Reproductive Health

Beyond the numbers: What’s it like to have an unplanned pregnancy?

kkrisberg — Fri, 17 Mar 2017 17:02:14 +0000

Beyond the numbers: What’s it like to have an unplanned pregnancy?

There’s a lot at stake for women’s health in the Republican plan to replace the Affordable Care Act, which eliminated out-of-pocket costs for birth control and has been highly successful in breaking down barriers to affordable family planning. The cost-sharing changes alone are saving individual women hundreds of dollars each year on their choice of contraception.

So far, the Republican replacement proposal, known as the American Health Care Act, doesn’t impact the Obama-era contraception coverage provisions, nor does it touch other women’s health benefits, such as designating maternity care an essential health benefit. But it does attempt to cut off funding to Planned Parenthood, which serves millions of women and men every year; restrict insurance coverage of abortion; and roll back Medicaid funding, which experts predict will disproportionately impact low-income women. (It is important to note, however, that on the issue of contraceptive coverage and other essential health benefits important to women, Health and Human Services Secretary Tom Price does have the power to change the rules governing those benefits through the agency’s rulemaking process. In turn, it’s probably too early to say the ACA’s contraceptive benefits are safe.)

All these potential policy changes come with very real impacts to women’s health and economic security. The Urban Institute released a new health policy brief this month that illuminates those impacts and helps us gain a deeper understanding of the role of family planning in women’s lives. Part of a multiyear project known as “Beyond Birth Control: Family Planning and Women’s Lives,” the new brief focuses on prevalence and perceptions of unplanned births. It’s based on data from the Urban Institute’s Survey of Family Planning and Women’s Lives, a nationally representative survey of nearly 2,000 women of reproductive age. Among the brief’s key findings, significant numbers of U.S. women experience an unplanned birth in their lifetimes, and such experiences have serious impacts on their lives and opportunities.

Researchers found that more than one-third of women surveyed in 2016 — or more than 36 percent — said they had experienced at least one unplanned birth. Among women who already had children, that rate was more than six in 10, or 62 percent. Marital status underscored the greatest difference in unplanned birth numbers, with married women having the lowest prevalence. Still, about half of married women reported an unplanned birth. Majorities of women said an unplanned birth would negatively affect their education, job, income and mental health. More than 40 percent said an unplanned birth would have a negative impact on their physical health. Brief authors Emily Johnston, Brigette Courtot, Jacob Fass, Sarah Benatar, Adele Shartzer and Genevieve Kenney report:

Women’s responses in follow-up interviews reinforced the negative reported perceptions of the effect an unplanned birth would have on a woman’s education, job, and income. For example, one 21- year-old woman said, “Kids are expensive, and I wouldn’t be able to finish my degree and get the high- paying job that I want. It would definitely change my future plans in a bad way.” When discussing the effect an unplanned birth would have on her life compared with that of her partner, a 28-year-old woman said, “Unfair as it is, it probably wouldn’t affect his career or education as much as it would affect mine.” One 35-year-old respondent expressed concerns about her mental health and stated, “Emotionally and financially we would be better prepared to have another child in a year, but we would make it work if it happened.”

Among 26 survey respondents participating in follow-up interviews, about half had a positive or neutral reaction to the idea of an unplanned pregnancy. However, women pretty much agreed that an unplanned pregnancy would have significant financial and emotional costs. Some women said having another baby would mean big new expenditures, like a new house, new car and additional childcare. Several said a new baby would result in them quitting their jobs. Quotes from respondents:

•Being a mom, I know that babies change things and you change your plans. We’ve always just managed to just change our work hours around so that someone was always home with the children. That may be a factor. — 44-year-old married woman

• I would be extremely scared and very upset and worried about my future. As a female I’m applying for grad school, and it would put a kink in my educational plans and financial plans in the long term. — 28- year-old single woman

• I wouldn’t be depressed, but I would be overwhelmed because I have a lot of goals to accomplish before that happens. — 22-year-old woman living with a partner

Among women who had experienced an unplanned birth, more than half agreed that it positively impacted their motivation to achieve their goals. Nearly half said it had a negative impact on their income and 40 percent said an unplanned birth negatively impacted their mental health. Hispanic and black women were more likely to report mostly positive effects than white women. The brief concludes:

Women’s concerns about the negative effects of unplanned births underscore the importance of access to reproductive health and family planning services, which allow women to plan their pregnancies and prevent unplanned births. For women who experience an unplanned birth, access to targeted services and supports could reduce the negative impact of an unplanned birth on a woman’s life.

The future of the Affordable Care Act is unsure. But every one of the 62 percent of women of reproductive age who use contraception — and the many, many more who’ll need it in the future — will be impacted by its fate.

Download a copy of the new policy brief at the Urban Institute.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for 15 years.

kkrisberg Fri, 03/17/2017 - 13:02

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Affordable Care Act

government

healthcare

Public Health - General

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women's health

American Health Care Act

I am 60 years old and was a teenager when Rowe vs Wade was passed by the SCOTUS. It was a happy day for me not because I think abortion is a great thing but because I knew school teenagers that had to have abortions. Some were forced by parents with money sent to NY. Others were poor and scared and went to back alley butchers. This is why I want abortion legal. No women wants an abortion it is life or health reasons that make them choose. I doubt there are many that have more than one abortion in their life. But it needs to be legal and safe.

