News articles in recent weeks have documented the spread of misinformation about hormonal birth control methods on popular social media platforms like TikTok, YouTube and X, formerly called Twitter. Influencers with large and small followings are sharing unsubstantiated claims about the side effects of contraceptives, while directly or indirectly encouraging others to stop using them.

This trend has not escaped researchers, who for several years have been investigating what people who can get pregnant are posting on social media platforms about hormonal and non-hormonal birth control methods. Understanding the drivers of these trends is important because they have implications for policy and patient care, according to researchers. Some worry that during the post-Dobbs era, when there are continued strikes against reproductive rights in the U.S., misinformation about birth control on social media could have a negative influence on contraceptive preferences — potentially leading to more unwanted pregnancies.

More than 90% of women of reproductive age have used at least one contraceptive method, according to a 2023 report by the U.S. National Center for Health Statistics. However, the report also finds that the use of male condoms and withdrawal methods increased between 2006 and 2019, while the use of the birth control pill decreased. Non-hormonal contraception methods, including condoms, spermicides, withdrawal and menstrual cycle tracking, are 10% or less effective than hormonal contraceptives. The only exceptions are surgical sterilization and the copper intrauterine device.

To be sure, not all birth control-related content posted on social media platforms is negative, studies show. Health care professionals are sharing educational material with a high rate of engagement and non-health care professional users share their positive experiences with the birth control methods they use.

But as you will see in the studies curated below, researchers also find that social media users, including influencers, share inaccurate information about hormonal contraceptives on various social media platforms, discuss their discontinuation of birth control in favor of non-hormonal methods and engage in unsubstantiated fear-mongering of hormonal contraceptives.

Researchers also have learned that the content posted on social media platforms has changed in tone over time, mirroring the shift in the national political discourse.

In a 2021 study published in the American Journal of Obstetrics & Gynecology, researchers analyzed more than 800,000 English-language tweets mentioning at least one contraceptive method between March 2006, when Twitter was founded, and December 2019. They coded the sentiment of tweets as positive, neutral or negative.

“What we found over time was that the number of neutral tweets went down for each and every one of the birth control methods, and people became more polarized with regards to how they talk on these social media platforms over those 13 years,” says study co-author Dr. Deborah Bartz, an OB-GYN at Brigham and Women’s Hospital with expertise in complex family planning and an associate professor at Harvard Medical School.

In a February 2024 commentary in the Journal of Women’s Health, University of Delaware researchers Emily Pfender and Leah Fowler argue that ongoing dialogue about contraception on social media provides “a glimpse into public sentiment about available options” to people who can get pregnant.

The authors also note that misinformation and disinformation about hormonal contraception may have a larger effect on health disparities, especially among historically marginalized groups who may already mistrust the medical establishment.

“This may contribute to unintended pregnancy and delayed care, further widening health disparities and hindering progress toward equitable reproductive health outcomes,” Pfender and Fowler write.

Side effects

There are known side effects to hormonal birth control methods, including headaches, nausea, sore breasts and spotting. Most are mild and disappear with continued use or with switching to another method. Among hormonal contraceptives, only the Depo-Provera injection has been linked with weight gain, studies show.  

But some social media influencers have spread false claims about the potential side effects of hormonal birth control methods, ranging from infertility to abortion to unattractiveness. Despite these false claims, physicians and professional organizations such as the American College of Obstetricians and Gynecologists find today’s contraceptive options safe and very effective.

“They’re about the most low-risk prescription that I give,” says Dr. Megana Dwarakanath, an adolescent medicine physician in Pittsburgh. “I always joke that if something goes wrong in someone’s life, they’re within the reproductive years, it always gets blamed on birth control.”

Dwarakanath says her young patients are most worried about two side effects: weight gain and mood. “Those are the things that they will almost always attribute to their birth control at a time that their bodies are also changing very rapidly,” she says. “Things like mental health diagnoses or personality disorders also tend to crop up during the time young people have started or have been on birth control.”

Most research on the link between oral contraceptives and cancer risk comes from observational studies, according to the National Cancer Institute. Overall, the studies have consistently shown that the risks of breast and cervical cancer are slightly increased for women who use oral contraceptives, whereas the risk of endometrial, ovarian and colorectal cancers are reduced.

The use of hormonal birth control has also been associated with an increase in the risk of developing blood clots, studies show. But that risk is not universal for everyone who takes hormonal birth control. This risk is higher for women 35 and older, those who smoke, are very overweight or have a history of cardiovascular disease. Overall, 3 to 9 out of 10,000 women who take the pill are at risk of developing blood clots within a given year. The risk for women who don’t take the pill is 1 to 5 out of 10,000.

There is no association between the pill and mood disorders, according to a large body of research, including a 2021 cohort study of nearly 740,000 young women. 

It’s worth noting the dearth of research into women’s reproductive health due to chronic underfunding of women’s health research. An analysis of funding by the U.S. National Institutes of Health finds that in nearly three-quarters of the cases where a disease affects mainly one gender, the institute’s funding pattern favored males. Either the disease affected more women and was underfunded, or the disease affected more men and was overfunded, according to the 2021 study published in the Journal of Women’s Health.

Aside from underfunding, conducting robust research into the long-term effects of birth control is complex.

“Historically, people haven’t felt that it’s ethically OK to randomize people to birth control methods in large part because the outcome of unintended pregnancy is greater,” for people who are given the placebo, Bartz says.

Research on birth control misinformation on social media

Social media use is widespread among young adults. More than 90% of Americans between 18 and 29 reported ever using YouTube, while 78% said they had used Instagram, 62% used TikTok and 42% used Twitter, according to a 2023 survey of 5,733 U.S. adults by Pew Research Center.

These years overlap with the demographic of people who are most likely to use birth control. And because the use of contraceptives is less stigmatized today, people are more likely to talk with one another about their questions and concerns or share that information online.

In addition to investigating the general landscape of social media posts about birth control, researchers are also interested in the type of content influencers, who typically have 20,000 or more followers, post, because of their persuasive power over their audiences.

“When influencers disclose personal experiences and beliefs about various topics, audience members tend to form similar attitudes especially when they feel connected to the influencer,” Pfender and M. Marie Devlin write in a 2023 study published in the journal Health Communication.

Below we have curated several studies published in recent years documenting the spread of birth control misinformation on social media. The roundup is followed by a quick reference guide on female contraceptives and their actual potential side effects.

Contraceptive Content Shared on Social Media: An Analysis of Twitter
Melody Huang, et al. Contraception and Reproductive Medicine, February 2024.

The study: The authors explore how contraceptive information is shared on X and understand how those posts affect women’s decisions. They analyze a random 1% of publicly available English-language tweets about reversible prescription contraceptive methods, from January 2014 and December 2019. The 4,434 analyzed tweets included at least 200 tweets per birth control method — IUDs, implants, the pill, patch and ring.

The findings: 26.7% of tweets about contraceptive methods discussed decision-making and 20.5% discussed side effects, especially the side effects of IUDs and the depot medroxyprogesterone acetate (DMPA or Depo-Provera) shot. Discussions about the pill, patch or ring prompted more discussions on logistics and adherence. About 6% of tweets explicitly requested information. Tweets about IUDs were most popular in terms of likes.

More importantly, 50.6% of the tweets were posted by contraceptive users, while only 6% came from official health or news sources. Tweets from news or journalistic sources were more frequent than tweets from a health care professional or organization.

Some tweets contained misinformation represented as facts, such as the unsubstantiated claim that IUDs can cause fertility issues. Others were outwardly misogynistic, shaming women and claiming that they wouldn’t be able to have kids because of using hormonal birth control.

One takeaway: “While Twitter may provide valuable insight, with more tweets being created by personal contraceptive users than official healthcare sources, the available information may vary in reliability. Asking patients about information from social media can help reaffirm to patients the importance of social networks in contraceptive decision-making while also addressing misconceptions to improve contraceptive counseling,” the authors write.

What Do Social Media Influencers Say About Birth Control? A Content Analysis of YouTube Vlogs About Birth Control
Emily J. Pfender and M. Marie Devlin. Health Communication, January 2023.

The study: To explore what social media influencers shared on YouTube about their experiences with hormonal and non-hormonal methods of birth control, the researchers analyzed 50 vlogs posted between December 2019 and December 2021. Most of the 50 influencers were categorized on YouTube as Lifestyle (72%) and Fitness (16%). They had between 20,000 and 2.2 million subscribers each.

The findings: In total, 74% of the influencers talked about discontinuing hormonal birth control. About 44% said the main reason they were discontinuing birth control was to be more natural, while 32% said they wanted to improve their mental health and 20% were concerned about weight gain.

Forty percent of influencers mentioned using non-hormonal birth control methods such as menstrual cycle tracking, condoms, non-hormonal IUDs and the pull-out method. Twenty percent reported switching from hormonal to non-hormonal methods.

One takeaway: “Our content analysis revealed that discontinuation of hormonal birth control is commonly discussed among [social media influencers] on YouTube and sexual health information from influencers might not provide accurate educational information and tools… this is especially concerning given that social media is young adults’ primary tool for sexual health information. Future research is needed to understand the effects of SMI birth control content on sexual health behaviors,” the authors write.

Hormonal Contraceptive Side Effects and Nonhormonal Alternatives on TikTok: A Content Analysis
Emily J. Pfender, Kate Tsiandoulas, Stephanie R. Morain and Leah R. Fowler. Health Promotion Practice, January 2024.

The study: The authors analyzed the content of 100 TikTok videos that used the hashtags #birthcontrolsideeffects and #nonhormonalcontraception. Their goal was to understand the types of content about side effects of hormonal and non-hormonal contraceptives on TikTok.

The findings: The videos averaged about 1 minute and garnered an average of 27,795 likes, 251 comments and 623 shares. For #birthcontrolsideeffects, 80% of the audience was 18 to 24 years old and videos with that hashtag had 43 million views worldwide as of July 7, 2023.

Thirty-two percent of the videos were by regular users (non-influencers), 26 by clinicians, 13% by health coaches and 2% by companies. Only 3% had a sponsorship disclosure and 6% included a medical disclaimer, that the person was not a doctor or was not providing medical advice.

Most of the 100 videos (71%) mentioned hormonal contraception. Among them 51% discussed unspecific hormonal contraceptives, 31% talked about the pill and 11% about hormonal IUDs. Four of the 71 creators explicitly recommended against using hormonal contraceptives.

Claims about hormonal contraceptives were mostly based on personal experience. About 25% of the creators cited no basis for their claims, 23% included outside evidence, including unspecified studies or information from the FDA insert, and 11% used a combination of personal and outside evidence.

Almost half (49%) mentioned discontinuing their hormonal contraception, with negative side effects cited as the most common reason.

The creators talked about mental health issues, weight gain, headaches, and less common risks of various cancers or chronic illness, change in personality and blood clots. They were less likely to mention the positive aspects of birth control.

About 52% of videos mentioned non-hormonal contraception, including copper IUDs and cycle tracking.

Nine of the 100 creators expressed feeling dismissed, pressured, gaslit or insufficiently informed about contraception by medical providers.

One takeaway: “Our findings support earlier work suggesting social media may fuel ‘hormonophobia,’ or negative framing and scaremongering about hormonal contraception and that this phobia is largely driven by claims of personal experience rather than scientific evidence,” the authors write. “Within these hashtag categories, TikTok creators frame their provider interactions negatively. Many indicate feeling ignored or upset after medical appointments, not sufficiently informed about contraceptive options, and pressured to use hormonal contraceptives. This finding aligns with previous social media research and among the general population, suggesting opportunities for improvements in contraceptive counseling.”

Popular Contraception Videos on TikTok: An Assessment of Content Topics
Rachel E. Stoddard, et al. Contraception, January 2024.

The study: Researchers analyzed 700 English-language TikTok videos related to hormonal contraception, with a total of 1.2 billion views and 1.5 million comments, posted between October 2019 and December 2021. Their aim was to explore the types of contraception content on TikTok and to understand how the platform influences the information patients take into birth control counseling visits.

The findings: More than half of the videos (52%) were about patient experiences and how to use contraceptives. Other common topics included side effects (35%) and pregnancy (39%).

Only 19% of the videos were created by health care professionals, including midwives, physician assistants and medical doctors, although those videos garnered 41% of the total views, indicating higher engagement. While 93% of health care providers shared educational content, 23% of non-health care providers shared educational content.

One takeaway: “Our findings show an exceptional opportunity for education around contraception for young reproductive-aged individuals, given the accessibility and popularity of these videos. This may also extend to other topics around sex education and family planning, including sexually transmitted infection prevention and treatment and procuring abortion care,” the authors write.

TikTok, #IUD, and User Experience With Intrauterine Devices Reported on Social Media
Jenny Wu, Esmé Trahair, Megan Happ and Jonas Swartz. Obstetrics & Gynecology, January 2023.

The study: Researchers used a web-scraping application to collect the top 100 TikTok videos tagged #IUD on April 6, 2022, based on views, comments, likes and shares. Their aim was to understand the perspectives and experiences of people with IUDs shared on TikTok. The videos had a total of 471 million views, 32 million likes and 1 million shares. Their average length was 33 seconds.

The findings: Some 89% of the creators identified as female and nearly 90% were from the United States; 37% were health care professionals; and 78% were 21 years or older.

Video types included patients’ own experiences with IUD removal (32%), educational (30%) and humorous (25%). More videos (38%) had a negative tone compared with 19% with a positive tone. The videos that portrayed negative user experiences emphasized pain and distrust of health care professionals.

Half of the videos were very accurate, while nearly a quarter were inaccurate (the authors did not use the term misinformation).

One takeaway: “The most liked #IUD videos on TikTok portray negative experiences related to pain and informed consent. Awareness of this content can help health care professionals shape education given the high prevalence of TikTok use among patients,” the authors write. “TikTok differs from other platforms because users primarily engage with an algorithmically curated feed individualized to the user’s interests and demographics.”

