Analysis Health Systems

What Dr. Hathaway Told Mr. Pitts: Contraception is Necessary Preventive Care

Dr. Mark Hathaway

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.

See all our coverage of the November 2011 Mandate Hearing here.

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.[1]

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.[2] 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.[3]

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.

Thank you.

Works Cited:

[1] Ruth Lesnewski and Linda Prine, “Initiative Hormonal Contraceptive,” American Family Physician, Vol 1 No 74, July 2006. pp 105-112.

[2] 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.

[3] Washington University in St. Louis, School of Medicine, Department of Obstetrics and Gynecology,“Preliminary Study & Findings,” The Contraceptive Choice Project, September 2011.

News Politics

Clinton Campaign Announces Tim Kaine as Pick for Vice President

Ally Boguhn

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

The Clinton campaign announced Friday that Sen. Tim Kaine (R-VA) has been selected to join Hillary Clinton’s ticket as her vice presidential candidate.

“I’m thrilled to announce my running mate, @TimKaine, a man who’s devoted his life to fighting for others,” said Clinton in a tweet.

“.@TimKaine is a relentless optimist who believes no problem is unsolvable if you put in the work to solve it,” she added.

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

Kaine signed two letters this week calling for the regulations on banks to be eased, according to a Wednesday report published by the Huffington Post, thereby ”setting himself up as a figure willing to do battle with the progressive wing of the party.”

Charles Chamberlain, executive director of the progressive political action committee Democracy for America, told the New York Times that Kaine’s selection “could be disastrous for our efforts to defeat Donald Trump in the fall” given the senator’s apparent support of the Trans-Pacific Partnership (TPP). Just before Clinton’s campaign made the official announcement that Kaine had been selected, the senator praised the TPP during an interview with the Intercept, though he signaled he had ultimately not decided how he would vote on the matter.

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Kaine’s record on reproductive rights has also generated controversy as news began to circulate that he was being considered to join Clinton’s ticket. Though Kaine recently argued in favor of providing Planned Parenthood with access to funding to fight the Zika virus and signed on as a co-sponsor of the Women’s Health Protection Act—which would prohibit states and the federal government from enacting restrictions on abortion that aren’t applied to comparable medical services—he has also been vocal about his personal opposition to abortion.

In a June interview on NBC’s Meet the Press, Kaine told host Chuck Todd he was “personally” opposed to abortion. He went on, however, to affirm that he still believed “not just as a matter of politics, but even as a matter of morality, that matters about reproduction and intimacy and relationships and contraception are in the personal realm. They’re moral decisions for individuals to make for themselves. And the last thing we need is government intruding into those personal decisions.”

As Rewire has previously reported, though Kaine may have a 100 percent rating for his time in the Senate from Planned Parenthood Action Fund, the campaign website for his 2005 run for governor of Virginia promised he would “work in good faith to reduce abortions” by enforcing Virginia’s “restrictions on abortion and passing an enforceable ban on partial birth abortion that protects the life and health of the mother.”

As governor, Kaine did support some existing restrictions on abortion, including Virginia’s parental consent law and a so-called informed consent law. He also signed a 2009 measure that created “Choose Life” license plates in the state, and gave a percentage of the proceeds to a crisis pregnancy network.

Regardless of Clinton’s vice president pick, the “center of gravity in the Democratic Party has shifted in a bold, populist, progressive direction,” said Stephanie Taylor, co-founder of the Progressive Change Campaign Committee, in an emailed statement. “It’s now more important than ever that Hillary Clinton run an aggressive campaign on core economic ideas like expanding Social Security, debt-free college, Wall Street reform, and yes, stopping the TPP. It’s the best way to unite the Democratic Party, and stop Republicans from winning over swing voters on bread-and-butter issues.”

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.