Worth reading: Tuberculosis activism, “locker room talk,” and Clean Air Act enforcement

lborkowski — Tue, 25 Oct 2016 17:09:11 +0000

Worth reading: Tuberculosis activism, “locker room talk,” and Clean Air Act enforcement

A few of the recent pieces I’ve liked:

Eric Boodman at STAT: Night sweats, bloody cough — and a diagnosis that turned a doctor into an activist

Laura Fink in The San Diego Union-Tribune: Debt of gratitude owed to Trump accusers

Eliza Barclay at Vox: How to confront sexist “locker room talk,” according to science

Jie Jenny Zou at Center for Public Integrity: State cutbacks, recalcitrance hinder Clean Air Act enforcement

Joerg Drewke in Guttmacher Policy Review: “Fungibility”: The Argument at the Center of a 40-Year Campaign to Undermine Reproductive Health and Rights

Lenny Bernstein and Scott Higham in the Washington Post: Investigation: The DEA slowed enforcement while the opioid epidemic grew out of control

lborkowski Tue, 10/25/2016 - 13:09

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Public Health - General

Study: Fracking chemicals linked to reproductive health abnormalities in mice

kkrisberg — Fri, 16 Sep 2016 21:53:00 +0000

Study: Fracking chemicals linked to reproductive health abnormalities in mice

In a new study — the first of its kind — researchers fed water laced with fracking chemicals to pregnant mice and then examined their female offspring for signs of impaired fertility. They found negative effects at both high and low chemical concentrations, which raises red flags for human health as well.

“These are preliminary findings,” Susan Nagel, the study’s senior author and an associate professor in Obstetrics, Gynecology and Women’s Health at the University of Missouri School of Medicine, told me. “But I think they suggest that we should absolutely be looking more closely at the potential health effects (of these chemicals).”

Published in the September issue of Endocrinology, the study adds to a growing body of research on the human health effects of fracking chemicals and the potential hazards of related air and water contamination. Just earlier this year, Nagel co-authored another study that found water located downstream from a fracking wastewater site contained levels of endocrine-disrupting chemicals high enough to negatively effect the aquatic inhabitants.

In this most recent study, Nagel and colleagues selected 23 chemicals found in oil and gas operations, including fracking, and mixed them at four different concentrations to mimic what’s been found in drinking water and groundwater as well as in industrial wastewater. More specifically, the contaminated water samples were designed to reflect “environmentally relevant” concentrations, with the two lowest doses equivalent to what’s been reported in drinking water in drilling regions and the highest dose meant to mimic industrial wastewater. The contaminated water was then given to pregnant mice on day 11 of pregnancy through birth. The female offspring that were exposed to the chemicals in utero were then compared to female offspring that did not receive the contaminated water. The study noted that of the more than 1,000 chemicals used in unconventional oil and gas operations, at least 130 are known or suspected endocrine disrupters.

The researchers found that the exposed group presented notable differences in key hormones related to reproductive health, including disruptions in the development of the ovarian follicle, which is central to egg development. In particular, the female mice offspring exposed to smaller concentrations of the fracking chemicals had fewer ovarian follicles, which may suggest fewer eggs and shorter fertile periods. On the other end, the offspring exposed to high doses of chemicals experienced a follicle increase, which suggests “inappropriate follicle activation (or accumulation) and ultimate follicle death.”

In addition to reproductive health impacts, the exposed mice also had altered pituitary hormone production, increased body weights, and increased cardiac fibrosis (a thickening of the heart muscle and an indicator of future heart failure) as well as increased heart weights. (In a 2014 study, researchers found a relationship between proximity to natural gas wells and the prevalence of congenital heart defects in human babies.) Nagel told me that while the reproductive health findings don’t automatically mean the exposed offspring will have trouble getting pregnant or staying pregnant, “it is likely that suppressed reproductive hormones will alter fertility.” Nagel also noted that when it comes to the “developmental effects of endocrine disrupter exposure, mice have been very good predictors of human health.”

In terms of which specific chemicals might be responsible for the altered development in exposed mice, the researchers aren’t sure.

“We can’t say which chemical is the culprit,” Nagel said. “We’ll be dissecting the chemical question further in the future, but right know we don’t’ know. It’s definitely a chemical soup.”

Also published in September in the journal Fertility and Sterility was a systematic literature review on the relationship between oil and gas extraction and human reproduction. Co-authored by Nagel as well, she her colleagues — Victoria Balise, Chun-Xia Meng, Jennifer Cornelius-Green, Christopher Kassotis and Rana Kennedy — concluded:

The integration of the evidence suggests negative health impacts on reproduction from occupational and residential exposure to oil and gas extraction activities. Specifically, there is moderate evidence for increased risk of miscarriage, prostate cancer, birth defects, and decreased semen quality. However, no conclusions can be drawn for the following end-points. The evidence is low and inadequate for testicular, breast, or female reproductive cancers, birth outcomes associated with paternal exposures, and stillbirth. The evidence for both sex ratio and low birth weight is inconsistent.

There is ample evidence for disruption of the estrogen, androgen, and progesterone receptors with individual chemicals and complex mixtures of chemicals and waste products related to oil and gas extraction. These data provide a strong mechanistic rationale for how oil and gas activities may increase the health risks outlined herein.

To continue building on the mouse research, Nagel said she and colleagues plan to study the actual fertility of the female mice exposed to fracking chemicals prenatally (i.e., whether they can get and stay pregnant and if their number of offspring are affected) as well as follow up on the metabolic and heart findings. To request a full copy of the mouse study, visit Endocrinology.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.

kkrisberg Fri, 09/16/2016 - 17:53

Study: High levels of endocrine-disrupting activity found downstream from fracking disposal site

kkrisberg — Fri, 15 Apr 2016 15:14:26 +0000

Study: High levels of endocrine-disrupting activity found downstream from fracking disposal site

Lead isn’t the only toxin threatening the safety of community drinking water. A recent study on water located downstream from a West Virginia fracking disposal site uncovered levels of endocrine-disrupting chemicals high enough to adversely impact the aquatic animals living there. And that means human health could be at risk too.

“We can’t make any direct (human health) assumptions about this particular water,” said study co-author Susan Nagel, an associate professor in the University of Missouri School of Medicine’s Division of Obstetrics, Gynecology and Women’s Health. “But we certainly know that humans are sensitive to endocrine-disrupting chemicals — we know (these chemicals) negatively affect human reproduction and fetuses.”

