deliver such health care has gone through the roof. Many public health facilities can no longer afford to offer the most effective and easiest-to-use new contraceptive methods. Funding shortfall may be part of the reason why the number of sexually active women who are not using any birth control has gone up, especially among low-income women.

Publicly funded family planning services currently prevent an estimated 1.3 million unintended pregnancies each year. Without public funding for such services, the U.S. abortion rate would likely be 40% higher than it is. A good 10-year goal would be to reduce abortion another 40% by getting more resources to hard-strapped family planning clinics. Our country actually has a related goal: In 2000, we made it a national public health priority to reduce unintended pregnancy by 40%. But at the moment, we're making zero progress.

Instead, the disparity in unwanted pregnancy by income group has grown significantly. Unintended pregnancy has gone up 29% among poor women, and down 20% among better-off women. A poor woman is now four times as likely to have an unintended pregnancy, five times as likely to have an unintended birth and more than three times as likely to have an abortion as a woman living above 200% of the poverty level.

There are some easy ways to get things back on track, if our leaders would care to try. Many of them are revenue-neutral, meaning they cost nothing to implement or they pay for themselves quickly. The best examples are the 24 state Medicaid waivers that expand eligibility for family planning coverage to more low-income women. A recent Guttmacher study finds that making eligibility for contraceptive services the same as eligibility for Medicaid-covered pregnancy-related care would avert almost 500,000 unplanned pregnancies, 225,000 unplanned births and nearly 200,000 abortions a year, while also saving $1.5 billion in net state and federal expenditures.

Another good investment would be adequate funding for the categorical federal family planning program known as Title X. In inflation-adjusted dollars, funding for the program is just 40% of what it was in 1980.

We should also look for ways to make effective contraceptive use easier and less expensive for everyone. Following the example of Plan B, many experts think birth control pills and other newer hormonal methods should also be made available without a prescription. Regardless, we should try to remove unnecessary medical barriers that merely raise costs and inconvenience women. I believe conservatives call this deregulation.

Let's revisit contraceptive labeling. It's often outdated, inappropriately scary, confusing, incomprehensible or all of the above. Wouldn't it make better sense to have up-to-date, science-based labeling that most women could actually read?

We also need better public education programs - not just for teenagers, but for adults as well - education that stresses personal responsibility and that gives people medically accurate information on the safety and effectiveness of modern contraceptives, preferably before they start having sex.

We know how to make abortion rates start going down again. Let's stop wasting time and get on with the job.

Editor's note: this piece was adapted from Sharon Camp's op-ed in The Philadelphia Inquirer.