Commentary

Reproductive Health: It Takes a Health Worker — and Saves Money and Lives

Laura Hoemeke

All of the contraceptive technologies and reproductive health interventions in the world will not make a difference if there are not skilled health workers to deliver them.

See all our coverage of the 2012 Global Family Planning Summit here.

During last year’s International Conference on Family Planning, IntraHealth promoted health worker empowerment with the slogan “Family Planning: It Takes a Health Worker.” We had the phrase printed on posters and buttons, proudly displayed at our booth and on our lapels. We posited that all of the contraceptive technologies in the world will not make a difference if there are not skilled health workers to deliver them. Visitors to our booth, seeing our theme, sometimes laughed and said, “Well, technically it doesn’t take a health worker to put on a condom or promote abstinence.”

During the conference, I responded — and continue to assert — that it does take a health worker, or more accurately millions of health workers, to meet the need that hundreds of millions of couples worldwide have for family planning. It takes a health worker not only to administer most modern methods of contraception but also to provide counseling and services in a holistic way, and to offer reproductive and other health services throughout the life cycle of both women and men.

A new report issued by the Guttmacher Institute and UNFPA this week, Adding It Up: Costs and Benefits of Contraceptive Services—Estimates for 2012, supports that notion. Guttmacher and UNFPA released the report in preparation for next month’s Family Planning Summit to be held on July 11 in London with the support of the Government of the United Kingdom and the Bill & Melinda Gates Foundation. The summit aims to mobilize new partners and more resources to address family planning needs, especially in the developing world. Labor — or salaries of health workers — currently accounts for an estimated $0.7 billion of the $4 billion spent on family planning in developing countries in 2012, but we need to invest more, globally, to ensure that health workers are there to expand access and offer services. At IntraHealth, we truly hope that the summit also will focus on the need for health workers — not only in numbers but also in training, deployment, and ongoing support.

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Modern Contraceptive Methods and Health Workers

There has undoubtedly been increased international attention to family planning over the past several years, as illustrated during the International Conference on Family Planning in Kampala, Uganda, in 2009 and during the second international conference in Dakar, Senegal, in 2011. (I had the opportunity to attend and blog about both the Kampala and the Dakar conferences.) Despite this attention, however, the report documents that the annual increase in modern contraceptive users between 2008 and 2012 was significantly lower than between 2003 and 2008 — 10 million versus 20 million per year.

The Guttmacher Institute and UNFPA report outlines the grim ramifications of the unmet need for family planning. In 2012, an estimated 291,000 women in developing countries will die from pregnancy-related causes; more than one-third of these women will not have wanted to become pregnant. And approximately one-third of newborn deaths and one-fourth of later infant deaths are associated with unintended pregnancies. 

The report highlights, too, the incredible benefits and potential of family planning. If all women, and all couples, worldwide could use the contraceptive methods that they want and need, unintended pregnancies would decline by two-thirds: from 80 million to 26 million. There would be 26 million fewer abortions. There would be 21 million fewer unplanned births, and 7 million fewer miscarriages. Pregnancy-related deaths would drop by 79,000. And, amazingly, there would be 1.1 million fewer infant deaths.

According to the report, 645 million women of reproductive age (15–49 years) in the developing world are now using modern contraceptive methods, up from 603 million in 2008. However, population growth accounts for about half of the increase. The overall proportion of married women using a modern method — 92 percent of all modern method users — plateaued between 2008 and 2012, at just over 50 percent. However, there were significant regional variations, with substantial increases in Eastern Africa (from 20 percent to 27 percent) and Southeast Asia (from 50 percent to 56 percent), and stagnation — or even declines—in countries in Western Africa and Central Africa, where fewer than 10 percent of married women use modern contraceptives.

To meet the global unmet need for family planning, the report calls for the “training of health workers and others involved in provision of these services” as well as improved access to high-quality services.  This includes not only training health workers to administer contraceptives but also to offer counseling and follow-up support and to recognize clients’ rights. Offering client-friendly services means that health workers have to be skilled to respect confidentiality and provide family planning services — to adolescents and unmarried individuals, too — with a nonjudgmental attitude. Tracking health workers is important, too. The report also calls for systematic data collection of indicators, including numbers of health workers and the training they receive.

