Making contraception easy and available: we are going in the wrong direction!

It is 2017. It is more than 100 years since Margaret Sanger advocated for contraception, and more than 50 years since the oral contraceptive pill became available. The last two generations of women – and men – have never known a world where there was no effective form of contraception. They probably do not recall when even condoms, although “over the counter” (in that no prescription was required) were stocked “behind the counter” and required requesting them from the pharmacist often with (if you were young) a disapproving glare, and maybe worse, a raft of questions.

The verbal and physical indignations and worse, including even murder committed on unmarried women who got pregnant and were unable, of course, to have access to abortion should be things of the past. They are, horrifically documented in Dan Barry’s New York Times piece “The Lost Children of Tuam”. The film “The Magdalene Sisters” shows the intolerable treatment of girls who may not have even gotten pregnant but were, perhaps, just a little too familiar with boys. Both the Magdalene laundries and the mother-baby home in Tuam were in Ireland, which was perhaps extreme in the poverty, ignorance, and fast ties to the Roman Catholic Church, but the treatment of women in England and the US were also inexcusably harsh. The British drama “Call the Midwife” tells the story of an unmarried teacher who gets pregnant in the early 1960s and is fired from her job (morally unfit to care for children!), tries to self-induce abortion with a coat hanger, and almost dies. Finally, post-hysterectomy so that she will never be able to have children, she is driven out of town. The most sympathetic characters in the show see it as sad, but none indicate it is horrific, immoral, and inhuman. And this was commonplace, even in the 1960s and beyond.

We should not, in 2017, even be discussing the availability of contraception, not to mention whether it works. Amazingly, we are. Teresa  Manning, appointed by President Trump in May to be the director of the Office of Population Affairs, the main family planning arm of the federal government, is not only a former employee of two anti-abortion groups, but has expressed skepticism of the effectiveness of contraception itself! Manning, a lawyer and not a health professional (although this is not an excuse), is completely wrong. The data is in. Contraception dramatically decreases unplanned pregnancy (regardless of marital status). Time recently ran an article accurately describing the science titled “No, birth control doesn’t make you have riskier sex”. That is the truth, but in fact, even if it is was associated with riskier sex for some people, that would be no reason to restrict access to it. The more contraception is available, the lower the rate of bad outcomes of virtually all kinds. It even, of course, reduces the rate of abortion; in fact, the only two things ever to have been shown to significantly reduce the rate of abortion are comprehensive and accurate sex education and easy and cheap availability of contraception. Indeed, the degree to which contraception is effective in decreasing the incidence of unplanned and undesired pregnancy is directly related to the ease of its availability, including financial availability. Unsurprisingly, reducing the cost of and increasing the ease of access to contraception has the greatest impact on teens and on the poor.

So it is amazing that, in what The Atlantic refers to as “one of its boldest moves yet” (I don’t think that they meant it was positive, but “cowardly”, as well as “stupid” and “reactionary” come to mind as better adjectives) has reversed the ACA’s requirements that employers and insurers provide contraception at no cost to women. Politically, it is part of the administration’s efforts to dismantle the ACA piece by piece, since they were unsuccessful in doing it as a whole. Morally, it is an imposition of a minority’s religious values on the rest of us, and is particularly ironic being spearheaded by Donald Trump. It will cause great harm to individual women (and men) and to the society as a whole. Arguments that the cost of contraception is “only” $50 a month may wash with those in the middle class and up, but for poor women and teens, $50 a month is a lot. The most effective methods of contraception, IUDs and implants (collectively referred to as LARC, long-acting reversible contraception) may have a lower amortized cost over the use period but a high upfront cost that is unaffordable, without subsidies, for many women. (The reason, lack of cash on hand, is the same one that leads many poor families, as described by Barbara Ehrenreich in her wonderful and depressing book “Nickel and Dimed”,  to live in expensive weekly motel rentals – the overall cost may be more than an apartment, but the upfront cost, including deposits, rent in advance, etc., is prohibitive for them.) The impact on the teens who will be denied free access is described movingly by a pediatrician in Vox.

The other important impact of such a policy would – and perhaps will -- be on the economy. This is articulately addressed in a column by Bryce Covert in the NY Times, October 29, 2017. The reasons start with individual women, and the cost of purchasing birth control, money which will not be available for them to spend on other goods – with more than 57 million women using contraception, in one year that is $1.3 billion. But the larger impact is societal – women who cannot control their own reproduction, who do not know when and if they will get pregnant – are in a poorer position to contribute to the workforce and to the economy. Again, going back to the history I address at the start of this piece, we know this empirically, not just theoretically:

… a raft of evidence has definitively found that when women gained greater access to the pill in the late 1960s and early ’70s, they were able to delay marriage and childbirth and invest in careers through education, job training and staying in paid work….Legal access to the pill transformed the economy in that era. It increased young women’s labor force participation by 7 percent….about a third of the increase in how many women attained careers in fields like law and business was due to birth control. Women with earlier access to the pill also made 8 percent more than their peers, and the pill was responsible for about a third of the decrease in the gender wage gap by 1990.

And it is still critical. Perhaps Trump himself is just cynically pandering to his base, and probably much of that base depends upon contraception, women directly but men just as much. Opposition to contraception cannot be justified except by the small minority of religious purists (and of course they are welcome to not use it); opposition to making contraception easily and freely available is almost as bad, as it is completely discriminatory. It is still, as Covert describes,

…still playing the economic role that it did in the 1970s. About half of women who use it say they do so to complete education or to get and keep a job. Contraception is still increasing the share of women who get educated and get paid work, particularly prestigious jobs.