Types of female birth control

Most female hormonal contraceptives contain the synthetic version of natural female hormones estrogen and progesterone. They affect women’s hormone levels, preventing mature eggs from being released by the ovaries, a process that’s known as ovulation, hence, preventing a possible pregnancy.

Of the two hormones, progesterone (called progestin in synthetic form) is primarily responsible for preventing pregnancy. In addition to playing a role in preventing ovulation, progesterone inhibits sperm from penetrating through the cervix. Estrogen inhibits the development of follicles in the ovaries.

The information below is sourced from the CDC, the National Library of Medicine, the Cleveland Clinic and the Mayo Clinic.

Intrauterine contraception

Also called Long-Acting Reversible Contraception, or LARC, this method works by thickening the cervical mucus so the sperm can’t reach an egg. There are two types of IUDs: hormonal and non-hormonal.

• Levonorgestrel intrauterine system is a T-shaped device that’s placed inside the uterus by a doctor. It releases a small amount of progestin daily to prevent pregnancy. It can stay in place for 3 to 8 years. Its failure rate is 0.1% to 0.4%.
• Copper T intrauterine device is also T-shaped and is placed inside the uterus by a doctor. It does not contain hormones and can stay in place for up to 10 years. Its failure rate is 0.8%.
• Side effects: Copper IUDs may cause more painful and heavy periods, while progestin IUDs may cause irregular bleeding. In the very rare cases of pregnancy while having an IUD, there’s a greater chance of an ectopic pregnancy, which is when a fertilized egg grows outside of the uterus.

Hormonal methods

• The implant is a single, thin rod that’s inserted under the skin of the upper arm. It releases progestin over 3 years. Its failure rate is 0.1%, making it the most effective form of contraception available.
• Side effects: The most common side effect of an implant is irregular bleeding.
• The injection Depo-Provera or “shot” or “Depo” delivers progestin in the buttocks or arms every three months at the doctor’s office. Its failure rate is 4%.
• Side effects: The shot may cause irregular bleeding. The shot is also the only contraceptive that may cause weight gain. It may also be more difficult to predict when fertility returns once the shot is stopped.
• Combined oral contraceptives or “the pill” contain estrogen and progestin. They’re prescribed by a doctor. The pill has to be taken at the same time daily. The pill is not recommended for people who are older than 35 and smoke, have a history of blood clots or breast cancer. Its failure rate is 7%. Among women aged 15 to 44 who use contraception, about 25% use the pill.
• The skin patch is worn on the lower abdomen, buttocks or upper body, releasing progestin and estrogen. It is prescribed by a doctor. A new patch is used once a week for three weeks. No patch is worn for the fourth week. Its failure rate is 7%.
• Hormonal vaginal contraceptive ring releases progestin and estrogen. It’s placed inside the vagina. It is worn for three weeks and taken out on the fourth week. Its typical failure rate is 7%.
• Side effects: Contraceptives with estrogen, including the pill, the patch and the ring, increase the risk of developing blood clots.
• Progestin-only pill or “mini-pill” only has progestin and is prescribed by a doctor. It has to be taken daily at the same time. It may be a good option for women who can’t take estrogen. Its typical failure rate is 7%.
• Opill is the first over-the-counter daily oral contraceptive in the U.S., approved by the Food and Drug Administration in 2023. Opill only has progestin and like other birth control pills, it has to be taken at the same time every day. It should not be used by those who have or have had breast cancer. Its failure rate is 7%.
• Side effects: The most common side effect of progestin-only pills is irregular bleeding, although the bleeding tends to be light.

Non-hormonal birth control methods include using barriers such as a diaphragm or sponge, condoms and spermicides, withdrawal, and menstrual cycle tracking. Emergency contraception, including emergency contraception pills (the morning-after pill), is not a regular method of birth control.

Additional research studies to consider

Population Attitudes Toward Contraceptive Methods Over Time on a Social Media Platform
Allison A. Merz, et al. American Journal of Obstetrics & Gynecology, December 2020.

Social Media and the Intrauterine Device: A YouTube Content Analysis
Brian T. Nguyen and Allison J. Allen. BMJ Sexual and Reproductive Health, November 2017.

The post How influencers and content creators discuss birth control on social media: What research shows appeared first on The Journalist's Resource.

This piece on maternal mortality was updated on September 19, 2022, to reflect new data from the CDC.

Each year, at least 700 women die in the United States because of pregnancy or delivery complications. Four in five of those deaths are preventable, according to the latest data from the Centers for Disease Control and Prevention.

These deaths are defined as maternal mortality or pregnancy-related deaths. The maternal mortality data are typically reported as rates, which is the number of maternal deaths per 100,000 live births.

Worldwide, the maternal mortality rate was estimated at 211 in 2017. The World Health Organization’s goal is to reduce that rate to 70 by 2030.

The U.S. maternal mortality rate is 23.8, according to the latest data from the Centers for Disease Control and Prevention. That’s considered “very low” globally, yet it is far higher than many other wealthy nations including Sweden, Italy, Austria and Japan.

To be sure, the U.S. maternal mortality rates dropped steadily throughout the 20th century, from over 800 deaths per 100,000 live births in 1900 to 6.6 per 100,000 in 1987. The decline was attributed to several factors, including better disease monitoring, access to health care, better nutrition and advances in medicine.

But since then, the rate has been steadily increasing. By 2018, the maternal mortality rate was at 17.3 per 100,000, then at 20.1 in 2019 and 23.8 in 2020, according to the CDC. Factors contributing to the increase include disparities in access to care, increasing maternal age and increase in chronic conditions such as diabetes and obesity, studies show.

In June, the White House released a Blueprint for Addressing the Maternal Health Crisis, with a vision that the U.S. “will be considered the best country in the world to have a baby” in the future. Among the first steps is improving and expanding Medicaid coverage, better data collection, diversifying the perinatal workforce and providing better economic and social support for people before, during and after pregnancy.

Disparities in maternal mortality

There are stark and persisting racial disparities in maternal mortality in the U.S. Black people are more than three times as likely as white women to die from pregnancy-related causes, according to the CDC. American Indian and Alaska Native people are more than twice as likely.

Between 2018 and 2020, the maternal mortality rate for Black people was 55.3, compared with 19.1 among white people and 18.2 among Hispanic people, according to the latest CDC data.

In comparison, the maternal mortality rate was 41.4 among Black people, compared with 13.7 for white people between 2016 and 2018. The rates were 26.5 for American Indian or Alaska Native people, 14.1 among Asian or Pacific Islanders and 11.2 for Hispanic people, according to the CDC.

While factors such as access to care and health insurance coverage play a role in pregnancy outcomes, research also points to disparities in social determinants of health such as income, age and housing. Many of these disparities are related to systemic and structural racism.

“It’s important to be clear that it’s racism, not race,” says Dr. Rachel Hardeman, Blue Cross Endowed Professor of Health and Racial Equity at the University of Minnesota School of Public Health, and the founding director of the Center for Antiracism Research for Health Equity at the University of Minnesota. “It’s about systems and structures that historically have been built to not ensure that Black people and Black working people thrive.”

And until structural racism and related factors such as implicit bias in health care are addressed, “we will continue to see the disparities,” says Dr. Veronica Gillispie-Bell, associate professor at Ochsner Clinical School and head of Women’s Services at Ochsner Medical Center in Kenner, Louisiana.

Advice for journalists

For journalists covering the issue, especially after the Supreme Court overturned Roe v. Wade in June and in light of the upcoming midterm elections, it’s important to explain what’s driving current disparities in maternal mortality and how abortion bans can potentially worsen those disparities.

“When we are forcing people to remain pregnant, that means statistically speaking, there are more people who will be pregnant in the United States because Roe has been overturned, which means there are more people in that risk pool for adverse outcomes,” says Hardeman.

The state bans also adversely affect people with fewer resources because they are less likely to have the ability to travel to states where abortion remains available.

“That means you have to have a job that offers paid leave. It means you have to have childcare. It means you have to have the resources to drive, to fly, to wherever you need to go and then stay there for a while,” says Hardeman. “So we are perpetuating a cycle of disadvantage for people who already are very disadvantaged in our communities.”

Abortion bans can also lead to disruption of care because health-care providers, including physicians and pharmacists, may fear criminal prosecution if they provide abortion-related services.

“Anytime you have disruptions in care, Black and brown people are the ones who suffer the most,” says Gillispie-Bell, who is also medical director for Louisiana’s Maternal Mortality Review Committee and Perinatal Quality Collaborative.

Explain to your audiences that maternal mortality can affect anyone: “I think that people still think that this is a problem among poor people or poor Black people or uneducated, poor Black people,” says Gillispie-Bell. “And then they feel like ‘Well, that makes sense that they would have worse outcomes.’”

But as stories have documented in recent years, Black women with resources, including professional tennis player Serena Williams, can also be at risk of developing serious complications, which can be deadly if they’re dismissed by medical professionals.

“[Willliams] was begging for somebody to listen because she was having a blood clot in her lungs,” adds Gillispie-Bell.

Explain to your audiences how racism is one of the main drivers of health disparities today. And have conversations with scholars who are from the communities that are most impacted by these issues, says Hardeman. Seek diverse sources.

And while highlighting disparities in maternal health, also point out solutions and improvements, says Gillispie-Bell.

“The reason I say that is because while we want everybody to be aware [of disparities], we need to highlight [improvements], because we are finding out patients are just extremely fearful of going into the health-care system,” she says. Highlight local efforts and improvements and let audiences know what they can do to help improve outcomes.

Differences in definition of maternal mortality

The World Health Organization defines maternal mortality as the death of a woman from pregnancy-related causes during pregnancy or within 42 days after the end of pregnancy.

The CDC’s Pregnancy Mortality Surveillance System extends that period to 1 year from the end of pregnancy, while the agency’s National Center for Health Statistics, uses WHO’s definition.

Take note of the research studies’ definition of maternal mortality, especially when comparing data. In a 2020 article in ProPublica, Nina Martin explains the definition of maternal mortality that ends at 42 days leaves out many new mothers who die within a year after giving birth and may lead to underestimation of maternal mortality rates in the U.S.

A note on pregnancy terminology

There are currently no standards for an inclusive terminology for people who are pregnant and give birth.

The AP Stylebook says “pregnant women” is fine, and so is “pregnant people.”

The Society for Maternal-Fetal Medicine, a nonprofit organization in the U.S. dedicated to improving maternal and child outcomes, advises health providers to use the gender pronouns preferred by the patient.

“When addressing or referring to a cohort of pregnant people for whom gender identity is known to be uniformly women, both ‘pregnant women’ and ‘pregnant people’ are accurate, though ‘pregnant women’ is more specific,” according to the society.

“When addressing or referring to pregnant people as a whole group, for whom gender identity is unknown and should not be assumed, the terms ‘pregnant people,’ ‘pregnant individuals,’ ‘birthing people,’ or ‘birthing individuals’ are most accurate, as they include cisgender women, transgender men, and nonbinary people who are capable of experiencing pregnancy,” it adds in a statement published in April 2022.

In the research roundup below, we use the language used by the researchers. The studies summarized below address topics such as news coverage of disparities in maternal mortality, the impact of the COVID-19 pandemic and the potential impact of abortion bans. They are followed by additional reading recommendations and resources for journalists.

Research roundup

Historical and Recent Changes in Maternal Mortality Due to Hypertensive Disorders in the United States, 1979 to 2018
Cande V. Ananth; et al. Hypertension, Sept. 2021.

The study assesses how maternal age, year of death and year of birth contributed to hypertension-related maternal death trends in the United States from 1979 to 2018. There were 3,287 maternal deaths related to high blood pressure during those years. The women included in the study were between 15 to 49 years old. The study defines maternal mortality as death during pregnancy or within 42 days of pregnancy.

The findings: The hypertension-related maternal mortality rate among Black women was 5.4 per 100,000 live births. For white women the rate was 1.4. The overall rate was 2.1. Researchers also found being older was associated with an increased rate of hypertension-related maternal mortality. The rate was highest among women 45 to 49 years old. They also found an association between obesity rates and hypertension-related maternal mortality.

Key takeaway: “The study critically underscores the need (1) to develop targeted prenatal interventions, including tight blood pressure control and efforts to reduce body mass index, to ameliorate rates of hypertensive conditions before and during pregnancy and (2) to address the prevailing and concerning race disparity in maternal deaths with hypertension as the cause,” the researchers write.

A related study: “Treatment for Mild Chronic Hypertension during Pregnancy,” by Alan Tita; et al., published in the New England Journal of Medicine in May 2022, finds that controlling blood pressure of pregnant women with mild chronic hypertension leads to better pregnancy outcomes. Also, see this list of solutions from the National Heart, Lung, and Blood Institute.

All-Cause Maternal Mortality in the U.S. Before vs. During the COVID-19 Pandemic
Marie Thoma and Eugene Declercq. JAMA Network Open, June 2022.

The study examines the role of the COVID-19 pandemic in 2020 maternal death rates in the U.S. after the National Center for Health Statistics reported the maternal mortality rate increased 18.4% between 2019 and 2020. Researchers used NCHS data from 2018 to 2020. The study defines maternal mortality as death during pregnancy or within 42 days of pregnancy.

The findings: In 2018 and 2019, 1,588 maternal deaths occurred, a rate of 18.8 per 100,000 live births. The number of maternal deaths during the pandemic, in 2020, was 684, or a rate of 25.1 per 100,000. That’s a relative increase of 33.3%. Absolute and relative changes from before and during pandemic were highest for Hispanic and Black women. COVID-19 was listed as secondary cause of death in 15% of maternal deaths in the second, third and fourth quarter of 2020. This percentage was highest for Hispanic women (32%) and Black women (13%), compared with white women (7.3%), the authors report.