Saving Lives Saves Money—and It Does Take a Health Worker

Meeting the unmet need would not only save lives: it would save money, too. Given the current global economic environment, cost-effective solutions are essential. The current level of contraceptive care in the developing world costs about $4 billion annually but saves $5.6 billion in maternal and newborn health service costs. Fully meeting all need for modern contraceptive methods would cost $8.1 billion per year but would save a total of $11.3 billion. For every dollar spent, $1.40 would be saved. Is there another cause or investment opportunity out there that provides more bang for the buck?

At IntraHealth, we know that it takes a health worker not only to offer family planning counseling and services but also to support individuals, families, and communities. While it is true that family planning can happen without health workers, one thing is sure: family planning is not happening nearly enough without them.

Commentary Contraception

Hillary Clinton Played a Critical Role in Making Emergency Contraception More Accessible

Susan Wood

Today, women are able to access emergency contraception, a safe, second-chance option for preventing unintended pregnancy in a timely manner without a prescription. Clinton helped make this happen, and I can tell the story from having watched it unfold.

In the midst of election-year talk and debates about political controversies, we often forget examples of candidates’ past leadership. But we must not overlook the ways in which Hillary Clinton demonstrated her commitment to women’s health before she became the Democratic presidential nominee. In early 2008, I wrote the following article for Rewirewhich has been lightly edited—from my perspective as a former official at the U.S. Food and Drug Administration (FDA) about the critical role that Clinton, then a senator, had played in making the emergency contraception method Plan B available over the counter. She demanded that reproductive health benefits and the best available science drive decisions at the FDA, not politics. She challenged the Bush administration and pushed the Democratic-controlled Senate to protect the FDA’s decision making from political interference in order to help women get access to EC.

Since that time, Plan B and other emergency contraception pills have become fully over the counter with no age or ID requirements. Despite all the controversy, women at risk of unintended pregnancy finally can get timely access to another method of contraception if they need it—such as in cases of condom failure or sexual assault. By 2010, according to National Center for Health Statistics data, 11 percent of all sexually experienced women ages 15 to 44 had ever used EC, compared with only 4 percent in 2002. Indeed, nearly one-quarter of all women ages 20 to 24 had used emergency contraception by 2010.

As I stated in 2008, “All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.”

Now, there are new emergency contraceptive pills (Ella) available by prescription, women have access to insurance coverage of contraception without cost-sharing, and there is progress in making some regular contraceptive pills available over the counter, without prescription. Yet extreme calls for defunding Planned Parenthood, the costs and lack of coverage of over-the-counter EC, and refusals by some pharmacies to stock emergency contraception clearly demonstrate that politicization of science and limits to our access to contraception remain a serious problem.

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Today, women are able to access emergency contraception, a safe, second chance option for preventing unintended pregnancy in a timely manner without a prescription. Sen. Hillary Clinton (D-NY) helped make this happen, and I can tell the story from having watched it unfold.

Although stories about reproductive health and politicization of science have made headlines recently, stories of how these problems are solved are less often told. On August 31, 2005 I resigned my position as assistant commissioner for women’s health at the Food and Drug Administration (FDA) because the agency was not allowed to make its decisions based on the science or in the best interests of the public’s health. While my resignation was widely covered by the media, it would have been a hollow gesture were there not leaders in Congress who stepped in and demanded more accountability from the FDA.

I have been working to improve health care for women and families in the United States for nearly 20 years. In 2000, I became the director of women’s health for the FDA. I was rather quietly doing my job when the debate began in 2003 over whether or not emergency contraception should be provided over the counter (OTC). As a scientist, I knew the facts showed that this medication, which can be used after a rape or other emergency situations, prevents an unwanted pregnancy. It does not cause an abortion, but can help prevent the need for one. But it only works if used within 72 hours, and sooner is even better. Since it is completely safe, and many women find it impossible to get a doctor’s appointment within two to three days, making emergency contraception available to women without a prescription was simply the right thing to do. As an FDA employee, I knew it should have been a routine approval within the agency.