The study, published earlier this month in Science of the Total Environment, focused on four sites associated with a fracking disposal well near Fayetteville, West Virginia: one upstream from the well, one near the well and two downstream from the well. The study didn’t test the actual wastewater stored in the disposal site. These disposal wells contain the wastewater that returns to the surface after drilling for oil and gas at fracking extraction sites. About 1,000 different chemicals are used in the fracking industry, with more than 100 being known or suspected endocrine disruptors. About 36,000 such disposal wells have been permitted throughout the U.S., though little is known about their potential to contaminate nearby water sources.

To conduct the study, which is part of a larger U.S. Geological Survey (USGS) study in the region, researchers collected surface water samples and sent them to Nagel and her colleagues in Missouri, where they used a process known as solid-phase extraction to isolate the chemicals and test them in human cells. The tests revealed greater endocrine-disrupting chemical activity on and downstream of the fracking disposal site, compared to samples taken upstream from the site. Nagel told me that in exposing both female and male mammalian sex hormones to the water, researchers found that the water blocked the hormones’ normal processes. She noted that while the study did not examine drinking water, the tested surface water was collected from a creek that eventually flows into a drinking water source.

“I wasn’t surprised to see the elevated (endocrine-disrupting) activity,” Nagel told me. “But I was surprised at the amount of the activity.” She said the activity she found in the West Virginia samples were at least 10-fold higher than similar surface water testing she’s conducted near fracking sites in Colorado.

Nagel and study co-authors Christopher Kassotis, Luke Iwanowicz, Denise Akob, Isabelle Cozzarelli, Adam Mumford and William Orem write:

As a class II injection well, this site is permitted to accept wastewater from unconventional oil and natural gas extraction. However, this site may accept wastewater and fluids from other industries as well, and the hormonal activity profile exhibited may be due in part to other sources. As such, caution should be taken in the extrapolation of these results to unconventional oil and gas activities specifically. To address this concern, research performed concurrently describes in detail the analytical and geochemical profiling that identified inorganic and organic constituents indicative of (unconventional oil and natural gas) wastewater at these sites. Specifically, elevated conductivity, sodium, chloride, and barium concentrations, and strontium isotopes suggest that the contamination profile is specifically due to the handling of (unconventional oil and natural gas) wastewater from shale gas and coal bed methane production. In addition, numerous organic chemicals were identified in water and sediments downstream of the injection facility, many associated with (unconventional oil and natural gas) operations.

The study found chemical activities well within range to affect the health of aquatic animals — in fact, chemical activities found downstream of the fracking disposal site were well above levels linked to adverse health effects in such animals. Researchers noted that “even with considerable dilution,” the levels of endocrine-disrupting chemicals in the sampled water would still be capable of disrupting normal development in fish and aquatic animals. Nagel added that “fish are actually very good sentinels — we do have a lot of the same hormone receptors that control a lot of the same processes.”

Nagel emphasized that the study doesn’t pinpoint the source of the surface water contamination — in other words, the study does not make a conclusive link between the contaminated water and a leak or spill from the nearby fracking wastewater site. Though she said there have certainly been previously confirmed cases of drinking water contamination linked to fracking disposal wells.

“We don’t know how (the endocrine-disrupting chemicals) got there,” she said. “But it’s absolutely essential to find out where this is coming from. We need a national dialogue that is very specific about looking into the human health impact, and we need a systematic approach to do that.”

Nagel has also been involved in research in Colorado, where she and her colleagues concluded that fracking activities may be contributing to elevated levels of endocrine-disrupting chemical activity in surface and groundwater. In another 2014 study, Nagel and colleagues found that fracking byproducts in the air and water may be linked to infertility, miscarriage, impaired fetal development, birth defects and diminished semen quality.

To request a full copy of the study, visit the University of Missouri newsroom. For more on USGS fracking research, visit http://toxics.usgs.gov/investigations/uog.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.

kkrisberg Fri, 04/15/2016 - 11:14

So the current economic paradigm seems to be to dilute pollution to the point where it is not readily detectable, disperse it in ways that are not readily assignable or traceable, assume that sufficient dilution has been made by meeting antiquated standards, and fight tooth and nail anyone who challenges the paradigm. Since endocrine disrupting effects occur at and are sometimes enhanced by a particular low concentration range, the very notion of endocrine disrupting chemicals creates a big challenge for the economic paradigm. Similarly, the notion that an invisible trace gas from fossil fuel combustion could ultimately submerge the economic apple cart looks to much of the business community as an attack at all things holy. But I note that since most of us benefit from cheap energy, petrochemical materials, and access to relatively clean water that is not acutely toxic, we carry on in this devil's bargain, not complaining too much, hoping that we dodge enough poison to have a good life, hoping that the consequences of climate disturbance hold off long enough to be solved by future technology. One group of us is pushing economic progress, development, and exploitation of resources, the other is trying to prevent large scale poisoning, flooding, loss of water resources, and agricultural failure. The cost of fracking, in terms of its disruption and permanent loss of water resources, is likely to be born by future generations. Our economic system, great at hiding costs, runs two sets of books.

> dilute pollution to the point
> where it is not readily detectable

Or simply reclassify the toxic waste as a saleable product, as with the fracking chemicals, or MTBE, or ....

Study: Chemical alternative in BPA-free products may not be safer

kkrisberg — Fri, 12 Feb 2016 17:57:51 +0000

Study: Chemical alternative in BPA-free products may not be safer

Manufacturers who market their products as “BPA-free” aren’t just sending consumers a message about chemical composition. The underlying message is about safety — as in, this product is safe or least more safe than products that do contain BPA. However earlier this month, another study found that a common BPA alternative — BPS — may not be safer at all.