Key takeaway: “Change in maternal deaths during the pandemic may involve conditions directly related to COVID-19 (respiratory or viral infection) or conditions exacerbated by COVID-19 or other health care disruptions (diabetes or cardiovascular disease), but could not be discerned from the data,” researchers write. “Future studies of maternal death should examine the contribution of the pandemic to racial and ethnic disparities and should identify specific causes of maternal deaths overall and associated with COVID-19.”

The Pregnancy-Related Mortality Impact of a Total Abortion Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant
Amanda Jean Stevenson. Demography, December 2021.

The research note estimates the increase in pregnancy-related deaths that would occur because of a higher risk of death from continuing a pregnancy rather than being able to have a legal abortion. The author uses CDC data from 2017.

The findings: If there were a total ban on abortion in the U.S., the estimated number of pregnancy-related deaths would increase by 7% from 675 to 724 in the first year. In following years, the number would increase to 815, a 21% increase. Black people would experience the greatest increase in deaths, at 33% after the first year of a hypothetical total abortion ban across the country.

Key takeaway: “Any state-level total or nearly total ban on abortion could also cause more pregnancy-related deaths … if pregnant people do not successfully access abortion via self-management or travel to another state,” Stevenson writes. “Similarly, other abortion bans (e.g., banning abortions sought for specific reasons or at specific gestations) will also cause more deaths if they lead to more pregnancies being continued.”

Preventing Pregnancy-Related Mental Health Deaths: Insights From 14 U.S. Maternal Mortality Review Committees, 2008-17
Susanna Trost; et al. Health Affairs, October 2021.

The study looks at pregnancy-related deaths due to mental health conditions, including substance use disorders and suicides, based on data from 14 state Maternal Mortality Review Committees between 2008 and 2017. The committees define maternal mortality as death during pregnancy or within one year after pregnancy.

The findings: Among 421 pregnancy-related deaths, 11% were due to mental health conditions. All the pregnancy-related mental health deaths in this study were determined by Maternal Mortality Review Committees to be preventable. Most deaths occurred 36 to 43 days after delivery. In total, 63% of pregnancy-related mental health deaths were by suicide. They were more likely to occur among white people (86%), compared with 2% among Black people. The authors note that the observed racial and ethnic disparities may reflect actual differences in leading causes of death, and differences in screening and identification practices. “For example, White people are more likely to be screened for depression at delivery than Black people,” they write.

Key takeaway: “Our findings show that maternal health cannot be promoted without addressing maternal mental health,” the authors write. “As evidenced by MMRC recommendations, there are many opportunities for preventing pregnancy-related mental health deaths through improvements in coordination of care; access to and availability of naloxone; access to treatment and services for SUD and other mental health conditions; prescribing practices; screenings and assessments; social, family, and peer support; and education for patients, providers, and the public.”

Related: “Pregnancy-Related Deaths: Data from 14 U.S. Maternal Mortality Review Committees, 2008-2017,” by Nicole Davis, Ashley Smoots and David Goodman, published by the Centers for Disease Control and Prevention in 2019, summarizes data from 14 Maternal Mortality Review Committees in the U.S. between 2008 and 2017 to identify trends.

State Abortion Policies and Maternal Death in the United States, 2015‒2018
Dovile Vilda; et al. American Journal of Public Health, May 2021.

The study aims to examine the association between variations in state-level abortion restriction policies in 2015 and maternal mortality rates from 2015 to 2018 in the U.S.

The findings: States that had more abortion restriction policies in place had a 7% increase in maternal mortality compared with states that had fewer restrictions. Abortion-restricting laws may contribute to maternal death directly and indirectly, the authors explain. Abortion restrictions can lead to more unsafe and illegal abortions. They can also put the lives of pregnant women with chronic health conditions at risk, who are forced to carry an unwanted pregnancy to term.

Key takeaway: Restricting access to abortion care at the state level may increase the risk for maternal mortality, the authors write. “Our findings suggest the cumulative impact of abortion restrictions on maternal death, adding to a limited body of empirical studies linking rising maternal mortality and reduced access to reproductive health services in the United States,” they write.

Black Maternal Mortality in the Media: How Journalists Cover a Deadly Racial Disparity
Denetra Walker and Kelli Boling. Journalism, January 2022.

The study is based on interviews with four women journalists who specialize in women’s issues and health and explores how they cover Black maternal mortality. The reporters were Sarah Fentem, a white health reporter who covers medical news for St. Louis Public Radio, an NPR affiliate; Rochaun Meadows-Fernandez, a Black health journalist who writes cultural pieces about Black health; Dr. Cynthia Greenlee, a Black woman who works as a senior editor for an online reproductive health publication; and Nina Martin, a Latina, who worked for ProPublica at the time, covering gender and sexuality issues.

The findings: “Women journalists in this study aimed to be objective and not take a position as advocates, while balancing their work to frame this topic as a public health issue,” the authors write. “By purposefully centering Black women, doctors, and families in stories as sources, the journalists elevated their voices in a broader, societal view to shed light on the experiences of Black women.”

Key takeaway: “The practice of using the voices of marginalized groups to tell their story is an important lesson,” researchers write. “The journalists were clear they were not taking a hard stance on their position as advocates; however, they did feel as if elevating the stories of Black women helped frame this topic as important.”

More studies of note

• “Black maternal mortality in the media: How journalists cover a deadly racial disparity,” by Denetra Walker and Kelli Boling, published in Journalism in January 2022, is based on interviews with four women journalists and finds: “The practice of using the voices of marginalized groups to tell their story is an important lesson. The journalists were clear they were not taking a hard stance on their position as advocates; however, they did feel as if elevating the stories of Black women helped frame this topic as important.”
• “Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 U.S. States, 2017–2019,” by Susanna Trost; et al., published in September 2022 by the CDC, finds that 80% of pregnancy-related deaths in the U.S. are preventable and that the leading cause of pregnancy-related death varies by race and ethnicity. During the study period, 22% of deaths occurred during pregnancy, 25% occurred on the day of delivery or within 7 days after, and 53% occurred between 7 days to 1 year after pregnancy, the report finds.
• “Abortion Access as a Racial Justice Issue,” by Katy Backes Kozhimannil, Asha Hassan, and Rachel R. Hardeman, published in the New England Journal of Medicine in September 2022, is a perspective article in which the authors say, “Abortion access is a racial justice issue, and it is today’s civil rights battle worthy of tenacious engagement by professionals in medicine, policy, and public health.”
• “Structural Racism and Maternal Health Among Black Women,” by Jamila K. Taylor, published in the Journal of Law, Medicine & Ethics in January 2021, provides a historical overview of racism in American, including the study of obstetrics and gynecology using enslaved Black women in the 1800s, and describes the path to today’s racial inequalities in health care and poor maternal health among Black women.
• “Maternal Mortality in the United States: A Review of Contemporary Data and Their Limitations,” by Dr. Andreea Creanga, published in Clinical Obstetrics and Gynecology in June 2018, provides an overview of maternal mortality data and their limitations in the United States. “Of about 16.1 million induced abortions performed in the United States during 1998 to 2010, 108 women died from abortion-related complications for a mortality ratio of 0.7 deaths per 100,000 induced abortion procedures,” Creanga writes.
• “The Impact of Racism on Maternal Health Outcomes for Black Women,” by Gabrielle T. Wynn, published in University of Miami Race & Social Justice Law Review in December 2019, is a 25-page Juris Doctor dissertation that explores the role of racism on maternal health disparities and offers solutions.
• “U.S. Maternal Mortality Within a Global Context: Historical Trends, Current State, and Future Directions,” by Regine Douthard, et al., provides a perspective on maternal mortality trends in the U.S. and evaluates it in a global context.
• “Healthcare Utilization and Maternal and Child Mortality During the COVID-19 Pandemic in 18 Low- and Middle-Income Countries: An Interrupted Time-Series Analysis with Mathematical Modeling of Administrative Data,” by Tashrik Ahmed; et al., published in PLOS Medicine in August 2022, finds that reduced use of health-care services during the COVID-19 pandemic threatens to reverse global gains in reducing maternal and child mortality.
• “Developing Tools to Report Racism in Maternal Health for the CDC Maternal Mortality Review Information Application (MMRIA): Findings from the MMRIA Racism & Discrimination Working Group,” by Rachel Hardeman; et al., published in Maternal and Child Health Journal, January 2022, describes the results from a working group selected by the CDC Foundation in partnership with maternal health experts, to develop a definition of racism that can be used on the Maternal Mortality Review Information Application form, which is used by Maternal Mortality Review Committees.
• “Maternal Mortality: Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them,” by the U.S. Government Accountability Office, published in March 2020, describes the Health and Human Services’ ongoing efforts to prevent pregnancy-related deaths.
• “A Call to Action: Cardiovascular-Related Maternal Mortality: Inequities in Black, Indigenous, and Persons of Color,” by Erin Ferranti; et al., published in the Journal of Cardiovascular Nursing in July 2021, calls for a “focus on comprehensive and systemic approaches that address the social and structural issues underlying maternal health inequities.”
• “Racial Disparities in Maternal and Infant Health: An Overview,” by Samantha Artiga, Olivia Pham, Kendal Orgera and Usha Ranji, published by the Kaiser Family Foundation in November 2020, provides an overview of disparities in maternal and infant health in the U.S.
• “Maternal Mortality in the United States: A Primer,” by Eugene Declercq and Laurie Zephyrin, published by The Commonwealth Fund in December 2020, provides an overview of maternal mortality and related data in the U.S.
• “Maternal Mortality Measurement: Guidance to Improve National Reporting,” by the United National Maternal Mortality Estimation Inter-Agency Group, published by the World Health Organization in July 2022, outlines best practices for data collection and interpretation.

Additional reading

• “Lost Mothers: Maternal Care and Preventable Deaths,” by Nina Martin; et al., published in ProPublica in 2017, is a series about maternal mortality in the United States.
• “When the Water Breaks,” by Layla A. Jones, published in The Philadelphia Inquirer in July 2022, traces America’s maternal mortality crisis back to Philadelphia and America’s first delivery wards and the persisting racial disparities today.
• “Stark Disparities Persist in Missouri’s Maternal Mortality Rate, State Board Finds,” by Tessa Weinberg, published in the Missouri Independent in August 2022, is about a multi-year report that analyzes Missouri’s maternal mortality trends.
• “Postpartum Care Falls Short for Black Women. One Mother is Trying to Fix That,” by Juana Summers, Michael Levitt and Sarah Handel, published on National Public Radio’s All Things Considered in August 2022, is about She Matters, a digital platform focused on disparities in postpartum care for Black mothers.
• “New Alabama Maternal Mortality Report Highlights Preventable Deaths, Substance Abuse,” by Sarah Swetlik, published on AL.com in August 2022, explains the findings of Alabama’s Maternal Mortality Review Committee’s latest report.
• “Raising The Stakes To Advance Equity In Black Maternal Health,” by Michele Cohen Marill, published in Health Affairs in March 2022, is about Penn Medicine tying executive compensation to the goal of reducing complications from giving birth.
• “Getting To The Heart Of America’s Maternal Mortality Crisis,” by Michele Cohen Marill, published in Health Affairs in December 2021, is about a cardio-obstetrics program in a Missouri hospital and a national registry that targets the leading causes of maternal death.

More resources for journalists

• “Maternal Mortality Rates in the United States, 2020,” by Donna Hoyert, published in CDC’s National Center for Health Statistics’ E-Stats in February 2022, provides the latest maternal mortality data in the United States.
• March of Dimes, a U.S. nonprofit organization that focuses on improving health of mothers and babies, has accessible information and annual reports on maternal and infant health in the U.S. Here’s the organization’s information page on maternal deaths.
• The Guttmacher Institute is a research and policy organization focused on sexual and reproductive health rights around the world.
• Black Mamas Matter Alliance is a nonprofit group that advocates for Black maternal and reproductive health. Here’s a list of other organizations advocating for Black mothers.
• Center for Reproductive Rights is a global human rights organization of lawyers and advocates of reproductive rights.
• Perinatal Quality Collaboratives are state or multistate networks of teams that focus on improving the quality of care for mothers and babies. Here’s a list by state.
• Maternal Mortality Review Committees are multidisciplinary committees in states and cities that perform comprehensive reviews of deaths among women within a year of the end of pregnancy. Here’s a list by state.
• Every Mother Counts is a nonprofit organization working to make pregnancy and childbirth safe for mothers around the world. It was founded by American model and humanitarian Christy Turlington Burns after experiencing her own childbirth complications.
• “Eliminating Preventable Maternal Mortality and Morbidity,” is The American College of Obstetricians and Gynecologists’ policy statement on combating maternal mortality.

Free multimedia collections for news stories

• CDC’s Public Health Image Library (PHIL) has some photo and illustration options. You can also download and use charts and graphs from CDC reports, including Morbidity and Mortality Weekly Report.
• SciLine offers video interviews with experts, which journalists can download and use for free.

The post Maternal mortality: An explainer and research roundup appeared first on The Journalist's Resource.

Google searches for abortion medications reached an all-time high in the hours and days after the May 2 leak of a draft Supreme Court majority opinion in favor of overturning Roe v. Wade, and the searchers were more common in states with restrictive reproductive rights, according to a research letter published on June 29 in JAMA Internal Medicine. 

The surge in searches highlights the importance of providing women with information on where they can legally and safely obtain abortion medications, including telemedicine consultations with health care professionals, researchers note. 

“Elevated interest in abortion medications should alert physicians that many of their patients may pursue this option with or without them,” they write in “Internet Searches for Abortion Medications Following the Leaked Supreme Court of the United States Draft Ruling.” 