Plan B emergency contraception is just like birth control pills—it is not the “abortion pill,” RU-486, and most people in the United States don’t think access to safe and effective contraception is controversial. Sadly, in Congress and in the White House, there are many people who do oppose birth control. And although this may surprise you, this false “controversy” not only has affected emergency contraception, but also caused the recent dramatic increase in the cost of birth control pills on college campuses, and limited family planning services across the country.  The reality is that having more options for contraception helps each of us make our own decisions in planning our families and preventing unwanted pregnancies. This is something we can all agree on.

Meanwhile, inside the walls of the FDA in 2003 and 2004, the Bush administration continued to throw roadblocks at efforts to approve emergency contraception over the counter. When this struggle became public, I was struck by the leadership that Hillary Clinton displayed. She used the tools of a U.S. senator and fought ardently to preserve the FDA’s independent scientific decision-making authority. Many other senators and congressmen agreed, but she was the one who took the lead, saying she simply wanted the FDA to be able to make decisions based on its public health mission and on the medical evidence.

When it became clear that FDA scientists would continue to be overruled for non-scientific reasons, I resigned in protest in late 2005. I was interviewed by news media for months and traveled around the country hoping that many would stand up and demand that FDA do its job properly. But, although it can help, all the media in the world can’t make Congress or a president do the right thing.

Sen. Clinton made the difference. The FDA suddenly announced it would approve emergency contraception for use without a prescription for women ages 18 and older—one day before FDA officials were to face a determined Sen. Clinton and her colleague Sen. Murray (D-WA) at a Senate hearing in 2006. No one was more surprised than I was. All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.

Sometimes these success stories get lost in the “horse-race stories” about political campaigns and the exposes of taxpayer-funded bridges to nowhere, and who said what to whom. This story of emergency contraception at the FDA is just one story of many. Sen. Clinton saw a problem that affected people’s lives. She then stood up to the challenge and worked to solve it.

The challenges we face in health care, our economy, global climate change, and issues of war and peace, need to be tackled with experience, skills and the commitment to using the best available science and evidence to make the best possible policy.  This will benefit us all.

Culture & Conversation Family

‘Abortion and Parenting Needs Can Coexist’: A Q&A With Parker Dockray

Carole Joffe

"Why should someone have to go to one place for abortion care or funding, and to another place—one that is often anti-abortion—to get diapers and parenting resources? Why can’t they find that support all in one place?"

In May 2015, the longstanding and well-regarded pregnancy support talkline Backline launched a new venture. The Oakland-based organization opened All-Options Pregnancy Resource Center, a Bloomington, Indiana, drop-in center that offers adoption information, abortion referrals, and parenting support. Its mission: to break down silos and show that it is possible to support all options and all families under one roof—even in red-state Indiana, where Republican vice presidential candidate Gov. Mike Pence signed one of the country’s most restrictive anti-abortion laws.

To be sure, All-Options is hardly the first organization to point out the overlap between women terminating pregnancies and those continuing them. For years, the reproductive justice movement has insisted that the defense of abortion must be linked to a larger human rights framework that assures that all women have the right to have children and supportive conditions in which to parent them. More than 20 years ago, Rachel Atkins, then the director of the Vermont Women’s Center, famously described for a New York Times reporter the women in the center’s waiting room: “The country really suffers from thinking that there are two different kinds of women—women who have abortions and women who have babies. They’re the same women at different times.”

While this concept of linking the needs of all pregnant women—not just those seeking an abortion—is not new, there are actually remarkably few agencies that have put this insight into practice. So, more than a year after All-Options’ opening, Rewire checked in with Backline Executive Director Parker Dockray about the All-Options philosophy, the center’s local impact, and what others might consider if they are interested in creating similar programs.

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Rewire: What led you and Shelly Dodson (All-Options’ on-site director and an Indiana native) to create this organization?

PD: In both politics and practice, abortion is so often isolated and separated from other reproductive experiences. It’s incredibly hard to find organizations that provide parenting or pregnancy loss support, for example, and are also comfortable and competent in supporting people around abortion.