“BPS works very similarly to BPA,” said Nancy Wayne, a reproductive endocrinologist and professor of physiology at the University of California-Los Angeles David Geffen School of Medicine. “We’re not the first to show this, but what’s captured people’s attention is that we did the work side by side — observing the effects of BPS alongside BPA. For people who are concerned about (endocrine-disrupting chemicals)…this is a big deal.”

Wayne co-authored a study published this month in the journal Endocrinology that found BPS (Bisphenol S), a common replacement for BPA (Bisphenol A), speeds up embryonic development in animal models and adversely impacts the reproductive system. The study is the first to examine the impacts of BPA and BPS on brain cells and genes involved in reproductive functions.

A known endocrine disrupter, the chemical BPA is used to make plastics and epoxy resins and is found in food and beverage containers, paints, adhesives, dental sealants, paper products and water supply pipes. According to the National Institute of Environmental Health Sciences, most of us are exposed to BPA through food and drink, and BPA is so ubiquitous that federal public health officials estimate that nearly all of us have detectable levels in our bodies. The U.S. Food and Drug Administration says that BPA is safe at current levels in the food supply, though the agency did ban BPA in baby bottles, children’s cups and infant formula packaging.

To conduct the study, Wayne and her research colleagues observed the effects of BPA and BPS on zebrafish embryos. Wayne told me that zebrafish have become very popular animal models for understanding the genetic regulation of organ and cellular development for two main reasons. First, their embryos are transparent, so scientists can actually watch their development. (“It’s amazing biology,” Wayne noted.) Second, the zebrafish was one of the first animals after humans to have its genome cloned — that means all of its genes are known, which is critical to understanding the genetics of organ, tissue and cellular development. (And in case it’s not completely obvious, scientists can’t do these types of studies on humans.)

“Humans are not rats, humans are not chimpanzees,” Wayne said. “However, we all have similar cellular organizations and share many of the same genes that are affected in similar ways by chemicals. We should be concerned when a growing body of literature is showing that BPA is altering cellular functions. I think it’s a wake-up call.”

Here’s what Wayne and her colleagues found: When exposing the zebrafish embryos to low levels of BPA and BPS — levels equivalent to what’s found in polluted river waters or what the researchers called “ecologically relevant levels” — the embryos grew much faster, speeding up the hatching time and leading to what we’d call premature birth. BPA and BPS exposures also affected the development of brain cells that control reproduction as well as the genes that control reproduction into adulthood. BPA impacted the brain cells that control puberty and fertility, increasing the number of endocrine neurons by up to 40 percent, which the researchers said suggested that BPA overstimulates the reproductive system. Similar effects were found with BPS.

Wayne and fellow researchers also found that BPA and BPS manifest their effects through both estrogen and thyroid pathways. This is important because BPA is typically thought of as an estrogen mimic, which is how it impacts the endocrine system; however, the study found evidence that it could also be stimulating thyroid hormones, which are critical to fetal brain development. BPS, which is considered a safer alternative to BPA because of its lower estrogenic activity, showed similar effects, leading researchers to write: “Therefore, BPA-free plastic products are not necessarily safer than products containing BPA.”

Wayne and study co-authors Wenhui Qiu, Yali Zhao, Ming Yang, Matthew Farajzadeh and Chenyuan Pan write:

The present study provides foundational information using a unique model system for investigating mechanisms by which endocrine disrupting chemicals interfere with early-life development. Moreover, this is the first study to describe the impact of low-level BPA and BPS exposure on the Kiss/Kissr system (part of the zebrafish reproductive system) during embryonic development in any species. It also provides important supporting evidence that BPS is not necessarily a safer alternative to BPA, as suggested by earlier studies focusing solely on its estrogenic activities.

So, why is this important to human health? While BPA, and now BPS, has been shown to impact animal reproductive systems, the risk for humans is not yet definitive. Still, many scientists who study these chemicals hypothesize that they may be contributing to a number of worrisome human health trends, including increasing rates of premature birth, earlier onset of puberty, more genital malformations in babies, and a rise in reproductive and prostate cancers.

“We don’t have a smoking gun in humans,” Wayne told me. “But it’s consistent with what we see in animal models. We have a strong suspicion that endocrine-disrupting chemicals in the environment could be contributing to this.”

As for how consumers can act on the new findings, Wayne is realistic: “We’re not going to get rid of plastics — that’s not going to happen. But we can try to control what we can control,” she said. She told me that after she first began studying BPA in 2007, she went home and threw out all of her plastic food containers, along with the food inside them, and switched to glass containers. Her advice to consumers is to do the same — purchase foods and drinks packaged in glass whenever possible and consider switching out plastic storage containers with glass or stainless steel.

In the next phase of research, Wayne plans to study the long-term effects of BPA and BPS exposures — from embryo to adult — to learn more about their impacts on the reproductive system and gain clearer insights into the effects of continuous environmental exposure. She noted that she doesn’t have federal grant support for her research, but she hopes other scientists interested in endocrine-disrupting chemicals “will become inspired” and build on the work she’s published. As she put it: “That’s how science advances.”

Wayne’s study noted that 5.5 billion kilograms of BPA were projected to be produced in the U.S. and Europe by 2015. And a total of about 2.5 million kilograms of BPA were released into the environment in 2007, with more than 13,000 kilograms released directly into water.

“BPS is not necessarily safer — we just swapped one endocrine-disrupting chemical for another,” Wayne said. “I hope we can continue as a scientific community to push this research forward.”

To request a full copy of the BPA/BPS study, visit Endocrinology or the UCLA Newsroom.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.

kkrisberg Fri, 02/12/2016 - 12:57

In wake of Affordable Care Act, dramatic declines in out-of-pocket spending on contraception

kkrisberg — Fri, 10 Jul 2015 16:06:39 +0000

In wake of Affordable Care Act, dramatic declines in out-of-pocket spending on contraception

Thanks to the Affordable Care Act, American women are saving hundreds of dollars on birth control, according to the first study to document the impact of health reform on prescription contraception spending.