Using Google Trends, which analyzes the popularity of individual Google searches and provides relative search volumes with a value between 0 to 100, the researchers retrieved Google searches in the U.S. for abortion pill or abortion medications mifepristone (brand name, Mifeprex) and misoprostol (brand name Cytotec) from Jan. 1, 2004, when Google began collecting data, to May 8, 2022. 

They analyzed weekly national online search trends for the medications for the entire study period, finding that the weekly search volume reached its historic peak during the week of the Supreme Court draft leak, with 350,000 searches. The volume was 1.67 times higher than the prior week and twice as high as 2012, according to the researchers.

They also looked at hourly search volumes for the three days before and after the Supreme Court draft leak. The spike in searches for abortion medications were cumulatively 162% higher than they had projected for the 72 hours after the leak. The spike was immediate in the hour that Politico reported the leak, study co-author John W. Ayers wrote in an e-mail to The Journalist’s Resource.

Researchers also find a correlation between the volume of searches and women’s reproductive rights in states — such as public funding for abortion and access to abortion services providers.

For instance, Nebraska had the highest search volume for abortion medications in the three days following the leak, followed by Iowa and Missouri. The three states have received grades of F, C+ and D respectively, from the Institute for Women’s Policy Research, which assigns each state a letter grade based on the level of reproductive rights. Hawaii, which received an A- from the institute, had the lowest online search volume for the medications. 

The study was accepted for publication on May 31, before the Supreme Court officially overturned Roe v. Wade in a 5-4 decision on June 24, ending five decades of federal abortion rights and sending back to the states the authority to ban or allow abortions. 

The team has not analyzed the online search data after the official Supreme Court ruling on June 24, wrote Ayers, vice chief of innovation at U.C. San Diego Medicine, in the email to JR.

A search on Google Trends shows that the search volume for “abortion pill” on June 24 was more than twice as high as the peak on May 3.

Medication abortion, also known as medical abortion or abortion with pills, involves taking two different drugs, mifepristone and misoprostol, during the first 10 weeks of pregnancy, according to Kaiser Family Foundation, a nonprofit organization that conducts health and health policy research. Since the Food and Drug Administration approved the drugs in 2000, half of abortions at 8 weeks gestation or less have been medication abortions, according to KFF.

Mifepristone, sold under the brand name Mifeprex and also known as the abortion pill or RU-486, blocks progesterone, a hormone essential to the development of a pregnancy, and prevents an existing pregnancy from progressing. Misoprostol, marketed under the brand name Cytotec, is taken 24 to 48 hours after mifepristone and empties the uterus by causing cramping and bleeding, similar to an early miscarriage, according to KFF. 

The researchers note their study is limited in that it can’t confirm whether the searches were linked to an abortion attempt, but the authors provide some potential reasons for the online searches.

“Although mifepristone/mifeprex or misoprostol/cytotec require a prescription and their use is restricted in some states, internet searches may reflect people exploring the safety and effectiveness of these medicines, how to obtain them, or stockpiling in anticipation of curtailed access,” the authors write. “Some searchers may be seeking substitute and/or illicit abortion medications as alternatives.”

Shortly after the Supreme Court ruling on June 24, the demand for the emergency contraceptive medicines known as “Plan B” or “morning after pills,” which prevent pregnancy, surged to such an extent that several retailers and drugstore chains, including Amazon, Rite Aid and CVS, began limiting the number of pills consumers can buy on their website or in their stores, according to CNBC and the Associated Press.

The ruling also led to a surge of social media posts offering women abortion pills, prompting Facebook and Instagram to swiftly begin removing them, according to NPR. 

In 32 states, only physicians are allowed to prescribe abortion pills. In the rest of the states, rest advanced practice clinicians, including advanced practice registered nurses and physician assistants, can also prescribe them, according to Kaiser Family Foundation and the Guttmacher Institute, a sexual and reproductive health research organization.

Since January, at least 20 states have proposed bills to restrict or ban access to abortion pills, according to Pew Stateline. 

Additional resources:

• Medication Abortion. This is a comprehensive explainer by the Guttmacher Institute.
• Lay of the Land: Abortion Policies and Access in the United States. The interactive map by the Guttmacher Institute shows each state’s abortion policies, demographic information and statistics. 
• The Availability and Use of Medication Abortion. Provided by the Kaiser Family Foundation, this report provides an overview of medication abortion, insurance coverage and access by state. 
• Medication Abortion and Telemedicine: Innovations and Barriers During the COVID-19 Emergency. This report by the Kaiser Family Foundation provides an overview of barriers and opportunities in using telemedicine to prescribing abortion pills.
• Medication Abortion Up to 70 Days of Gestation. This practice bulletin by the American College of Obstetricians and Gynecologists provides evidence-based guidance on the provision of medication abortion up to 70 days (or 10 weeks) of gestation.
• Medication Abortion: Q&A with experts.  In May, SciLine, a free service for journalists and scientists based at the American Association for the Advancement of Science, asked experts about the fundamentals of medication abortion to help reporters cover the topic.

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In January, Journalist’s Resource attended a four-day fellowship on cardiovascular health, “Covering the Heart Beat,” organized by the National Press Foundation. Researchers, physicians and journalists gathered with the goal of improving news coverage of cardiovascular health.

At the training, Dr. Noel Bairey Merz and Dr. Martha Gulati delivered presentations on women’s heart health. Bairey Merz is director of the Barbra Streisand Women’s Heart Center at Cedars-Sinai Medical Center in Los Angeles, and chairs the National Institutes of Health-sponsored Women’s Ischemic Syndrome Evaluation (WISE) initiative, a project aimed at better understanding heart disease in women. Gulati is chief of cardiology at the University of Arizona College of Medicine-Phoenix and co-author of the book Saving Women’s Hearts.

They broke down oft-repeated myths about cardiovascular disease in women and shared the facts of the matter. This tip sheet summarizes a few of their key points.

Myth: Cardiovascular disease is a man’s disease.

Reality: Women and men have similar rates of cardiovascular disease.

Nearly half of all women in the U.S. — 60 million — have cardiovascular disease, which includes coronary heart disease, heart failure, stroke and hypertension, according to the most recent statistics from the American Heart Association. A similar number of men — 61.5 million — have cardiovascular disease. For comparison, about 3.5 million U.S. women have breast cancer.

Myth: Women don’t die from cardiovascular disease nearly as often as men do.

Reality: Cardiovascular disease is the leading cause of death for both sexes. In 2017, 418,655 women and 440,460 men died of cardiovascular disease.

Myth: Heart disease looks the same in men and women.

Reality: Bairey Merz said research has found that heart disease in women often looks different, quite literally, than it does in men. For example, plaque on the walls of women’s arteries looks different from the plaque on men’s. It also affects their arteries differently.

Diagnosing a heart attack in women requires more sensitive blood testing, Bairey Merz added, because their hearts are generally smaller and release smaller amounts of troponin, a protein the body releases when the heart muscle has been damaged.

These differences might explain why heart disease in women isn’t always diagnosed and treated promptly. But researchers haven’t always considered men and women separately enough, Bairey Merz said.

She described a consequential 1991 letter to the editor in the New England Journal of Medicine written by Dr. Bernadine Healy, then director of the National Institutes of Health. “Yentl, the 19th-century heroine of Isaac Bashevis Singer’s short story, had to disguise herself as a man to attend school and study the Talmud. Being ‘just like a man’ has historically been a price women have had to pay for equality. Being different from men has meant being second-class and less than equal for most of recorded time and throughout most of the world,” Healy writes.

Healy applies the story of Yentl to heart disease. She argues that only recognizing heart disease in women when it presents similarly to men’s heart disease, and treating women’s heart disease as the same as men’s, leads to inferior diagnosis and treatment of heart disease in women.

“The problem is to convince both the lay and the medical sectors that coronary heart disease is also a woman’s disease, not a man’s disease in disguise,” she writes. “Decades of sex-exclusive research have reinforced the myth that coronary artery disease is a uniquely male affliction and have generated data sets in which men are the normative standard. The extrapolation of these male-generated findings to women has led in some cases to biased standards of care and has prevented the full consideration of several important aspects of coronary disease in women.”

Bairey Merz added that the “Yentl syndrome” still afflicts the field today: “The health care establishment still, I think, has these gendered ideas of not doing research in women.”

Myth: Men and women both receive the standard of care for cardiovascular disease.

Reality: Men often are more likely to receive care that follows established guidelines for treating cardiovascular disease than women.

“When a woman has a heart attack, do we even treat women equally?” Gulati asked. The short answer, she said, is: no.

The long answer: A 2012 paper in the American Journal of Medicine found that women were less likely to receive care concordant with established guidelines for heart attack — and were more likely to die from the condition — than men. The study looked at a sample of 31,544 patients from 369 hospitals across the U.S. between 2002 and 2008.

A few of the differences highlighted in the study:

• Women were less likely to get aspirin or a beta blocker within 24 hours of a heart attack, which is the standard of care.
• They were less likely to undergo any type of invasive procedure to treat the heart attack.
• They also were less likely to receive anti-blood clotting therapy within 30 minutes of going to the hospital, another standard of care.
• In addition, women were less likely to receive timely coronary angioplasty – the insertion of a tiny balloon into the artery to clear a blockage, which is recommended within 90 minutes of being admitted to the hospital.
• Younger women experiencing heart attacks suffered worse outcomes than older women — higher mortality rates and lower-quality care.

“The only thing women do better is die,” Gulati said. “Even when we don’t have all the answers about the [sex-related cardiovascular disease] differences… if we just followed the guidelines, we would save lives.”

Differences in care aren’t limited just to the clinical setting. Gulati said that in out-of-hospital cases of cardiac arrest, women are less likely to receive bystander-initiated cardiopulmonary resuscitation (CPR) than men. “We know the sooner we initiate CPR, the more likely we are to save lives,” she said. As it stands, women are less likely to survive cardiac arrest than men.

Gulati suggested the reasons why CPR is not performed as often on women might have to do with concerns about touching women, or the fact that people are trained to perform CPR on male mannequins rather than female figures. That might lead individuals to believe they do not know how to perform CPR appropriately on a woman, Gulati said.

Myth: Women experiencing heart attacks report so-called “atypical” symptoms such as stomach pain, pain in the jaw and heart palpitations, rather than “typical” symptoms like chest pain, pressure or tightness.

Reality: Research shows that women are actually more likely than men to report typical symptoms, but are also more likely to list a greater number of symptoms.

“The public health message has really somehow gone out there as if every woman will present atypically rather than most people will present with the typical symptoms,” Gulati said.

A 2018 study in Circulation finds that a similar percentage of men and women reported chest pain when seeking help for a heart attack — 89.5% and 87%, respectively. Women, however, were also more likely to report three or more additional symptoms than men. Additionally, both women and their healthcare providers were less likely to consider women’s symptoms heart-related than men and their providers. For example, women were more likely to consider their symptoms related to stress or anxiety, and 53% of women reported that their provider did not think their symptoms were heart-related, compared with 37% of men.

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Exposure to extremely hot weather relative to the norm during pregnancy puts women and infants at risk for health problems, finds a new study of maternal health in three states with varying climates.

For mothers, extreme heat increases the likelihood of hospitalization during pregnancy and hypertension during childbirth. For infants, the risks include dehydration at birth and being hospitalized in the first year of life.

Black mothers are especially vulnerable, according to a new working paper from the National Bureau of Economic Research, “What to Expect When It Gets Hotter: The Impacts of Prenatal Exposure to Extreme Heat on Maternal and Infant Health.”

The findings have sobering implications for maternal health trends, particularly as global temperatures rise.

“Given that extreme heat days are rising steeply in frequency and also in severity in just the next few decades, I think this sheds light on what’s going to happen to mothers’ health, and also the health disparities between black women versus white women,” says Jiyoon Kim, an assistant professor of economics at Elon University. She co-authored the paper with Ajin Lee, assistant professor of economics at Michigan State University, and Maya Rossin-Slater, assistant professor of health research and policy at Stanford University School of Medicine.

The paper looks at data collected on all maternal and child inpatient hospitalizations in three states with dissimilar climates — Arizona, New York and Washington. The data include records corresponding to a total of 2.68 million infants and 2.24 million mothers spanning from 2003 through 2013.

Kim explains that the project was motivated by her own experience as a mother.

“I had to move from Indiana to Florida in the middle of my pregnancy,” she says. “And then that led to an extreme weather change during my pregnancy period. That actually motivated this research question, personally, to me, to see whether there is any effect of extreme weather shocks during pregnancy — on my health, as well as on the infant’s health.”

The researchers matched corresponding county-level weather data — including average, maximum and minimum ground temperature and precipitation levels — from the National Oceanic and Atmospheric Administration (NOAA) to the hospitalization data.

They focused on relative temperature shocks — that is, unexpected variation in weather given the area’s average climate. They considered days in which a county’s average temperature was at least three standard deviations above the monthly average to be an extremely hot day. Standard deviation indicates the variation of a given value from the average. The more standard deviations away from the average a value is, the farther it is from that value. For that reason, standard deviation is a helpful tool to indicate relative extremes in temperature.

Kim adds that another personal experience influenced the study design. While her first pregnancy did not overlap with the summer months, her second did. Kim wondered whether this kind of prolonged, seasonal weather exposure might also have an effect on maternal and infant health.

She explains that it’s difficult to study these questions through a randomized experiment. Randomized, controlled trials are generally considered the gold standard of medical studies because their design — in which an intervention is randomly assigned to some participants in a trial and tested against a control group, which receives a standard treatment or a placebo — can provide evidence of causation. Where people live isn’t randomly assigned, and people can control when and whether they conceive.

With these considerations in mind, the researchers designed their study such that the findings point at a causal association between weather variation and health outcomes. They compared health outcomes among women of the same race and ethnicity who lived in the same county and gave birth in the same month. The key difference: the year they gave birth.