Easy and affordable (affordable for all those who need to use it, not just billionaires or even the upper middle class!) is not a “women’s issue”, it is not a “special interest” issue. It is a core need for people. People with the views of Teresa Manning should not be given center stage, and certainly not given authority over contraception. We need to guarantee permanent access to contraception for all, and for accurate sex education. 

Now.

"Call the Midwife": If Britain could afford to create a National Health Service after WWII, we can now!

The main argument against not cutting (not to mention expanding) social services, including health care, for the most needy, is that we “cannot afford it”. This is the argument of the governors and legislatures in states that have refused to expand Medicaid, despite clear and convincing evidence that it will cost states much more to not do so (see Medicaid expansion will leave out many of the poorest: What is wrong with this picture?, May 26, 2013). This is portrayed in a very funny – except it’s really not -- “Daily Show” segment, cited by Dr. Allen Perkins in his blog, “Training Family Doctors”, Medicaid Expansion by the Numbers. Not being able to “afford” it is the mantra not only in the US, but also across Europe as those austerity hawks have been cutting off their people’s noses – and their election chances – in thrall to a false god.

So it was very interesting for me to watch the first episode of the British (BBC One) television series (now in its second season) “Call the Midwife”. Set in a poverty-stricken area of East London in 1957, midwives pedal their bicycles around the crowds of people and rubble that still covers the streets more than a decade after the end of World War II to attend to

pregnant women in their homes, delivering prenatal care and babies and even caring for the babies afterward. It is a not a beautiful scenario; the young midwife, Jenny Lee (based on the real life midwife Jennifer Worth, whose memoirs form the basis for the series and who died in 2011) has never seen such poverty, such crowding, such filth, so many children. It is the height of the “baby boom”, attributed initially to returning GIs who had to wait to start their families, but continuing with no end in sight; the women portrayed are having their fourth or fifth baby in their early 20s and many far more. In fact, of course, the end of this “boom” was not the aging out of the reproductive population but the introduction of effective and widely available contraception (especially birth control pills) in the 1960s.

The midwives, all nurses and many Anglican nuns, set up clinics in a gym in the interval between the pensioners’ breakfast and the evening dance classes, as well as attending women at home. They practice an obstetrics that is quaintly anachronistic, both in its tools (the wooden “fetoscope” to amplify the fetus’ heart sounds, and the glass rectal tube), and in practice (shaving the pubic area and administering enemas – “high, hot, and a helluva lot!”) but they provide much safer pregnancies and deliveries than had ever been available to this population in the past. At one point, a woman in her 23^rd (!!) pregnancy (already with 24 children, because of two sets of twins) goes into premature labor and the midwife is there to deliver what seems to be a stillbirth and begin care for the hemorrhaging mother while awaiting the arrival of the “obstetrics flying squad” with its ambulance, obstetrician, and pediatrician to continue to care, including blood transfusion in the home. When, miraculously, the baby comes to life, the mother refuses to send it to the hospital, feeding it milk with a dropper. The senior midwife tells Jenny that “we don’t ever care for these babies anymore; in the old days they died; now they go to the hospital.” When asked what they will do, she tells her they will visit three times a day until the baby is stable, and then at least once a day thereafter. In the home.

It is a dramatic and engaging story, but what fascinates me is that these services were available to these poor women. Home visits for prenatal care and delivery. Visits from nurses three times a day. An obstetrics “flying squad” to come to the homes of women who would otherwise die in childbirth. Where did the money for these services come from? Who paid these midwives, and these flying squad doctors? Well, the National Health Service (NHS). The NHS, established after the war, in 1948, to provide health care to all people in the UK. Not established at a time of prosperity, when we could “afford” it, but right after World War II, with both the nation’s economy and its literal infrastructure in shambles, with the piles of rubble still on the streets of London in 1957, 15 years after the Blitz. The National Health Service was not founded as a gesture of magnanimity from the wealthy, but as but as an explicit and well-thought out policy to provide one of the most basic of needs, health care, to all of the British people even though there was not much money; it was seen as a priority. In the second episode of "Call the Midwife", a woman who has lost 4 babies because of a pelvis contracted from rickets (vitamin D deficiency in childhood) is delivered of a healthy baby by Caesarean section. Rickets itself, the senior midwife says, is a disease of poverty and malnutrition eliminated by the NHS.

From the time I went to college and met upper-middle-class people, through my career as a doctor when I know lots of them, I have heard “horror stories” about the NHS, about the waits for things “we” never have to wait for, like elective surgeries. “My cousin says”, or “the people we had visiting from England told us”. But it was always apparent to me that this was a skewed group; the folks visiting from Britain on holiday were not the poor, were not the Welsh coalminers who had never had health care before. It is hard, I guess, when you have always been at the front of the queue, when the queue has always been so short for you that you didn’t even know there was one, to have to take your place in it; to wait in line with the hoi polloi. But ask those who never had had care, ask the poor, ask the women having babies in the Docklands.

My point here is not to romanticize poverty, or to suggest that things have always been perfect with the British NHS. It is, rather, to say that the provision of basic health care to all people is not and never has been a question of economics, it has always been a question of will. We can afford do it; indeed we cannot afford not to. Not only is it a “good investment”, it is essential humanity. Paul Krugman calls the group of health care expansion opponents “The Spite Club”, (June 7, 2013), arguing convincingly that their opposition is ideological, not fiscal. It is doubly sad to see this ideology acting in Europe, cutting the social safety net that has been in place there for decades.

When you think about what we can “afford” in health care, think about midwives making home visits to premature infants three times a day in the poorest areas of London in 1957. The expansion of Medicaid under the Affordable Care Act (Obamacare) may not be the best vehicle to bring care to the poorest (I still argue for a single-payer, Medicare-for-all, system), but opposing it is not fiscally responsible; it is both fiscally and morally reprehensible.