To conduct the study, which was published this month in Health Affairs, researchers analyzed claims data from a large national insurer between January 2008 and June 2013, eventually examining data linked to more than 790,800 women. They found that the average out-of-pocket expense decreased for nearly all prescription contraceptive methods on the market. In particular, the average out-of-pocket savings per patient was an annual savings of $255 for the oral contraceptive pill and $248 for an intrauterine device (more commonly known as an IUD, a long-acting, reversible contraceptive that is inserted into a woman’s uterus). The average out-of-pocket costs for both the pill and IUDs dropped by 20 percentage points after the ACA kicked in. With implementation of the ACA, prescription contraceptives are among an array of preventive services that private insurers must now cover without cost sharing. (However, the contraceptive requirement does not apply to certain grandfathered plans and employers who are exempted for religious reasons.)

So, why is this so important? Well, in addition to widening access to a critical component of women’s health care and giving women control over their reproductive lives, the study’s authors — Nora Becker and Daniel Polsky — noted that contraception access has far-reaching social and economic benefits as well. They write:

Contraceptive use also has important effects on families and the economy. Studies of the effects of legalization of the contraceptive pill in the 1960s and 1970s found that increased access to contraception was associated with lower rates of subsequent entry into poverty, higher rates of labor-force participation and entry into professional school, and higher wages for women. These economic gains also affect subsequent generations: The children of women with increased access to contraception have higher rates of college completion and higher incomes, compared to children whose mothers did not have access to family planning.

The Health Affairs study found that between June 2012 and June 2013, average out-of-pocket costs from the pill dropped from $33.58 to $19.84, while costs for an IUD insertion fell from $293.28 to $145.24. In addition to those two forms of contraception, researchers also found significant reductions in out-of-pocket spending for emergency contraception, diaphragms, contraceptive implants and contraceptive injections.

The authors write: “Median spending for almost all contraceptive methods fell to zero within 10 months of implementation (of the ACA), and mean spending dropped by large percentages (38-93 percent, depending on the (contraceptive) method).” However, the study found that mean (or average) out-of-pocket spending on contraceptives remained above zero for two main reasons: not all contraceptive brands are required to be covered at no cost to beneficiaries and grandfathered insurance plans aren’t subject to the no-cost-sharing rule. (To clarify the last two sentences: “Median” refers to the mid-point separating the higher and lower halves of the data sample; while “mean” represents the average amount women are paying.)

The researchers noted that before the Affordable Care Act, a significant amount of out-of-pocket health care spending among women who use prescriptive birth control went toward contraception. In fact, the researchers estimated that based on the more than 6 million U.S. women using the pill, the Affordable Care Act requirements are leading to $1.4 billion per year in out-of-pocket savings.

"It's possible that by decreasing out-of-pocket expenses, more women will use contraception, or switch to a longer-term method, but additional research is needed to determine both the socioeconomic and health effects for women," study co-author Polsky, executive director of the Leonard Davis Institute of Health Economics, said in a news release. "In the long term, if we do in fact see an increase in the use of contraceptives, that could potentially lead to a lower overall fertility rate, and potentially increased economic opportunities for women and their families."

In related and unfortunate news, some members of Congress are proposing a complete elimination of funding for the Title X program, a proven and effective initiative that funds a network of clinics in providing millions of low-income women with contraception and family planning services, cancer screenings, disease testing and reproductive health services. The Pump Handle’s Liz Borkowski wrote about the proposed budget cut earlier this month and why it makes no sense for women’s health or health care spending. And read this piece from the Guttmacher Institute on why Title X remains vital to millions of American women, even with the ACA insurance expansion.

To request a full copy of the Health Affairs study, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

kkrisberg Fri, 07/10/2015 - 12:06

Worth reading: Measles, heroin, and unsafe chicken

lborkowski — Wed, 04 Feb 2015 17:21:34 +0000

Worth reading: Measles, heroin, and unsafe chicken

A few of the recent pieces I've liked:

Tara C. Smith at Slate: Measles is Horrible

Jason Cherkis in the Huffington Post: Dying to Be Free ("There’s A Treatment For Heroin Addiction That Actually Works. Why Aren’t We Using It?")

Sara Ainsworth at RH Reality Check: Lawyers for Fetuses? Yes, It’s Absurd, But It’s Worse Than You Realize

Wil S. Hylton in the New Yorker: A Bug in the System: Why last night's chicken made you sick

Sarah Goodyear at Citylab: More Women Ride Mass Transit Than Men. Shouldn't Transit Agencies Be Catering to Them?

lborkowski Wed, 02/04/2015 - 12:21

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Public Health - General

Tennessee’s Jekyll and Hyde Moment: Should Pregnant Women Who Use Drugs Be Treated as Criminals?

lborkowski — Wed, 23 Apr 2014 07:38:41 +0000

Tennessee’s Jekyll and Hyde Moment: Should Pregnant Women Who Use Drugs Be Treated as Criminals?

By Sara Satinsky

Should pregnant women who use drugs be charged as criminals or given help? From a public health perspective the choice is clear: provide treatment to help women quit drugs before their use harms their child.

Less than a year ago, Tennessee adopted a progressive policy to provide such treatment, but now is on the brink of taking a big step back. It could become the first state to criminalize pregnant women whose drug use harms a fetus or newborn baby.

The state legislature has passed a bill that, if signed by Gov. Bill Haslam, would authorize the filing of criminal assault charges against a mother if it is determined that she has harmed her fetus or newborn by using illegal drugs.According to The Guardian, the bill says charges can be brought against a woman for “the illegal use of a narcotic drug while pregnant, if her child is born addicted to or harmed by the narcotic drug or for criminal homicide if her child dies as a result of her illegal use of a narcotic drug taken while pregnant."