“The only difference between these two women is the year of birth,” Kim explains. “That could basically allow us to see the difference in their birth outcome by looking at the weather changes between these two years.”

The researchers find that for each additional day a pregnant woman spent in extreme heat during her second trimester, the odds  of her being hospitalized increased by 4.8%. For each additional day of extreme heat she endured during the third trimester, the likelihood that she was hospitalized increased by 3%. The increase in hospitalizations was mainly driven by pregnancy complications, including hemorrhage, high blood pressure and early labor.

Effects were larger for black women than white women. The likelihood of hospitalization for black women experiencing an additional day of extreme heat during any trimester increased by 5%, whereas for white women, the likelihood of hospitalization increased by 2.6%.

Extreme heat during pregnancy had effects on maternal health at childbirth, too. The researchers find each additional extreme heat day in the first trimester increased the probability of a complication at childbirth by 1%. An additional day of extreme heat during the third trimester increased the likelihood a mother would be diagnosed with high blood pressure at childbirth by 2.9% and increased the mother’s length of stay at the hospital by 0.3%.

Infants’ health was also affected by extreme heat. For each additional extreme heat day in the second trimester of pregnancy, the likelihood that a newborn was diagnosed with dehydration increased by 31%. The probability the infant was readmitted to the hospital within his or her first year of life increased by 3.4%. These re-hospitalizations were commonly caused by jaundice, blood disorders and respiratory diseases, which research links to dehydration.

There were not disparities in infant health by race or ethnicity, “which was pretty surprising because we were expecting to see a similar disparity in infants’ health,” Kim says. “That is the area where we’d like to investigate further in the future; why we do not see the disparity in infants but only for the mothers?”

The authors conclude: “Our findings suggest that, in the absence of mitigating interventions, the projected increase in exposure to extreme heat over the next century may contribute to further worsening of maternal health. Moreover, since black women are both more likely to be exposed to extreme heat … and experience larger adverse impacts of heat exposure on pregnancy-related health, our estimates imply that climate change could further exacerbate racial disparities in maternal health.”

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In late 2017 and early 2018, legislators in multiple states filed bills to eliminate taxes on feminine hygiene products. They are following the lead of several other states that have banished the so-called “tampon tax” in recent years. While state governments do not designate a special tax for feminine hygiene items such as tampons, sanitary pads and menstrual cups, most do charge sales tax on them, according to PolitiFact, a fact-checking journalism organization.

The cost of feminine hygiene products has been in the news a lot lately as lawmakers and others debate whether Americans should pay taxes on something half the population considers a basic need and the federal government considers a medical device. In some parts of the country, policymakers also are debating whether such items should be provided free of charge in certain locations – school restrooms and women’s prisons, for example. An Illinois law that took effect Jan. 1, 2018 requires public schools serving grades 6 through 12 to provide tampons and sanitary napkins in their bathrooms at no cost.

Florida is the latest state to make menstrual products tax exempt. Although the California legislature passed a bill in 2016 to remove these items from the state’s sales tax base, Gov. Jerry Brown vetoed it. At the time, Brown said he was vetoing seven bills that either created or expanded tax breaks, which, combined, would have cost his state hundreds of millions of dollars.

This policy issue is one that journalists on local and state beats are sure to be covering for years to come. Below, we’ve compiled a list of databases and other resources to help reporters learn more about sales taxes and feminine hygiene products. We also present a sampling of academic papers and government reports that offer additional insights in areas such as how menstrual taboo influences policy debates and whether a lack of feminine hygiene products really hurts girls’ school attendance.

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Resources

• The Tax Foundation provides a variety of data and reports on sales taxes, including a state-by-state comparison. Five states — Alaska, Delaware, Montana, New Hampshire and Oregon — do not have statewide sales taxes.
• PolitiFact created several maps showing which states charged sales tax on feminine hygiene items as well as Viagra and Rogaine in 2017. Most states tax pads and tampons as well as Rogaine but do not tax Viagra and other prescription medications.
• The American Medical Association (AMA) supports legislation to remove sales taxes on feminine hygiene products. AMA President David O. Barbe has spoken out on the issue.
• In August 2017, the U.S. Department of Justice issued a memo to federal prisons, requiring them to offer a range of free feminine hygiene products to female inmates.
• Jennifer Weiss-Wolf, an attorney at the Brennan Center for Justice at the New York University School of Law, writes frequently about gender and politics. She wrote the book Periods Gone Public: Taking a Stand for Menstrual Equity, released in late 2017.
• The Los Angeles Times editorial board wrote this 2016 editorial opposing exempting tampons and baby diapers from sales taxes.

Evidence from one state

“Who Would Benefit from Repealing Tampon Taxes? Empirical Evidence from New Jersey”
Cotropia, Christopher Anthony; Rozema, Kyle. Working paper from the University of Richmond School of Law and University of Chicago Law School, 2017. SSRN: https://ssrn.com/abstract=2999970.

Conclusion: “New Jersey’s experience with repealing the tampon tax empirically confirmed two points made by tampon tax repeal advocates. First, women consumers do bear the burden of tampon taxes. The data shows that all purchasers bear at least some of the burden of the tax. Second, the tampon tax burden is greater on women with low incomes and without a college degree. This means that tampon tax repeal is likely to benefit women who most need relief when purchasing MH [menstrual hygiene] products. The repeal of the tampon tax even facilitated some New Jersey women to upgrade the quality of MH product they used.”

State revenue loss estimates

“Assembly Bill 9: Legislative Bill Analysis”
Report from the California State Board of Equalization, 2017.

Summary: According to this bill analysis, the state of California would lose an estimated $21.7 million in 2018-19 if it exempts feminine hygiene products from its sales and use tax.

“Fiscal Note & Local Impact Statement”
Ridzwan, Ruhaiza. Report from the Ohio Legislative Service Commission, October 2017.

Summary: This legislative analysis finds that Ohio would lose $3.2 million to $4 million a year in state revenue if it exempts feminine hygiene products from its sales and use tax. Local governments would lose $800,000 to $1 million annually.

“The Florida Senate Bill Analysis and Fiscal Impact Statement”
Report of the Committee on Appropriations, 2017.

Summary: A bill that exempts the sale of feminine hygiene products from Florida’s sales and use tax “reduces General Revenue receipts by $3.8 million in Fiscal Year 2017-2018 and by $8.9 million on a recurring basis. It reduces local revenue by $1.0 million in Fiscal Year 2017-2018 and by $2.3 million on a recurring basis. The Department of Revenue is expected to incur additional costs of approximately $90,000 to notify sales tax dealers of this new exemption.”

“Final Fiscal Note”
Report from the Colorado Legislative Council, May 2017.

Summary: According to this legislative analysis, a bill that would eliminate sales tax on feminine hygiene items in Colorado is “expected to reduce General Fund sales and use tax revenue by $1.2 million in FY 2017-18 and $2.4 million in FY 2018-19, and by similar amounts in subsequent years.” The bill has been postponed indefinitely.

How menstrual taboo influences policy debate

“The ‘Tampon Tax’: Public Discourse of Policies Concerning Menstrual Taboo”
Hunter, Lea. Hinckley Journal of Politics, July 2016. ISSN: 2163-0798.

Abstract: “The ‘tampon tax’ is a policy in which feminine hygiene products are taxed as ‘luxury goods’ despite the fact that many countries exempt ‘necessary goods — such as basic groceries and medical products — from sales tax. In the summer of 2015, the Canadian parliament took steps to exempt feminine hygiene products. Academic literature supports the idea that menstrual taboo, which stigmatizes open discussion of menstruation, has contributed to the global pervasiveness of gendered taxation policies like the tampon tax. This study examines arguments for and against the tampon tax as well as how menstrual taboo plays into the public discourse in formal (e.g., parliamentary debate and news reporting) and informal (e.g. Twitter) platforms through content analysis.”

Lack of hygiene products: Impacts on school attendance, health

“Menstruation, Sanitary Products, and School Attendance: Evidence from a Randomized Evaluation”
Oster, Emily; Thornton, Rebecca. American Economic Journal: Applied Economics, 2011. DOI: 10.1257/app.3.1.91.

Abstract: “Policy-makers have cited menstruation and lack of sanitary products as barriers to girls’ schooling. We evaluate these claims using a randomized evaluation of sanitary products provision to girls in Nepal. We report two findings. First, menstruation has a very small impact on school attendance. We estimate that girls miss a total of 0.4 days in a 180-day school year. Second, improved sanitary technology has no effect on reducing this (small) gap. Girls who randomly received sanitary products were no less likely to miss school during their period. We can reject (at the 1 percent level) the claim that better menstruation products close the attendance gap.”

“Menstrual Cups and Sanitary Pads to Reduce School Attrition, and Sexually Transmitted and Reproductive Tract Infections: A Cluster Randomized Controlled Feasibility Study in Rural Western Kenya”
Phillips-Howard, Penelope A.; et al. BMJ Open, 2016. DOI: 10.1136/bmjopen-2016-013229.

Summary: Researchers looked at how providing girls in rural Kenya with feminine hygiene products affected their health and school attendance. They found that giving girls these items did not reduce their risk of dropping out of school. However, girls who received pads and menstrual cups were less likely to have sexually transmitted infections.

“Menstruation and School Absenteeism: Evidence from Rural Malawi”
Grant, Monica; Lloyd, Cynthia; Mensch, Barbara. Comparative Education Review, May 2013. DOI: https://doi.org/10.1086/669121.

Abstract: “The provision of toilets and menstrual supplies appears to be a promising strategy to promote adolescent girls’ school attendance and performance in less developed countries. In this article, we use the first round of the Malawi Schooling and Adolescent Survey (MSAS) to examine the individual- and school-level factors associated with menstruation-related school absenteeism. Although one-third of female students reported missing at least 1 day of school during their previous menstrual period, our data suggest that menstruation accounts only for a small proportion of all female absenteeism and does not create a gender gap in absenteeism. We find no evidence for school-level variance in menstruation-related absenteeism, suggesting that absenteeism due to menstruation is not sensitive to school environments. Rather, co-residence with a grandmother and spending time on schoolwork at home are associated with lower odds of absence during the last menstrual period.”

Want more research on taxes? Check out our other posts on soda taxes, gas taxes and cigarette taxes.

Photo by Stilfehler obtained from Wikimedia Commons and used under a Creative Commons license.

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Crisis pregnancy centers (CPCs) are pro-life organizations that often offer women incorrect, incomplete or misleading information about their reproductive options.

In response, some localities have passed legislation requiring CPCs to make disclosures to their clients. California, for example, passed the Reproductive FACT Act in 2015. Under this law, CPCs must notify clients of public resources available to prevent or terminate pregnancies. It also mandates that CPCs inform their patients if they are not licensed as a medical facility.

Anti-choice advocates have taken issue with these requirements. The National Institute of Family and Life Advocates has sued California’s attorney general on behalf of CPCs. In November 2017, the U.S. Supreme Court decided it would hear the case.

Two law review articles provide context. While papers published in law journals often promote a particular interpretation of the law, these sources offer background on CPCs and relevant legal precedent. A 2016 article in the American Journal of Law & Medicine looks specifically at the First Amendment and reproductive freedom. An article published in 2017 in the Northwestern Journal of Law & Social Policy, “Have Crisis Pregnancy Centers Finally Met Their Match: California’s Reproductive FACT Act,” suggests the California law will be held constitutional and represents a first step to regulating CPCs.

The upcoming Supreme Court case, National Institute of Family and Life Advocates v. Becerra, No. 16-1140, will evaluate whether requiring CPCs to disclose information that counters their beliefs is a violation of First Amendment rights to free speech.

But what, exactly, do these centers believe, and what information do they promote?

A number of academics have explored this topic, scouring the websites of CPCs. A 2016 paper published in the Journal of Pediatric and Adolescent Gynecology found that nearly half of the 85 websites surveyed promoted abstinence-only sexual education. Over 60 percent of these websites provided negative facts about condoms, including minimizing their efficacy and suggesting they break often, and less than 10 percent encouraged the use of condoms to prevent sexually transmitted infections.

A larger examination of 254 CPC websites, published in Contraception in 2014, found that 80 percent provided at least one item of false or misleading information — most commonly, claiming links between abortion and mental health concerns.

A study published in 2017 in Women’s Health Issues focused on the websites of crisis pregnancy centers in Georgia. It reviewed all of the accessible websites of the CPCs in the state and found that more than half had “false or misleading statements regarding the need to make a decision about abortion or links between abortion and mental health problems or breast cancer.” Eighty-nine percent of sites did not indicate that their centers do not offer contraceptives or direct patients to resources where they might find them.

Researchers from the University of North Carolina who visited 19 CPCs in the state from March to June of 2011 found that nearly half “provide counseling on abortion and its risks,” and over half provided at least one piece of information that was misleading or false, ranging from the efficacy of condoms to links between abortion and infertility, breast cancer and mental health problems.

In fact, research on the associations between abortion and mental health indicates that women who are denied abortions might have a higher risk of adverse psychological outcomes in the short term compared with women who received abortions. A 2017 study in JAMA Psychiatry found that eight days after seeking an abortion, women who were denied one reported more anxiety symptoms, lower self esteem and similar levels of depression as women who received abortions. In the longer term — 4 to 5 years after the abortion — women who terminated pregnancies were not at a higher risk of post-traumatic stress disorder, depression, or anxiety than those denied abortions.

Though research from the 1990s suggested a link between abortion and increased risk of breast cancer, these studies have come under scrutiny. More recent research indicates that abortions do not cause an increased risk of breast cancer.

While CPCs tend to provide inaccurate information about abortion, a study published in 2016 in Contraception suggests that many who visit these centers in-person are not seeking pregnancy counseling. The researchers looked at the reasons why 273 first-time clients went to a secular pregnancy resource center in Indiana and found that only 6 percent discussed pregnancy options during their visit. Most said they went to the center for parenting-related support, including free diapers and baby clothes.