On the flip side, many abortion or family planning organizations don’t provide much support for women who want to continue a pregnancy or parents who are struggling to make ends meet. And yet we know that 60 percent of women having an abortion already have at least one child; in our daily lives, these issues are fundamentally connected. So why should someone have to go to one place for abortion care or funding, and to another place—one that is often anti-abortion—to get diapers and parenting resources? Why can’t they find that support all in one place? That’s what All-Options is about.

We see the All-Options model as a game-changer not only for clients, but also for volunteers and community supporters. All-Options allows us to transcend the stale pro-choice/pro-life debate and invites people to be curious and compassionate about how abortion and parenting needs can coexist .… Our hope is that All-Options can be a catalyst for reproductive justice and help to build a movement that truly supports people in all their options and experiences.

Rewire: What has been the experience of your first year of operations?

PD: We’ve been blown away with the response from clients, volunteers, donors, and partner organizations …. In the past year, we’ve seen close to 600 people for 2,400 total visits. Most people initially come to All-Options—and keep coming back—for diapers and other parenting support. But we’ve also provided hundreds of free pregnancy tests, thousands of condoms, and more than $20,000 in abortion funding.

Our Hoosier Abortion Fund is the only community-based, statewide fund in Indiana and the first to join the National Network of Abortion Funds. So far, we’ve been able to support 60 people in accessing abortion care in Indiana or neighboring states by contributing to their medical care or transportation expenses.

Rewire: Explain some more about the centrality of diaper giveaways in your program.

PD: Diaper need is one of the most prevalent yet invisible forms of poverty. Even though we knew that in theory, seeing so many families who are struggling to provide adequate diapers for their children has been heartbreaking. Many people are surprised to learn that federal programs like [the Special Supplemental Nutrition Program for Women, Infants, and Children or WIC] and food stamps can’t be used to pay for diapers. And most places that distribute diapers, including crisis pregnancy centers (CPCs), only give out five to ten diapers per week.

All-Options follows the recommendation of the National Diaper Bank Network in giving families a full pack of diapers each week. We’ve given out more than 4,000 packs (150,000 diapers) this year—and we still have 80 families on our waiting list! Trying to address this overwhelming need in a sustainable way is one of our biggest challenges.

Rewire: What kind of reception has All-Options had in the community? Have there been negative encounters with anti-choice groups?

PD: Diapers and abortion funding are the two pillars of our work. But diapers have been a critical entry point for us. We’ve gotten support and donations from local restaurants, elected officials, and sororities at Indiana University. We’ve been covered in the local press. Even the local CPC refers people to us for diapers! So it’s been an important way to build trust and visibility in the community because we are meeting a concrete need for local families.

While All-Options hasn’t necessarily become allies with places that are actively anti-abortion, we do get lots of referrals from places I might describe as “abortion-agnostic”—food banks, domestic violence agencies, or homeless shelters that do not have a position on abortion per se, but they want their clients to get nonjudgmental support for all their options and needs.

As we gain visibility and expand to new places, we know we may see more opposition. A few of our clients have expressed disapproval about our support of abortion, but more often they are surprised and curious. It’s just so unusual to find a place that offers you free diapers, baby clothes, condoms, and abortion referrals.

Rewire: What advice would you give to others who are interested in opening such an “all-options” venture in a conservative state?

PD: We are in a planning process right now to figure out how to best replicate and expand the centers starting in 2017. We know we want to open another center or two (or three), but a big part of our plan will be providing a toolkit and other resources to help people use the all-options approach.

The best advice we have is to start where you are. Who else is already doing this work locally, and how can you work together? If you are an abortion fund or clinic, how can you also support the parenting needs of the women you serve? Is there a diaper bank in your area that you could refer to or partner with? Could you give out new baby packages for people who are continuing a pregnancy or have a WIC eligibility worker on-site once a month? If you are involved with a childbirth or parenting organization, can you build a relationship with your local abortion fund?

How can you make it known that you are a safe space to discuss all options and experiences? How can you and your organization show up in your community for diaper need and abortion coverage and a living wage?

Help people connect the dots. That’s how we start to change the conversation and create support.

This interview has been edited for length and clarity.

CORRECTION: This article has been updated to clarify the spelling of Shelly Dodson’s name.

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