Curbing the use of illegal drugs by pregnant women is a worthy public health goal, as are efforts to reduce the numbers of children born with symptoms of withdrawal from drugs. But a groundswell of medical, health, substance abuse, and women’s rights professionals and advocates are in emphatic agreement that the bill would do more harm than good. Here's why:

If a pregnant woman fears getting busted for drug use, she may avoid medical care. Research published in the journal Drug and Alcohol Dependence found that when faced with a punitive law, some women will "go underground," for fear of incarceration and losing custody of their child. By compelling a mother who is using drugs to avoid seeking care, the bill could cut pregnant women off from resources that would help them overcome their addictions -- even though the bill ostensibly aims to reduce addiction.
The bill could mean prison terms for women for whom treatment is a healthier option, at the expense not only of the mother's future but that of her child. The bill carries a sentence of up to 15 years – a penalty that would also sentence children to growing up without their mothers. Long-term separation of parent and child can trigger a lifetime of mental and physical health problems for children. A 2012 Health Impact Assessment by Human Impact Partners found that sending non-violent offenders to treatment rather than prison would mean healthier lives, stronger families, and safer communities.
The bill does not give equal opportunity to all women. It allows a woman to avoid a sentence if she commits to completing a drug treatment program. But programs are not available in all parts of the state, and less so to women in communities of color and rural areas, potentially creating a funnel to prison for these women who may lack access to treatment programs. “It’s poor women, black and brown women, rural women who will be criminalized,” said Cherisse Scott, chief executive of SisterReach, one of the groups calling for the governor to veto the bill.
The bill would mark a serious retreat from state policy designed to encourage pregnant women who are using drugs to seek treatment. Less than a year ago Tennessee enacted the landmark Safe Harbor Act, put forward by the Tennessee Medical Association, to address an alarming increase in the state of children born with symptoms of withdrawal from illegal and legal drugs – a tenfold increase over a decade, according to the state Department of Health. The Safe Harbor Act amended the previous law that allowed prosecution of women whose babies were born with withdrawal symptoms, and instead put pregnant women "to the front of the line" to receive drug treatment if they admitted use. Only 11 months have passed – not enough time to see if the Safe Harbor Act is working.

Proponents of the bill say their motivation is to support mothers in getting help for drug use and protecting children. This bill will do the opposite. And that’s why experts are calling on Gov. Haslam to weigh the evidence and veto the bill.

Sara Satinsky, MPH, is a senior researcher at Human Impact Partners, an Oakland, Calif., nonprofit that studies the health and equity impacts of public policy.

lborkowski Wed, 04/23/2014 - 03:38

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Massachusetts study: High demand for publicly funded family planning services, despite near universal insurance

kkrisberg — Fri, 07 Feb 2014 14:54:29 +0000

Massachusetts study: High demand for publicly funded family planning services, despite near universal insurance

Higher insurance rates don’t mean people stop seeking care at publically funded health centers, found a recent study of family planning clinics in Massachusetts. The findings speak to serious concerns within public health circles that policy-makers may point to higher insurance rates as a justification to cut critical public health funding.

Published in the Jan. 24 issue of Morbidity and Mortality Weekly Report, the study examines trends among uninsured patients seeking care at Massachusetts health centers that receive Title X Family Planning Program funds. (The federal Title X program supports access to high-quality family planning and related preventive services for low-income women and men.) In Massachusetts, which passed health reform legislation in 2006 and is often cited when trying to predict future impacts of the Affordable Care Act, researchers found that higher rates of people with health insurance had little effect on patient numbers at Title X-funded clinics. The study also found that the clinics continue to serve as a critical safety net for uninsured residents.

In addition to family planning and contraceptive services, Title X-funded clinics provide breast and cervical cancer screening, pregnancy testing and counseling, education and referrals, and testing for HIV and other sexually transmitted diseases.

“As more people get insurance, some might think that there’s no longer a need for safety net programs, but we just haven’t found that to be true,” said Jill Clark, a co-author of the study and assistant director of the Family Planning Program at the Massachusetts Department of Public Health. “From the other research we’ve done, people say they feel like they receive quality care (at these clinics), that their services are kept private and their confidentiality is respected. These are organizations that people are familiar with.”

Clark and her colleagues found that between 2005 and 2012, patient volume at Title X-funded clinics remained high. In 2012, the state’s five Title X-funded health care organizations served 66,227 patients, which translates to 90 percent of their 2005 patient volume. Also from 2005–2012, the overall percentage of Massachusetts residents served by Title X-funded organizations and who did not have insurance dropped from 59 percent to 36 percent. In 2005 and among different clinic sites, the percentage of clients who did not have insurance ranged from 77 percent to 46 percent; in 2012, those without coverage ranged from 52 percent to 24 percent. All age groups experienced declines in uninsurance, with the greatest declines among teens and adults ages 20 to 29 years old.

The overall message? Despite Massachusetts’ near universal coverage rate — 97 percent of residents had insurance as of 2011 — Title X-funded clinics continue to be critical access points for both insured and uninsured residents seeking family planning care. Authors Clark, Marion Carter, Kathleen Desilets, Lorrie Gavin and Sue Moskosky write:

The results of this study indicate that in the six years following health care reform in Massachusetts, publicly funded providers continued to be used as providers of choice for many clients with health care coverage and remained as a "safety net" for uninsured persons in need of family planning services. …The continued provision of safety net family planning services is important not just for the individual clients accessing services at these organizations but for broader health equity goals as well. Adults aged 20–29 years experience the most unintended pregnancies of any age group in the United States, and these clients constitute a large proportion of clients seen by these health centers. Yet insurance coverage among these young adults lagged behind that of other age groups.