For those seeking information about pregnancy options, even disclosure requirements like California’s disputed Reproductive FACT Act have their limits. Research suggests that publicly funded family planning clinics do not always offer women the full range of reproductive health care options.

A study published in Perspectives on Sexual and Reproductive Health in 2016 looked at survey data from 567 publicly funded family planning facilities across the country and found that a smaller proportion made abortion referrals compared to adoption referrals (84 percent versus 97 percent). Moreover, they found issues relating to access — less than 3 percent of rural facilities had a first-trimester abortion provider located within 20 miles.

Limited access and barriers to abortion care have consequences. A study published in 2017 in Perspectives on Sexual and Reproductive Health found that most women who had to travel across state lines or over 100 miles within their state to receive an abortion reported “delays in care, negative mental health impacts and consider[ed] self-induction.”

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A provision in the Affordable Care Act of 2010 made it compulsory for all new health insurance plans to fully cover the cost of contraceptives for their subscribers. This was part of Obamacare’s mandate that cost-sharing (the requirement for recipients of care to contribute a co-payment) be removed from some forms of preventative care.

There are, however, a few exceptions to this requirement. Plans that did not cover birth control before and were not substantially changed after the enactment of the ACA were grandfathered in — in other words, they remained the same. Further, the Supreme Court’s 2014 decision in Burwell v. Hobby Lobby Stores Inc. allowed for-profit employers an exemption from this provision on religious grounds.

A 2017 mandate widened this exemption, allowing any employer not to offer this benefit. Citing America’s “long history of providing conscience protections,” the rule, written by the Health and Human Services Department and two other agencies, now “encompasses non-governmental plan sponsors that object based on sincerely held religious beliefs, and institutions of higher education in their arrangement of student health plans.” It also expanded the grounds for objection to include “(non-religious) moral convictions.”

We assembled the latest research on women’s sexual health for journalists to consult amid these changes. The following studies highlight how contraceptive use has changed in recent years, trends in contraceptive costs, changes in insurance coverage nationwide and outcomes related to contraceptive use.

Contraceptive use

“Did Contraceptive Use Patterns Change After the Affordable Care Act? A Descriptive Analysis”
Bearak, Jonathan M.; Jones, Rachel K. Women’s Health Issues, May 2017, Vol. 27. DOI: 10.1016/j.whi.2017.01.006.
Findings: “We observed no changes in contraceptive use patterns among sexually active women. However, use of the pill nearly doubled, from 21 percent to 40 percent, among young women aged 18 to 24 who had not had sex in the last month. Many of these women cited benefits of the pill in addition to pregnancy prevention.”

“Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15-44: United States, 2011-2013”
Daniels, Kimberly; et al. National Health Statistics Reports, November 2015.
Abstract: “Among women currently using contraception, the most commonly used methods were the pill (25.9 percent, or 9.7 million women), female sterilization (25.1 percent, or 9.4 million women), the male condom (15.3 percent, or 5.8 million women), and long-acting reversible contraception (LARC) — intrauterine devices or contraceptive implants (11.6 percent, or 4.4 million women). Differences in method use were seen across social and demographic characteristics. Comparisons between time points reveal some differences, such as higher use of LARC in 2011–2013 compared with earlier time points.”

“Changes in Use of Long-Acting Reversible Contraceptive Methods Among U.S. Women, 2009–2012”
Kavanaugh, Megan L.; Jerman, Jenna; Finer, Lawrence B. Obstetrics & Gynecology, November 2015, Vol. 126. DOI: 10.1097/AOG.0000000000001094.
Findings: “The prevalence of LARC use among contracepting U.S. females increased from 8.5 percent in 2009 to 11.6 percent in 2012 (P<.01). The most significant increases occurred among Hispanic females (from 8.5 percent to 15.1 percent), those with private insurance (7.1-11.1 percent), those with fewer than two sexual partners in the previous year (9.2-12.4 percent), and those who were nulliparous (2.1-5.9 percent) (all P<.01). In multivariable analyses adjusting for key demographic characteristics, the strongest associations with LARC use in 2012 were parity (adjusted odds ratios [ORs] 4.3-5.5) and having a history of stopping non-LARC hormonal use (adjusted OR 1.9). Women aged 35-44 years (adjusted OR 0.3) were less likely to be LARC users than their counterparts (all P<.001). Poverty status was not associated with LARC use. There were no differences in discontinuation of LARC methods resulting from dissatisfaction between minority women and non-Hispanic white women.”

“Trends in Long-Acting Reversible Contraception Use in Adolescents and Young Adults: New Estimates Accounting for Sexual Experience”
Pazol, Karen; et al. The Journal of Adolescent Health, October 2016, Vol. 59. DOI: 10.1016/j.jadohealth.2016.05.018.
Findings: “Among adolescents and young adults, 56 percent and 14 percent, respectively, have never had vaginal intercourse, versus 1 percent-4 percent for women aged 25-44 years. Given the high percentage of adolescents and young adults who never had vaginal intercourse, LARC estimates were higher for these age groups (p < .05), but not for women aged 25-44 years, when limited to those at risk for unintended pregnancy. Among adolescents at risk, the increase in LARC use from 2006-2008 (1.1 percent) to 2008-2010 (3.6 percent) was not significant (p = .07), and no further increase occurred from 2008-2010 to 2011-2013 (3.2 percent); by contrast, among young adults at risk, LARC use increased from 2006-2008 (3.2 percent) to 2008-2010 (6.9 percent) and from 2008-2010 to 2011-2013 (11.1 percent).”

“Trends in Long-Acting Reversible Contraception Use Among U.S. Women Aged 15-44”
Branum, Amy M.; Jones, Jo. NCHS Data Brief, February 2015, No. 188.
Findings: “Use of long-acting reversible contraceptives (LARCs) declined between 1982 and 1988, remained stable through 2002, and then increased nearly five-fold in the last decade among women aged 15-44, from 1.5 percent in 2002 to 7.2 percent in 2011–2013.”

Contraceptive Costs

“Women Saw Large Decrease In Out-Of-Pocket Spending For Contraceptives After ACA Mandate Removed Cost Sharing”
Becker, Nora V.; Polsky; Daniel. Health Affairs, July 2015, Vol. 34. DOI: 10.1377/hlthaff.2015.0127.
Findings: The out-of-pocket costs for most contraceptive methods were significantly reduced after the introduction of the Affordable Care Act’s mandate that birth control be fully covered by private insurers. This included an average decrease for a six-month birth control pill prescription from $33.58 in June 2012 to $19.84 one year later. On average, women on the pill saved $254.91 per year. IUD and emergency contraception costs also fell. Out-of-pocket spending on the contraceptive ring and patch saw only minimal decreases.

“Impact of the Federal Contraceptive Coverage Guarantee on Out-of-Pocket Payments for Contraceptives: 2014 Update”
Sonfield, Adam; et al. Contraception, January 2015, Vol. 91. DOI: 10.1016/j.contraception.2014.09.006.
Findings: “The findings of this study suggest that the federal contraceptive coverage guarantee has had a substantial impact in eliminating out-of-pocket costs among privately insured women using some methods of contraception — including oral contraceptives, the most popular reversible method in the United States. Between fall 2012 and spring 2014, the proportion of pill users paying zero dollars out of pocket increased from 15 percent to 67 percent, with similar trends for injectable, ring and IUD users.”

Unintended Pregnancy and Teen Birth Rate Trends

“Investigating Recent Trends in the U.S. Teen Birth Rate”
Kearney, Melissa S.; Levine, Phillip B. Journal of Health Economics, May 2015, Vol. 41. DOI: 10.1016/j.jhealeco.2015.01.003.
Abstract: “We investigate trends in the U.S. rate of teen childbearing between 1981 and 2010, focusing specifically on the sizable decline since 1991. We focus on establishing the role of state-level demographic changes, economic conditions, and targeted policies in driving recent aggregate trends. We offer three main observations. First, the recent decline cannot be explained by the changing racial and ethnic composition of teens. Second, the only targeted policies that have had a statistically discernible impact on aggregate teen birth rates are declining welfare benefits and expanded access to family planning services through Medicaid, but these policies can account for only 12.6 percent of the observed decline since 1991. Third, higher unemployment rates lead to lower teen birth rates and can account for 16 percent of the decline in teen birth rates since the Great Recession began.”

“Declines in Unintended Pregnancy in the United States, 2008–2011”
Finer, Lawrence B.; Zolna, Mia R. New England Journal of Medicine, March 2016, Vol. 374. DOI: 10.1056/NEJMsa1506575.
Findings: “After a long period of minimal change, the rate of unintended pregnancy in the United States declined substantially between 2008 and 2011. The rate of 45 unintended pregnancies per 1,000 in 2011 was the lowest level seen in at least three decades. The decline occurred in nearly all demographic groups, including those defined by age, income, education, race and ethnicity, and religious affiliation. … A likely explanation for the decline in the rate of unintended pregnancy is a change in the frequency and type of contraceptive use over time. Evidence shows that the overall use of any method of contraception among women and girls at risk for unintended pregnancy increased slightly between 2008 and 2012. More important, the use of highly effective long-acting methods, particularly intrauterine devices, among U.S. females who used contraception increased from 4 percent to 12 percent between 2007 and 2012, and this increase occurred in almost all demographic groups. In a 2012 study, women and girls at high risk of unintended pregnancy who had free access to and used highly effective methods of contraception had much lower rates of unintended pregnancy than did those who used other methods, including commonly used methods such as the oral contraceptive pill.”

“Programs to Reduce Teen Pregnancy, Sexually Transmitted Infections, and Associated Sexual Risk Behaviors: A Systematic Review”
Goesling, Brian; et al. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine May 2014, Vol. 54. DOI: 10.1016/j.jadohealth.2013.12.004.
Findings: “This systematic review provides a comprehensive, updated assessment of programs with evidence of effectiveness in reducing teen pregnancy, STIs, or associated sexual risk behaviors. To conduct this assessment, we identified and assessed some 200 program impact studies released from 1989 through January 2011. Of the studies assessed, 88 met the review criteria for study design and execution. Analysis of the study impact findings identified 31 programs with evidence of effectiveness. To provide context for these findings and identify the relative strengths and weaknesses of the evidence, we also examined the study design quality and other characteristics of all 88 studies included in the analysis.”

“Game Change in Colorado: Widespread Use of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women”
Ricketts, Sue; Klingler, Greta; Schwalberg, Renee. Perspectives on Sexual and Reproductive Health, September 2014, Vol. 46. DOI: 10.1363/46e1714.
Findings: “The Colorado Family Planning Initiative increased access to LARC methods among young, low-income women, and this improved access was immediately followed by a substantial reduction in the birthrate among this population. Unlike other studies, this one was an ecological analysis of a population-based intervention. Therefore, while it has the limitations of an ecological analysis, we were able to measure changes in population health. Program data confirm the increase in LARC use among clients receiving Title X-funded services, and the effectiveness of these methods appears to be borne out in the decline in fertility rates, abortion rates, births to high-risk women and WIC [Women, Infants and Children] enrollment in the period after program rollout.”

“Provision of No-Cost, Long-Acting Contraception and Teenage Pregnancy”
Secura, Gina M.; et al. The New England Journal of Medicine, October 2014, Vol. 371. DOI: 10.1056/NEJMoa1400506.
Findings: “We found that pregnancy, birth, and abortion rates were low among teenage girls and women enrolled in a project that removed financial and access barriers to contraception and informed them about the particular efficacy of LARC [long-acting reversible contraception] methods. The observed rates of pregnancy, birth, and abortion were substantially lower than national rates among all U.S. teens, particularly when compared with sexually experienced U.S. teens. Stratification according to factors known to be associated with sexual behavior and pregnancy risk (age and race) showed that this was true among both older teens (18 to 19 years of age) and younger teens, as well as among both white and black teens.”

HPV 

“HPV Uptake Pre- and Post-Affordable Care Act: Variation by Insurance Status, Race, and Education”
Corriero, Rosemary; et al. Journal of Pediatric and Adolescent Gynecology, July 2017. DOI: 10.1016/j.jpag.2017.07.002.
Findings: “Vaccination uptake increased when comparing pre- and post-ACA waves of data. This increase in vaccination coverage could be related to the increased preventative service coverage, which includes vaccines, required by the ACA. Future studies may focus on the role insurance has on vaccination uptake, and meeting Healthy People 2020 objectives for vaccination coverage.”

Insurance Coverage

“Health Insurance Coverage among Women of Reproductive Age before and after Implementation of the Affordable Care Act”
Jones, Rachel K.; Sonfield, Adam. Contraception, May 2016, Vol. 93. DOI: 10.1016/j.contraception.2016.01.003.
Findings: “The proportion of women who were uninsured declined by almost 40 percent (from 19 percent to 12 percent), though several groups, including U.S.-born and foreign-born Latinas, experienced no significant declines. Among low-income women in states that expanded Medicaid, the proportion uninsured declined from 38 percent to 15 percent, largely due to an increase in Medicaid coverage (from 40 percent to 62 percent). Declines in uninsurance in nonexpansion states were only marginally significant.”

“Changes in Self-Reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act”
Sommers, Benjamin D.; et al. JAMA, July 2015, Vol. 314. DOI: 10.1001/jama.2015.8421.
Findings: “This analysis of a large national survey of U.S. adults demonstrated significant improvements in trends for self-reported coverage, access to a personal physician and medications, and health after the ACA’s first and second open enrollment periods. Consistent with other research, we found that national trends in coverage and access prior to the ACA were worsening. Those trends improved after October 2013, when the ACA’s open enrollment began. Subgroup analyses demonstrated that the largest improvements in coverage and access to medicine occurred among racial/ethnic minorities. The results suggest that the ACA may be associated with reductions in long-standing disparities in access to care, one of the goals of the ACA.”

