Because most philosophies that frown on reproduction don't survive.

Monday, February 28, 2011

Does Giving Women a Year's Supply of The Pill Reduce Abortions?

A reader asked me to take a look at this study (abstract here) and see if it reaches a valid set of conclusions. The study was conducted in California among ~80,000 women who receive birth control pills paid for by the state as part of a program for low income women. Previously, women in the program have received a 1 or 3 months supply of birth control at a time, and then have to go in to the clinic in order to receive a refill. In the study, a portion of these women were given a full year's supply instead of one or three months, and state medical records were then used to see if this resulted in a change in the rate of unplanned pregnancy and abortion among the women who received a full year supply of birth control.
Researchers observed a 30 percent reduction in the odds of pregnancy and a 46 percent decrease in the odds of an abortion in women given a one-year supply of birth control pills at a clinic versus women who received the standard prescriptions for one – or three-month supplies.

The researchers speculate that a larger supply of oral contraceptive pills may allow more consistent use, since women need to make fewer visits to a clinic or pharmacy for their next supply.

"Women need to have contraceptives on hand so that their use is as automatic as using safety devices in cars, " said Diana Greene Foster, PhD, lead author and associate professor in the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences. "Providing one cycle of oral contraceptives at a time is similar to asking people to visit a clinic or pharmacy to renew their seatbelts each month."
...
Oral contraceptive pills are the most commonly used method of reversible contraception in the United States, the team states. While highly effective when used correctly (three pregnancies per 1,000 women in the first year of use), approximately half of women regularly miss one or more pills per cycle, a practice associated with a much higher pregnancy rate (80 pregnancies per 1,000 women in the first year of use), according to the team. [source]
The details of that decrease are as follows:
Women who received a 1-year supply were less likely to have a pregnancy (1.2% compared with 3.3% of women getting three cycles of pills and 2.9% of women getting one cycle of pills). Dispensing a 1-year supply is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy compared with dispensing just one or three packs (confidence interval [CI] 0.57–0.87) and a 46% reduction in the odds of an abortion (95% CI 0.32–0.93), controlling for age, race or ethnicity, and previous pill use.[source]
So, what should a Catholic pro-lifer make of this?

Well, there may or may not have been methodological issues with this study. I read several science news stories about it, but I can't get access to the full text, so I don't know for sure how they dealt with sample bias, etc. However, I have to admit, that from what I've read it makes sense to me that the study results are valid as far as they go. But they also give us a window into the contraceptive mentality which is at play in feeding into abortion in this culture.

The women in the study are receiving birth control so that they can have sex at will while not getting pregnant. Nevertheless, some percentage of them are getting pregnant (around 1% of those getting the year supply, around 3% of the rest) during any given year. The good news is that they are like the rest of California women in that in 80% of these cases, they are carrying these unexpected children to term. The bad news is that 20% of the time they choose an abortion instead.

But part of what's feeding this problem is not the quantity of birth control that's being given out at a time, but the sense in which people's actions are (for whatever reason) not fitting with their desires. One article on the study includes this telling quote:
“It's a cost-savings thing, but it's also a quality-of-care issue — and it's the right thing to do,” she says. “People don't stop having sex when their pills run out.”
So people are taking birth control pills in order to have sex while not getting pregnant, but if they run out of pills -- they don't stop having sex.

The study's proposed solution to this is "let's just make sure they always have lots of birth control on hand" and I suppose in the context of them taking birth control, I really don't have any strong feelings about whether they get a month's supply or a years supply at a time. But it seems to me that we're looking at the root of a much deeper issue when we hear someone conducting a study on this topic saying that people do not appear to stop having sex when they run out of birth control -- even if they know it's only the birth control that's keeping them from getting pregnant as a result of having sex.

All other things staying constant, if it's true (as the study appears to indicate) that some women on birth control are late in refilling their prescriptions and thus gap out for a few days, yet continue having sex as normal (or abstain during the couple days they don't have pills, but then go back to having sex as normal as soon as they start taking the pills again without realizing that the unexpected fertility might well come a week or two after the gap, not during it) then it's pretty logical that reducing the frequency with which women have the potential to experience that gap would reduce the number of unplanned pregnancies. And if we assume that the same percentage of unplanned pregnancies will always result in abortions, then necessarily reducing the number of unplanned pregnancies will reduce the number of abortions.

I think this does suggest that for those people who are in the business of dispensing birth control pills, it would be an obvious thing for them to dispense large prescriptions, and perhaps to look into some sort of automatic reminder or shipment in order to help women avoid these gaps. Women who are coming to them for birth control obviously don't want to get pregnant, and they will do a better job of fulfilling those women's wishes if they help them avoid those gaps.

I don't think we pro-lifers who have moral objections to birth control need to go out and become cheerleaders for the idea of handing out larger prescriptions of The Pill -- though in light of this study I think we shouldn't actively try to keep birth control dispensers from dispensing larger amounts at a time. The moral content of taking birth control is the same regardless of how much you pick up at a time and the larger prescription amounts seem to have, on the whole, positive results from everyone's point of view.

I think the role for us as pro-lifers is two fold:

First, either way, we believe that everyone will be better off if abortion is simply not on the table. (For those birth control enthusiasts, this might even result in some more conscientious pill taking.) This clearly makes no different in our fight to remove abortion from the set of legal medical options.

Second, our society is clearly both confused and dysfunctional when it comes to sex, if we have a lot of people who are taking birth control in order to avoid getting pregnant yet don't stop having sex if they run out of birth control. The birth control advocates who are the sources of this study are going to be no help in solving these problems, because their whole worldview is built around the idea that sex should be totally separate from reproduction. It is up to us to build the cultural understanding that sex results in new human life, and that even "protected" sex does some percentage of the time. If you are having sex, you had better be sure that it is with a person whom you are willing to have a child with -- even if you're taking measure to reduce the likelihood of that happening in any given year down to around 1%. One person out of a hundred is still a pretty significant group of people, and a number of years your chances of ending up with a child at some point only go up.