In addition to direct clinical services, Clark told me that Title X-funded clinics are also key to effective community outreach and prevention education. Because such clinics spend years cultivating relationships with the communities they serve and have reputations for providing confidential care, they’re often better equipped to reach vulnerable and at-risk populations.

“There’s always going to be people who are not comfortable going to primary care for these services,” Clark said.

William Smith, executive director of the National Coalition of STD Directors, agreed, adding that many people simply don’t want to use their primary care doctors for sensitive health problems, such as STD screening. Plus, he said, Title X providers are often sexual health specialists who can catch diseases other providers might not. For example, lots of private providers are probably familiar with common STDs such as chlamydia, but many have probably never seen a case of syphilis in their careers.

“People really do want confidential care when it comes to sexual health issues,” Smith told me. “They want competent care and publicly funded family planning clinics and STD clinics really are centers of excellence and people know it. They know they’re going to get quality care and have providers who know what they’re doing.”

Smith said Title X funding is essential to reaching at-risk populations and preventing STD infections — “this is what public health does,” he says. And while he can’t cite an exact cause-and-effect relationship, he did note that as Title X funding has declined, rates of STDs have gone up. According to the National Family Planning & Reproductive Health Association, between fiscal years 2010 and 2013, Title X family planning funds were cut by more than $39 million. As a result, Title X clients declined from 5.22 million to 4.76 million, with no indication that they found other sources of care. Ironically, the budget cut — like many public health budget cuts — won’t save money in the long run: Research shows that every $1 invested in publicly funded family planning saves $5.68 in Medicaid costs related to unplanned births.

Even if demands for clinical services do change, Clark said that public health’s role as a trusted source of information, education and support remains the same. For example, a large portion of CDC funds for breast and cervical cancer screening must go toward direct clinical services for the uninsured. But as insurance coverage rose in Massachusetts, fewer and fewer residents qualified for the screening program. However, there was still an “incredible need” for related services, Clark said, such as patient care navigation, insurance enrollment and case management. In response, public health workers applied for a waiver and were able to use the funds to support services that help women stay in care and manage their health.

As the Affordable Care Act ushers in higher insurance numbers nationwide, Clark said that the Massachusetts study offers real lessons for public health workers and policy-makers across the country.

“We really do think it’s useful for other states as they’re figuring out what health reform means to them,” she said.

To read the full Massachusetts study, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

kkrisberg Fri, 02/07/2014 - 09:54

But the clinics could take ACA plans to pay for the services. There is no reason since not to and it reduces the taxpayers cost. Nothing says a person could not self refer to the clinics on insurance.

I think also There is no reason since not to and it reduces the taxpayers cost. Nothing says a person could not self refer to the clinics on insurance.

It makes sense that the X-funded clinics are still in high demand even though most of Massachusetts has insurance. Even when people have insurance it doesn't always mean that their insurance will pay for all of their family planning services. As more teens are having unplanned children, family planning services are a great way to reduce this and also for the teens, or whoever else, to get these services anonymously. According to the US Department of Health and Human Services, there were 29.4 births per 1000 adolescents in 2012 I know many girls that I went to high school with that used these free clinics to get birth control without their parents knowing. Even though this may seem controversial, these girls would not otherwise get birth control because of parents' wishes. Getting free STD testing could also contribute to the continuing need of these services. People do not want to go to their family doctor to get these tests done because of embarrassment or other personal reasons. The other benefits of having these clinics are great, too. I agree with Lyle that the clinics could use the ACA to find some sort of payment for the clinics, and if not, these services still, and will most likely always be needed.

Expanding Medicaid can improve birth outcomes

lborkowski — Wed, 18 Sep 2013 18:29:22 +0000

Expanding Medicaid can improve birth outcomes

Earlier this week, Michigan Governor Rick Snyder signed legislation that accepts the Affordable Care Act’s Medicaid expansion for his state, and Pennsylvania Governor Tom Corbett has signaled his intention to do so if the federal government approves his proposed program changes. Wonkblog’s Sarah Kliff notes that if Pennsylvania does expand its Medicaid program, that will mean the majority of the states have adopted one of the main aspects of the Affordable Care Act. This is good news for the millions of low-income uninsured US residents who will gain health coverage from Medicaid.

Another recent headline comes from a study, published in the journal Women’s Health Issues, reporting that nearly half of all US births (48%) in 2010 were covered by Medicaid. (Disclosure: Three of the study authors are from the George Washington University School of Public Health, where I work.) This is up from a previous estimate of 45% of all births, and it emphasizes the importance of Medicaid’s role in public health. The authors (Markus et al) note, “As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health as well as birth outcomes.” I hope governors and legislators in the 24 states that haven’t yet accepted the expansion will keep this in mind as they consider the future of their Medicaid programs.

First, some background: The Affordable Care Act, also known as Obamacare, has two main mechanisms to help those who are uninsured get affordable health insurance. First, it expands eligibility for Medicaid to citizens and legal residents of 5+ years who have incomes of up to 133% of the federal poverty level, and the federal government will cover 100% of the costs of this expansion initially and no less than 90% in all future years. (Generally, the federal government covers 50 – 75% of Medicaid beneficiaries’ healthcare costs; percentages vary depending on states’ economic circumstances.) Second, the ACA establishes state health insurance exchanges, or marketplaces, where all legal US residents can buy individual coverage and those with incomes of 100-400% FPL can get sliding-scale subsidies toward premiums. The Supreme Court made this all a lot more complicated when it decided that the Medicaid expansion portion of the law would be optional for states.

People eligible for coverage under the Medicaid expansion are far from wealthy: In 2013, the federal poverty level is $11,460 for a one-person family (133% is $15,282), and $23,550 for a four-person family (133% is $31,322).

