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The following is the text of testimony given on November 2, 2011 by Dr. Mark Hathaway to the House Energy and Commerce Committee Hearing on conscience clauses and contraceptive coverage under health reform.
My name is Dr. Mark Hathaway and I am a board certified OB/Gyn. I am the director of OB/Gyn outreach services for Women’s and Infants’ Services at Washington Hospital Center. I am also the Title X Medical Director at Unity Health Care Inc., Washington D.C.’s largest federally-qualified health center system and the Title X grantee for the District.
I work in several medical facilities here in Washington, D.C. My patients tend to be women of color, primarily African American and Latina, and of lower socioeconomic status. Many of the patients I see are uninsured or underinsured and seeking family planning services. Despite their obstacles, they desire to improve their lives, and to have and raise healthy children.
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I see every day how increasing women’s ability to plan their pregnancies makes a difference in their lives. And by the same token, I also see the negative consequences of unintended and unplanned pregnancy, late prenatal care, uncontrolled medical problems, poor nutrition, and sometimes depression. I see firsthand how cost can be a barrier when it comes to utilizing preventive care in general and using contraceptive services in particular.
That is why the IOM’s recommendation is so critically important. Contraceptive counseling and methods should be covered under the Affordable Care Act without cost-sharing. Any attempts to broaden exemptions to that coverage requirement would mean leaving in place insurmountable obstacles to contraceptive services for far too many women.
Cost is a barrier
I know from my day-to-day experiences what it means for patients who cannot afford to pay for their health services. The cost of a birth control method is frequently prohibitive for many of my patients. This is especially true for the more effective long-acting reversible contraceptive methods, aka LARC or “forgettable methods.” Women face many challenges in using contraception successfully. Too many women using methods like birth control pills, condoms and even injectables will experience an unplanned pregnancy during the first year of “typical use.” Indeed up to 50 percent of pill users will discontinue that method within the year, significantly increasing their chances of an unintended pregnancy.
Long-acting reversible methods, including intrauterine contraceptives and implants, are the most cost-effective methods because they have an extremely low failure rate and are effective at preventing pregnancy for several years. However, the up-front costs of these methods can costs several hundred dollars, placing them out of the reach of millions of women who would otherwise use them.
Three recent studies have found that lack of insurance is significantly associated with reduced use of prescription contraceptives. And several other studies have shown that when out-of-pocket costs are eliminated, women’s use of long-acting methods increases substantially. In St. Louis, researchers at Washington University have found that over 70 percent of women will choose a longer acting method if cost and barriers are eliminated.
Preventing unintended pregnancy is critical preventive health care.
There are those who assert that unintended pregnancy is not a health condition and therefore prevention of unintended pregnancy is not preventive health care. From my personal practice I can say that I cannot disagree more.
Just last week I met “Sarah.” She’s 22, has two children under the age of three, one a newborn, and came in for a pregnancy test. Her diabetes had gone unchecked which would put her in a medically high-risk category for pregnancy. She was visibly shaking waiting for her pregnancy test results. She’s working over 40 hours a week at 2 jobs, and was told by her primary clinic that she would need to pay a copay of $40 and a $300 fee for the intrauterine device that she so desperately wants and needs. She would have been devastated by a positive pregnancy test.
She was incredibly relieved to learn she was not pregnant. Unfortunately she is uninsured but we used our rapidly shrinking safety-net resources to provide her with long acting contraception.
The evidence is also conclusive regarding pregnancy spacing. It is directly linked to improved maternal and child health, and to reduced infant mortality and maternal mortality rates. Numerous studies in the United States and internationally have found a direct causal relationship between birth intervals and low birth weight as well as preterm births. A 2008 literature review also shows that throughout the U.S. and Europe, there is an association between pregnancy intention and delayed initiation of prenatal care as well as reduced breastfeeding after a child is born. In other words, we need to help women plan their pregnancies for their health as well as their children’s.
Birth control is the most effective way to prevent unintended pregnancy
Using contraception is the most effective way to prevent unintended pregnancy — and ultimately to reduce the need for abortion. Again, I have seen the success of contraceptive services in my own practice, and again the evidence on this is clear. According to a recent Guttmacher Institute study, the two-thirds of women at risk of unintended pregnancy who use contraception correctly and consistently account for only 5 percent of the 3 million unintended pregnancies that occur each year. Put another way, 95 percent of all unintended pregnancies occur among women who use contraception inconsistently or use no method at all. Indeed, couples who do not practice contraception have an 85 percent chance of experiencing an unintended pregnancy within the next year.
Importance of the IOM Recommendation/Coverage
For all these reasons, the Institute of Medicine women’s health recommendations are groundbreaking. Finally, all women will gain access to insurance coverage of family planning services regardless of income. All women will be able to get the counseling, education, and access to the most effective and medically-appropriate contraceptive for them. This breakthrough has the potential to bring about major benefits for the health and well-being of women and their families. This comes from giving women the information and services necessary to enable them to plan and space their pregnancies.
Most women will contracept for approximately three decades during their reproductive years.The adoption of the IOM’s recommendations holds so much promise for millions of women who currently lack basic resources like health insurance coverage.
All of my training and experience tells me that what we are striving for is healthy women. We are also working to ensure that if and when they are ready to have a child that they have a healthy pregnancy to increase the chances of a healthy child. The best way to achieve this is to help women and couples become as healthy as possible before pregnancy. This includes financial health, emotional health, and physical health. We should trust women and empower women to make the appropriate decisions for themselves. Therefore, I hope we can at least agree that guaranteeing contraceptive coverage and removing cost barriers to being able to utilize contraceptive services should be at the forefront of preventive care so that women can achieve their own goals.
 Ruth Lesnewski and Linda Prine, “Initiative Hormonal Contraceptive,” American Family Physician, Vol 1 No 74, July 2006. pp 105-112.
 KR Culwell and J. Feinglass, “Changes in prescription contraceptive use, 1995–2002: the effect of insurance status,” Obstetrics & Gynecology, 2007, 110(6):1371–1378. KR Culwell and J. Feinglass, “The association of health insurance with use of prescription contraceptives,” Perspectives on Sexual and Reproductive Health, 2007, 39(4): 226–230. J. Nearns, “Health insurance coverage and prescription contraceptive use among young women at risk for unintended pregnancy,” Contraception, 2009, 79(2):105–110.
 Washington University in St. Louis, School of Medicine, Department of Obstetrics and Gynecology,“Preliminary Study & Findings,” The Contraceptive Choice Project, September 2011.