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Raising the minimum wage results in lower teen birth rates, especially among white and Hispanic adolescents, a new study suggests.

Elected leaders nationwide are continually debating the benefits and consequences of raising the minimum wage in cities, states and at the federal level. Arguments often focus on how local business could be impacted and whether workers really would earn more money, considering companies might cut employees’ hours to control costs.

Scholars are examining the issue to help policymakers better understand the implications of a higher minimum wage. Much of the newest research focuses on how it may influence people’s health. A 2016 study published in the American Journal of Public Health, for example, indicates that raising the minimum wage to $15 in New York City would have prevented as many as 5,500 premature deaths between 2008 and 2012. A 2016 study from the National Bureau of Economic Research suggests a higher minimum wage is associated with higher infant birth weights and a decline in smoking during pregnancy.

A new study looks at how a higher minimum wage affects teen health.

An academic study worth reading: “The Effect of Minimum Wages on Adolescent Fertility: A Nationwide Analysis,” published in the American Journal of Public Health, 2017.

About the study: Lindsey Rose Bullinger of Indiana University’s School of Public and Environmental Affairs looks at how teen birth rates are affected by a rise in the minimum wage. She compares teen birth rates in states where the minimum wage increased to the birth rates in states where it did not. Her review spans the last quarter of 2003 through 2014.

Bullinger also examines how factors such as welfare benefits and contraceptive insurance coverage may also influence the number of women aged 15 to 19 having babies.

Key takeaways:

• A $1 increase in the minimum wage is associated with a 2 percent drop in the teen birth rate. That corresponds to approximately 5,000 fewer babies being born to teen moms in a year.
• Hispanic teens are most affected by a minimum wage increase. A $1 increase yields about 0.49 fewer births per 1,000 Hispanic teen girls, compared to 0.11 fewer births per 1,000 white, non-Hispanic teen girls.
• The birth rate for black, non-Hispanic teen girls does not appear to be impacted by a higher minimum wage. The birth rates of women aged 30 to 54 also appear to be unaffected.
• More generous welfare benefits are associated with a higher adolescent birth rate.
• Contraceptive insurance coverage is associated with lower teen birth rates.

Other resources:

• The Office of Adolescent Health, under the U.S. Department of Health & Human Services, provides a variety of reports on teen pregnancy and reproductive health.
• The U.S. Department of Labor offers state-by-state minimum wage data. In New Mexico, for example, the minimum wage is $7.50 while it’s $8.44 in New Jersey and $12.50 in the District of Columbia.
• A 2017 report from the U.S. Bureau of Labor Statistics finds that fewer teenagers are working summer jobs. In July 2016, 43.2 percent of teens ages 16 to 19 were working, down from 71.8 percent in July 1978.
• MIT’s Living Wage Calculator allows you to estimate the cost of living in a specific community, including how much you’d have to earn to support yourself and a family.
• The Fight for $15 movement — a push for higher wages and union rights — began with fast-food workers in New York City in 2012.

Related research:

• A 2017 study published in the Children and Youth Services Review, “Money Matters: Does the Minimum Wage Affect Child Maltreatment Rates?,” suggests that increasing the minimum wage leads to fewer reports of child abuse and neglect.
• Journalist’s Resource has compiled a collection of earlier research on the effects of raising hourly pay.

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The issue: Some academics, policy makers and advocates hypothesize that contraceptives and abortion are considered substitutes. The theory goes: In a society with widely available, inexpensive contraception, women will not have as many abortions. Conversely, if contraception such as birth control pills, IUDs and condoms are difficult to obtain, women will have more abortions. If such a relationship does exist, there could be major consequences for population policy and foreign aid programs targeting women’s health.

An academic study worth reading: “Population Policy: Abortion and Modern Contraception Are Substitutes,” published in Demography, July 2016.

Study summary: Grant Miller, director of the Stanford Center for International Development and an associate professor at the Stanford University School of Medicine, teamed up with Christine Valente, a lecturer in economics at the University of Bristol, to study whether women in Nepal use abortion and modern contraceptives interchangeably. For their research, they examined an unusual policy change adopted in Nepal in 2004. That year, abortion was legalized, but there was no significant change made to the supply of modern contraceptives.

To understand Nepalese women’s reproductive behavior, Miller and Valente studied data collected during four waves of the Nepalese Demographic and Health Surveys. The surveys were conducted in 1996 and 2001 – before the policy change – and then in 2006 and 2011 – after the change. The analysis involved a sample of 32,098 women.

Key findings of the study:

• Each new legal abortion provider in a woman’s district of residence was associated with a 2.6 percent decrease in the likelihood of using modern contraception.
• Each new legal abortion provider was associated with a 2.2 percent reduction in the odds of women undergoing sterilization. Centers have no effect on male sterilization, however.
• The decrease in contraception use was driven primarily by decreased usage of reversible birth control methods such as injections. To a smaller extent, there was a decrease in the use of condoms and birth control pills.
• The authors note that their estimates “provide evidence of true substitution between use of modern contraceptives and abortion.”

Helpful resources for reporters writing about this issue:

• The U.S. Centers for Disease Control and Prevention (CDC) tracks abortion and collects information about the characteristics of women who have obtained legal abortions since 1969.
• The CDC also tracks the number of women using contraceptives and the most commonly used contraceptives. It also offers reports on rates of unintended pregnancy.
• The Guttmacher Institute offers a variety of public reports and datasets related to reproductive health, including surveys of unmarried adults’ attitudes about contraception and surveys of abortion patients.
• The United Nations’ Population Division annually estimates and projects contraceptive prevalence among populations around the world.

Related research:

• A 2012 study from scholars at Washington University in St. Louis found a reduction in abortions and teen birth rates when women received free birth control as a part of the Contraceptive CHOICE Project.
• A 2015 study published in Health Affairs found that the federal Affordable Care Act reduced out-of-pocket costs for multiple types of birth control.
• A 2014 study by researchers from J.P. Morgan and Williams College found that early access to birth control can reduce the likelihood that a woman will live in poverty.

Keywords: birth control, family planning, fertility, abortion clinic, reproductive rights, pro-choice

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In the United States, the teen pregnancy rate is higher than in any other western industrialized country, according to the U.S. Centers for Disease Control and Prevention (CDC). At the same time, a growing number of American teens and young adults have been diagnosed with sexually transmitted diseases (STDs). While individuals aged 15 to 24 make up 27 percent of the U.S. population that is sexually active, the CDC estimates that they account for half of the 20 million new infections occurring annually.

Teen pregnancy and STDs have a range of health, social and financial consequences, which is why many policymakers support efforts to prevent them. Public money is often used to run programs aimed at educating young people about sexual health and the prevention of STDs and pregnancy. However, the design and function of these initiatives, which often are offered through public schools and after-school programs, can be controversial. In many parts of the country, community leaders have resisted following the CDC’s guidelines for sex education, at least partly because they recommend teaching adolescents how to get and use condoms. A December 2015 report indicates that fewer than half of U.S. high schools and one-fifth of middle schools provide sexual health education that meets CDC criteria.

Sex education programs, especially those that focus on abstinence-only education, have been heavily scrutinized in recent years. So has the trend of youth taking abstinence pledges, also known as purity pledges – a commitment to refrain from sexual intercourse until marriage. Over the past decade, a number of academic studies have examined the trend to gauge whether taking pledges has encouraged teens to delay sex and resulted in lower rates of pregnancy and STDs. A 2005 study by scholars at Yale and Columbia universities suggests that young adults who took abstinence pledges while they were in middle school or high school do end up delaying sex. But the vast majority of pledge-takers — 88 percent — have sexual intercourse before they get married. The study found that pledgers were just as likely to get STDs as those who never made a pledge of virginity.

An April 2016 study published in the Journal of Marriage and Family looks at abstinence pledges among girls and young women to determine whether those who take pledges are less likely to become pregnant outside of marriage or acquire STDs. For the study, “Broken Promises: Abstinence Pledging and Sexual and Reproductive Health,” a group of researchers analyzed data collected through Add Health, a nationally representative, longitudinal study of adolescents. The researchers, led by Anthony Paik of the University of Massachusetts–Amherst, focused on data collected during the first wave of the study in 1994 and 1995, when 20,745 students in grades 7 to 12 were asked about such things as their health, romantic relationships and whether they had taken abstinence pledges. Paik and his colleagues also focused on data collected in 2001 and 2002, when 15,197 of those individuals were re-interviewed as young adults. Female study participants were asked about pregnancies and a sample of them were tested for human papillomavirus (HPV), a common STD. The study’s authors examined the HPV test results of 3,254 women. Boys and men who had participated in the Add Health study were excluded from this analysis.

Among the findings of this 2016 study:

• As a whole, young women who did not take abstinence pledges and those who did but broke them were equally likely to acquire HPV. Approximately 27 percent of each group tested positive for HPV.
• Of the young women who had two or more sex partners, pledge breakers were more likely to have HPV. The difference was largest among women who had between six and 10 sex partners. One-third of women who had not taken a pledge and had six to 10 sex partners tested positive for HPV. Meanwhile, 51 percent of pledgers who had six to 10 sex partners acquired HPV.
• About 30 percent of pledgers and 18 percent of non-pledgers became pregnant within six years after they began having sexual intercourse outside of marriage.

This study highlights some of the unintended consequences of promoting abstinence-only programs. Girls and young women who take abstinence pledges may be less prepared to handle the risks of sexual activity because they “are more likely to receive cultural messages downplaying the effectiveness of condoms and contraceptives as well as to be exposed to the framing of premarital sexual activity as a form of failure,” the authors state. Sex education programs should help prepare young adults to manage their sexual and reproductive health once they become sexually active. According to the authors: “If adolescents either are provided inaccurate information about condom use or contraception or are socialized to be hostile to these practices, they could be in a bind when they break pledges, as almost all of them do.”

Related research: A 2014 study published in the Journal of Child and Family Studies, “Why Virginity Pledges Succeed or Fail: The Moderating Effect of Religious Commitment Versus Religious Participation,” considers how religiosity influences the decision to take an abstinence pledge and adhere to it. A 2015 paper published in the Archives of Sexual Behavior, “Changes in American Adults’ Sexual Behavior and Attitudes, 1972–2012,” examines trends in areas such as premarital sex and number of sexual partners.

Keywords: sex ed, STI, sexually transmitted infection, virginity pledge, True Love Waits, Silver Ring Thing, purity ring, Bristol Palin

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Under the federal Patient Protection and Affordable Care Act, private health plans must cover birth control methods that are approved by the Food and Drug Administration without charging out-of-pocket costs such as co-payments or deductibles. When contraceptives were added to the list of preventive-health services that had to be fully covered starting in August 2012, the change drew mixed reactions. Advocates praised the effort to make contraceptives more affordable and accessible for women while critics argued that it infringes on religious beliefs and could increase overall health-plan costs. The birth control mandate has prompted numerous lawsuits, including the Hobby Lobby case, which went before the Supreme Court in 2014 and resulted in the federal government allowing some businesses to claim religious objections and forgo birth-control coverage for employees.

While the mandate continues to be controversial, several recent studies show there are financial benefits for women, some of whom struggled in previous years to afford contraceptives. A 2015 study that focused on women with private health insurance found that the proportion of women who paid nothing out of pocket for birth control pills rose from 15% in 2012 — before the federal requirement took effect — to 67% in 2014 — after it was implemented. The trends were similar for women using injectable contraception, the vaginal ring and the intrauterine device. A 2014 study by the New Jersey-based IMS Institute for Healthcare Informatics found that the Affordable Care Act saved women approximately $483 million in out-of-pocket spending for contraceptives in 2013.

A July 2015 study published in Health Affairs, “Women Saw Large Decrease In Out-Of-Pocket Spending For Contraceptives After ACA Mandate Removed Cost Sharing,” takes another look at the policy’s impact on birth control expenses. The authors, Nora V. Becker and Daniel Polsky of the University of Pennsylvania’s Wharton School, used a sample of nationally-representative data from the claims database of a large national insurer to calculate monthly, out-of-pocket spending between January 2008 and June 2013 for eight types of contraception.

Findings include:

• Out-of-pocket spending declined for the two most commonly used, reversible forms of prescription birth control — the pill and the intrauterine device (IUD). The average, adjusted cost for a six-month pill prescription fell from $33.58 in June 2012 to $19.84 in June 2013. The out-of-pocket expense for an IUD fell from $293.28 to $145.24 over the same time period.
• A woman using the pill saved an average of $254.91 per year after the federal mandate took effect.
• There were large reductions in out-of-pocket spending for most of the other contraceptive methods investigated in this study. For example, the six-month, unadjusted average cost for emergency contraception was $26.16 between January and June 2012. It fell to $1.75 — a 93% reduction — between January and June 2013.
• Out-of-pocket spending for the contraceptive ring and patch, however, barely changed. The six-month, unadjusted average cost for the ring was $52.63 between January and June 2012 and was $51.53 between January and June 2013.
• Before the federal mandate, a large percentage of women’s healthcare costs went toward birth control. Out-of-pocket expenses for contraceptives for women using them had comprised 30% to 44% of these women’s total out-of-pocket health care expenses.
• There are an estimated 6.88 million privately-insured users of birth control pills in the United States. Under the Affordable Care Act, these women save approximately $1.4 billion per year in out-of-pocket savings on birth control pills alone.

This study indicates that while the Affordable Care Act likely will reduce out-of-pocket expenses for birth control in general, it is too early to predict whether more women will use birth control — a trend that the authors state could lower fertility rates and improve economic opportunities for women and their families. The authors suggest that it is possible that lowered costs might encourage more women to choose long-acting, reversible forms of birth control such as IUDs, which historically have been much more expensive. The authors also predict that the new federal guidelines for complying with the birth control mandate that were issued in May 2015 should benefit users of contraceptive rings and patches. “With this new clarification from the administration of President Barack Obama, we expect that the pattern of out-of-pocket expenses for the patch and the ring among the population we studied will soon resemble that of other methods,” the authors stated.