Medicaid and women of childbearing age
In order to get federal funds for their Medicaid programs, states have long been required to cover certain populations, including pregnant women and children up through age five with family incomes of up to 133% of the federal poverty level, children ages 6 – 18 with family incomes of up to 100% FPL, and low-income adults with dependent children (income cutoff limits for this group vary by state). Many states have expanded eligibility beyond the federal minimums; in the case of pregnant women, 19 states and the District of Columbia will enroll women with incomes of up to 185% FPL; 15 states have cutoffs of 200 – 299% FPL, and Iowa and Wisconsin allow pregnant women with incomes of up to 300% FPL to enroll in Medicaid. All women who become eligible for Medicaid based on pregnancy status retain the coverage for 60 days after giving birth.

Before becoming pregnant and after 60 days post-partum, though, it’s often hard for non-disabled low-income women under age 65 to get Medicaid coverage. Only eight states and the District of Columbia offer full Medicaid coverage to childless adults, and income cutoffs for parents of dependent children have a median of 61% for working parents and 37% for non-working parents. Several states have used Medicaid waivers and federal Title X funds to offer family-planning services and pre-conception or inter-conception care to low-income women, and some states have used waivers to extend Medicaid coverage to women who lose it after a baby’s birth or an increase in family income.

The ACA's Medicaid expansion does not address the health of undocumented immigrant women or those who have been in the US legally for fewer than five years, who are ineligible for Medicaid coverage. Strict requirements for proof of legal status can also pose a barrier to enrollment for women who are eligible but have difficulty obtaining the required documentation. Some states use their own funds to cover women who do not meet federal requirements for immigration status or documentation.

Women’s health and birth outcomes
It’s in states’ interest to cover pregnant women, so that they can have access to prenatal care that can contribute to healthy babies -- but women's health and healthcare prior to conception also matters. “Rising rates of maternal mortality, stagnant rates of infant mortality, high proportions of preterm and low birthweight births, and continuing disparities in pregnancy outcomes in the United States have prompted a number of states to increase their focus on the health risks faced by women of childbearing age,” reports Kay Johnson in a 2012 Commonwealth Fund issue brief. These risks include chronic health conditions such as diabetes and hypertension; smoking and heavy alcohol use; and depression, all of which disproportionately affect low-income women and women of color, Johnson notes. Treating these conditions prior to conception can improve pregnancy outcomes, as well as women’s overall health.

Birth spacing is another important factor in birth outcomes. Short intervals between pregnancies are associated with increased risks for preterm birth and for low birthweight in babies, and for preeclampsia in mothers. The 2020 Healthy People goals include reducing the number of pregnancies occurring within 18 months after giving birth, and recent research has found short birth spacing to be strongly linked to unintended pregnancies. Ensuring that women have access to contraception and medical guidance can allow for birth spacing that's favorable to the health of both mothers and children.

In 2006, the Institute of Medicine sounded the alarm about the growing public health problem of preterm births (those occurring before 37 weeks of gestation). Preterm babies are at higher risk for health and developmental problems than their full-term counterparts, and the IOM committee estimated that costs for medical care and disability associated with US preterm births top $26 billion per year. Reducing preterm births could result in substantial savings as well as improved quality of life.

Ideally, everyone would have access to the healthcare services they need to be in optimum health; given limited healthcare dollars, though, it makes sense to target them at women whose health will most directly influence the health of the next generation. And given that nearly half of all US pregnancies are unplanned, the best way to ensure that women have access to healthcare services prior to conceiving is to ensure that all women of childbearing age have access to healthcare.

Care from community health centers
Being insured isn’t necessarily synonymous with having access to healthcare, although in the US people with health insurance have better health outcomes than those without. Community health centers – also known as federally qualified health centers, or FQHCs – have long been a source of high-quality, affordable primary healthcare for low-income and uninsured individuals. In a 2008 article in Women’s Health Issues, Sara Wilensky and Michelle Proser describe how health centers deliver preconception care and how their low-income patients have better birth outcomes than low-income US women as a whole:

Almost 60% of health center patients are women, about half of whom are women of childbearing age. In addition, health centers provide care for >17% of low-income births in the United States. Most health centers offer their patients preconception services, such as HIV/AIDS screening and treatment, weight management, nutrition counseling, and smoking cessation programs, in addition to comprehensive primary care services. Three quarters of health centers provide mental health services and half provide substance abuse treatment services onsite; the rest provide these services in partnership with other providers. Health centers also participate in a number of community-based programs focused on improving women’s health and providing preconception care services.

... Low socioeconomic status (SES) women seeking care at health centers experience lower rates of low birth weight (LBW) babies compared with all low-SES mothers (7.5% vs. 8.2%), a trend that holds for each racial/ethnic group. This is particularly noteworthy for African American women of low SES who are especially at higher risk for adverse pregnancy outcomes. If the LBW black–white disparity seen at health centers could be achieved nationally, there would be 17,100 fewer LBW black infants annually (Shi et al., 2004).

Health centers are also a major source of primary care for Medicaid beneficiaries; in 2012, 40% of health center patients had Medicaid or CHIP coverage. Another 36% were uninsured. Health centers receive federal grants that help cover the cost of caring for uninsured patients, but they also rely heavily on Medicaid revenue. In recognition of the comprehensive care health centers provide (including nutritional counseling, case management, and translation services), health centers receive higher Medicaid payments than other providers. States’ decisions about accepting the Medicaid expansion will greatly affect the finances of their health centers – which in turn affects low-income women’s access to high-quality preconception and prenatal care.

The states that have not yet accepted the Medicaid expansion need to keep in mind that their decisions affect not only the health of their poorest residents, but of the next generation.

lborkowski Wed, 09/18/2013 - 14:29

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In many parts of the world, low-income groups are provided primary healthcare facilities via numerous ways. But in all of these, government intervention is considered to be very essential. Most of the time, this is the limitation of our thought that we don't even try to find out such ways wherein government is not involved but people easily get required healthcare services through a systematic method. Name it a private venture or something else, involvement of private sector can only boost healthcare provision to low income groups.