Related research: A 2014 study published in the Journal of Policy Analysis and Management, “The Effects of Contraception on Female Poverty,” examines the relationship between legal access to birth control and poverty rates among women and households headed by single women. A 2013 working paper for the National Bureau of Economic Research explores the relationship between family planning and long-term economic outcomes such as labor force participation and family income. A 2012 study published in Obstetrics & Gynecology, “Preventing Unintended Pregnancies by Providing No-Cost Contraception,” analyzes the relationship between free access to birth control and abortion rates.

Keywords: reproductive rights, IUD, abortion, unplanned pregnancy, birth control, Obamacare

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On June 30, 2014, the U.S. Supreme Court ruled that employers with “sincerely held” religious views could exempt themselves from the Affordable Care Act’s requirement that health insurance plans cover contraception. While the ACA itself survived a constitutional challenge in 2012, the latest decision has implications that extend far beyond the healthcare debate. The Court’s four dissenting judges expressed concern at the “startling breadth” of the decision, which they said paved the way for companies to “opt out of any law (saving only tax laws) they judge incompatible with their sincerely held religious beliefs.”

The ruling also reignited the debate about women’s health and reproductive rights that has continued since the Roe v. Wade ruling 40 years ago, and raised a series of questions. Research has found that providing no-cost contraception can have a range of positive effects, including reducing the number of unplanned pregnancies and their associated costs — up to $12.6 billion a year, according to a 2011 Brookings Institution study. A 2012 study from Washington University in St. Louis found that if no-cost contraception were made available throughout the United States, it could lower abortion rates by up to 78%.

In addition to the medical and financial impacts of no-cost contraception, research has shown that when mothers have access, their children’s incomes and education levels rise. Access also has been shown to improve women’s employment and wage rates in the decades after its introduction.

Given that poverty rates are higher for women and girls in every age group, it’s important to understand if improved access to contraception could improve the prospects of lower-income women. A 2014 study published in the Journal of Policy Analysis and Management, “The Effects of Contraception on Female Poverty,” uses Census data to examine the relationship between legal access to contraception and female poverty rates.

Although the FDA approved the first oral contraceptive in 1960, initially it was not legally available to unmarried women under the age of 21. Various states progressively reduced the age at which single women had access the 1960s and 1970s, and by 1975, all women had legal access at age 18. The study’s authors — Stephanie P. Browne of J.P. Morgan and Sara LaLumia of Williams College — use the differences in timing to construct a quasi-experiment, allowing them to better understand the link between access to contraception and the chances of a woman being in poverty.

The findings include:

• Early legal access (ELA) to birth control (by age 20) is associated with a reduction in the probability that a woman is in poverty by 1 percentage point, both as a direct consequence of access to birth control and through other channels that access to birth control might influence such as continuing education, or gaining greater work experience before starting a family.
• Even after controlling for many of the channels through which birth control access has been shown to positively affect women, such as educational attainment, the authors estimate that birth control access reduces the probability that a woman is in poverty by 0.5 percentage points.
• ELA reduced the likelihood of a woman’s being in deep poverty (defined as below 50% of the poverty line) as much as 0.8 percentage points.
• Because the average poverty rate for nonelderly adult women over the study period ranged from 10% to 15%, the effect of ELA on female poverty is about the same as reducing the state unemployment rate by 1% or increasing maximum welfare payments (under the old Aid to Families with Dependent Children program) by $100.
• Having access to the pill reduces the chance of becoming a young mother (under 21) by 0.4 percentage point. This underscores that preventing unplanned pregnancies, especially teenage pregnancies, is the primary channel through which oral contraceptives could work to reduce poverty among women.
• The effect of early legal access to contraception differs with age, and is greatest for women in their 20s, reducing their chances of poverty by 0.7 to 1 percentage points. Women in this age group are more likely to have left home and will have had time to realize the benefits that delayed parenthood can bring, including extended education or improved occupational choices.
• An association was observed between access to contraception and the likelihood of divorce: For women 30 to 44, ELA was associated with a 0.7 percentage point reduction in the likelihood of being divorced. (Research in 2012 suggests that the reduction in unplanned pregnancies allowed partners to find a better match and thus reduced divorces.)

The authors conclude that, although the effect of early access to birth control “may seem small relative to the persistently high poverty rates experienced by single-female-headed households, it is the result of a very low-cost intervention.” In comparison, the government spends approximately $12 billion on welfare payments through Temporary Aid to Needy Families (TANF), $49 billion on the Earned Income Tax Credit (EITC) and $30 billion on food stamps. The authors therefore recommend that “going forward, when policymakers are weighing the costs and benefits of increasing or decreasing the accessibility of birth control, they should take into account its effects on female poverty rates.”

Related research: A 2012 study published in the New England Journal of Medicine, “Effectiveness of Long-Acting Reversible Contraception,” looked at the failure rates of long-lasting methods of birth control. It found that IUDs and implants were 10 to 16 times more effective than other long-term contraceptive options.

Keywords: poverty, women, contraception, reproductive rights, family

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The Patient Protection and Affordable Care Act — popularly referred to as Obamacare — opened for business on October 1, 2013, when the system’s health-care exchanges began enrolling members. Among the many changes under the ACA, employer-provided health plans must cover prescription contraception with no co-payment.

The provision was challenged in late September by members of the House Republican caucus, which proposed a “conscience clause” that would allow employers and insurers to opt out on medical care they objected to on “moral or religious” grounds. The effects of decreased access to birth control could be significant, however: A 2012 study from Washington University in St. Louis found that no-cost access to contraception would significantly reduce unplanned pregnancies, which cost U.S. taxpayers as much as $12.6 billion every year.

While the issue is divisive today, the federal funding of family-planning programs has bipartisan roots. President Johnson’s 1964 Economic Opportunity Act provided the first federal support for local family planning programs, and Title X of the Public Health Service Act was enacted in 1970 with the support of President Nixon. Medicaid, Title X and state sources now provide a total of $2.37 billion of funding for family planning services (as of FY 2010). Despite such funding, the cost of contraception and family-planning services remains problematic for many: A 2010 Planned Parenthood survey found that 33% of women voters have struggled with the cost of prescription birth control at some point in their lives.

A 2013 working paper for the National Bureau of Economic Research, “Fifty Years of Family Planning: New Evidence on the Long-Run Effects of Increasing Access to Contraception,” looks at the relationship between family planning access and long-term economic outcomes. The researcher, Martha Bailey of the University of Michigan, analyzed the impact of increases in legal and financial access to contraceptives for mothers on their children’s lifetime incomes and education levels.

“The empirical literature provides evidence consistent with causal links running from family planning to children’s adult outcomes,” the researcher states. On average, larger families dedicate less parental time and resources to children, who in turn tend to have higher rates of academic and health problems. Later in life, “children from poorer households are less likely to graduate from high school and to complete college, which limits their earnings potential.”

The study was based on two major changes in contraceptive access: The introduction of the Pill in 1957 and a 1965 Supreme Court decision that led to the repeal of state laws banning contraceptive sales (these laws were present in almost half of U.S. states at the time). To look at financial impacts, the researcher compares outcomes for children from counties with better or worse access to federally funded family planning programs during the 1960s and 1970s.

The key findings include:

• Access to the Pill was associated with a 7% decrease in unwanted or ill-timed births between 1958 and 1965. This was consistently observed across women of all education levels and races, with the greatest effect on women with middle levels of education (between 12 and 16 years).
• The availability of contraceptives to mothers is associated with higher lifetime incomes and education for their children: “Children born from 1958 to 1965 in states permitting contraceptive sales had roughly 1.5% higher family incomes” than would be expected otherwise. In addition, “the relative share of men with 16 or more years of education grows by around 1% to 2% for cohorts born from 1958 to 1969 in states permitting contraceptive sales.” No effect was observed for women’s education.
• The effect on underprivileged families is particularly great: “Both increasing legal access and increasing financial access to the Pill are associated with a 2% to 3% increase in family income over all adults in the affected cohorts. Scaling these estimates by a guess at the share of children benefiting from them implies much larger effects, perhaps around a 20 to 30 percent gain in family incomes for the children of directly benefiting families.”
• The long-term, societal-wide economic impacts of increased access and financial support for contraception are significant. A “conservative estimate” for the 1973 birth cohort suggests that approximately 9,300 more individuals completed college than would have otherwise, which “implies a cost of no more than $32,271 per individual induced to complete college…. It implies family planning may be much cheaper than many other interventions to increase educational attainment. Head Start, for example, costs around $133,333, and Upward Bound $93,667, per student induced to attend college.”

“Overall, the results suggest that family planning programs provide a cost-effective strategy for promoting opportunities and the longer-term prosperity envisioned by their early proponents,” the author states.

For more research on this topic, of interest is a 2012 paper by Martha J. Bailey, Zoë M. McLaren, and Olga Malkova, “The Long-Term Effects of U.S. Family Planning Programs on Child Poverty.” In addition, a 2012 study for the National Bureau of Economic Research, “The Opt-In Revolution? Contraception and the Gender Gap in Wages,” examines how access to the Pill may have affected women’s wages over time and narrowed the gender wage gap in the 1980s and early 1990s. Finally, another 2012 NBER paper, “Why Is the Teen Birth Rate in the United States so High and Why Does It Matter?” looks at the issue of teen births using data from five sources, including the Vital Statistics survey and the National Surveys of Family Growth.

Keywords: family, parenting, sexuality,

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This year marked the 40th anniversary of Roe v. Wade, the landmark Supreme Court decision upholding a woman’s right to an abortion. While some — including President Obama — celebrated the ruling and pledged to defend it, a number of state legislatures continue to work to limit access to abortions. In June, Texas state senator Wendy Davis filibustered a bill that would have made abortions illegal after 20 weeks of pregnancy.

In addition to trying to make obtaining abortions increasingly difficult, some of these same states are also trying to limit access to birth control, especially for teenagers. Beyond the inevitable rise in unintended pregnancies that can result, such laws have also been shown to increase states’ financial burdens: A reseach project at the University of Texas at Austin found that cuts to the state’s family-planning clinics ended up costing the state $163 million it would have saved by preventing 30,000 unintended pregnancies.

Research has shown that unintended pregnancies in the United States cost taxpapers as much as $12.6 billion every year. A 2011 study in Perspectives on Sexual and Reproductive Health found that states’ unintended-pregnancy rates vary considerably: In Mississippi there are 69 for every 1,000 women, more than twice New Hampshire’s rate, 36 per 1,000 women; the median U.S. rate is 51 per 1,000 women. On average, 53% of all pregnancies in the United States are unintended, the study shows.

As part of the Affordable Care Act, which comes more fully into force in 2014, the White House moved ahead with a ruling that requires that most U.S. companies provide free insurance coverage for contraception for employees. The ruling came despite protests from religious organizations, and mandates coverage for a broad range of women’s health services, including FDA-approved birth control. (This has led to speculation that this issue may be taken to the Supreme Court.)

A 2012 study from Washington University in St. Louis published in Obstetrics & Gynecology, “Preventing Unintended Pregnancies by Providing No-Cost Contraception,” analyzes the relationship between free access to effective birth control and abortion rates. The researchers, Jeffrey F. Peipert, Tessa Madden, Jenifer E. Allsworth and Gina M. Secura, based their work on data from the Contraceptive CHOICE Project. The St. Louis initiative provided no-cost contraception for two to three years to 9,256 women at risk for unintended pregnancy. Using data from the Missouri Department of Health and Senior Services, as well as Planned Parenthood, the researchers were able to compare the rate of teen births and the percentage of repeat abortions — proxies for unintended pregnancies — of those in the CHOICE group with rates in the remaining metropolitan area and across the United States.

Key findings from the study include:

• Participants in the CHOICE program showed a significant reduction in abortion rates, repeat abortions, and teenage birth rates: The birth rate among participants aged 15 to 19 years was 6.3 per 1,000 compared with the national rate of 34.3. This represents an 82% reduction.
• Between 2008 and 2010, abortion rates for study participants ranged from 4.4 to 7.5 per 1,000 women, compared with regional rates between 13.4 and 17 and the national rate of 19.6.
• Intrauterine devices (IUDs) and contraceptive implants — often referred to as long-acting reversible contraceptive (LARC) methods — are not as highly used in the United States compared with other developed countries, where unintended pregnancy rates are lower. Related research shows that such long-lasting methods are much more effective than birth-control pills and other options.
• If no-cost contraception) were made available to the entire population of the sample region, the researchers estimate one abortion could be avoided for every 79 to 137 women and teenagers. Nationally, they estimate it could prevent as many as 62% to 78% of abortions performed annually.

The researchers of this study note that the Contraceptive CHOICE Project provided participants with free access to all FDA-approved contraceptive methods, simulating the results in their region of the birth control mandate of the ACA coming into effect. The authors ultimately conclude that based on their findings, “unintended pregnancies could be reduced by providing no-cost contraception and promoting effective, underused contraceptive methods.”

Additional data on family-planning services provided by the U.S. government under Title X of the Public Health Services act are available from the U.S. Department of Health and Human Services’ Office of Population Affairs.

A related 2012 study, “Effectiveness of Long-acting Reversible Contraception,” examines a range of contraception methods and finds that the failure rates for birth-control pills, patch or ring over the first three years were were 4.8%, 7.8%, and 9.4%, respectively. By comparison, the failure rates over the first three years for IUDs or implants were 0.3%, 0.6%, and 0.9%. “IUDs and implants were thus 10 to 16 times as effective as the other long-term contraceptive options,” the researchers conclude.

Keywords: reproductive rights, parenting, family

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