15 comments:

Anonymous said...

Proverbs 31:6-7 - "Let beer be for those who are perishing, wine for those who are in anguish! Let them drink and forget their poverty and remember their misery no more."

There is a general principle here, that one cannot expect non-Christians to live like Christians. After all, it is a genuine miracle when Christians live like Christians.

Regarding contraception, if the data in this study is accurate (and it certainly seems solid) then it is unequivocally good to give poor women larger batches of birth control pill. They are not going to adopt Christian sexual morals - no, they really won't, and we need to acknowledge that fact and make room for it in our policy analyses, as the writer of Proverbs understood. If giving larger batches of pills reduces abortion, then for goodness sake give larger batches of pills.

Joel

MomE. said...

The pill is "highly effective" because it can be and often is an abortifacient. So, in many, many instances, an abortion is taking place. It may be an unplanned pregnancy but an unwanted child? By whom? Not the couple who wait years and years to adopt an infant. The waiting period for adopting an infant has gone from 3 months in the 1960's to 10 years in this day and time. you can find these statistics at the Priests for Life website or any similar site.

Skywalker said...

What happens when they follow these people over 5 years, instead of 1 year. After all, even a years worth of pills has to be refilled at some point; will they remember at that time?

Mike said...

As MomE said, the pill is an abortifacient. A woman on the pill has a 4% chance of a pill induced abortion each year.

Also, there is a serious flaw in the study. It only counts pregnancies within a year of being given the pills. Just as the women with a 3 month supply get pregnant after 3 months, will the women with a 1 year supply get pregnant after 1 year? If so, then what good is giving them more.

To correct the numbers for this you would have to run the study for 4-12 years, or take the number of women with the 1 or 3 month supply, count the number of pregnancies during that month or 3 months, and scale the data to 1 year.

Comparing the number of women who get pregnant while they have a supply of the pill to those who have run out is bound to produce the kind of results they published.

Darwin said...

Skywalker,

I think that basic theory here is that if a randomly selected women is on The Pill, there is some finite chance X that she will get her refill late but keep having sex regularly (without using some additional form of birth control) and will get pregnant as a result. Thus, if she has to refill every three months her chances of getting pregnant over five years on a three month prescription would be 20(X) while if she got her prescription yearly it would be only 5(X).

Now, there already appears to be some pretty good evidence in the study that this relationship is not straightforward in that the women in the study who had to refill every three months had a higher chance of getting pregnant that those who had to refill monthly. (Whereas according to the theory of the authors, those refilling monthly should have been three times as high.) This might suggest that the ones who went monthly had a habit of doing so on time while those who went ever three months didn't, and that would tend to suggest that the ones going annually would gap even worse, which might even the odds over a multi year period.

Mike,

The article you link to has some good information, but it's hard to sort out the number of spontaneous abortions resulting from The Pill from it. The driving statistic appears to be that among a group of 100 women taking the pill, there are somewhere between 17 and 27 "breakthrough ovulations" years per year. However, there are only 4 pregnancies.

It's known that the pill does two other things in addition to suppressing ovulation in order to prevent pregnancy: it reduces the internal mucus which allows sperm to survive and make contact with an egg, and it thins the lining of the uterus which makes implantation less likely. Additionally, it's possible that a woman would be taking the pill but not happen to have sex within a couple days of her breakthrough ovulation.

So a woman taking the pill has somewhere between a 17% and a 27% chance of ovulation during a given year (according to those studies) but it's quite unclear what the chances are that the egg in that ovulation will become fertilized. (Obviously, there's at least a 4% chance, because there's a 4% chance of getting pregnant, according to those studies -- which we should probably note had a higher pregnancy rate than the California study here.) So a woman taking the pill has somewhere between a 4% chance and a 27% chance of conceiving in any given year, and the difference between whatever that chance is and 4% is the chance of the pill causing a spontaneous abortion.

From what I understand, we have basically no idea what that spread is, but we think it does exist. However, whether that means that the average woman on the pill experiences a spontaneous abortion every four years or once in 25 years is something we don't know.

In relation to this particular study -- where they're talking about people who miss just a couple doses of the pill and may or may not get pregnant as a result -- I'm not sure we could expect to see much of any change in the number of pill-caused abortions, because there simply wouldn't be enough of a chance for the chemicals from the pill to clear the woman's system and for the lining of the uterus to thicken. That's just a guess though.

And just to reiterate one more time for all: Having been asked to take a look at this, I wanted to try to answer as honestly as possible the question of whether this study in fact indicated that a reduction in the number of abortions results from doctors prescribing a year of the pill at a time instead of one or three months. I don't for a moment think that make using the pill anything other than a grave sin. I'm certainly not suggesting we advocate the use of the pill. I'm just narrowly looking at whether prescribing a different amount of it at a time resulted in less abortions.

Skywalker said...

"Now, there already appears to be some pretty good evidence in the study that this relationship is not straightforward in that the women in the study who had to refill every three months had a higher chance of getting pregnant that those who had to refill monthly. (Whereas according to the theory of the authors, those refilling monthly should have been three times as high.) This might suggest that the ones who went monthly had a habit of doing so on time while those who went ever three months didn't, and that would tend to suggest that the ones going annually would gap even worse, which might even the odds over a multi year period."

That was pretty much what I was trying to say...I don't think it proves that a years supply of pills would dramatically reduce the unintended pregnancy rate over a long period of time.

"The moral content of taking birth control is the same regardless of how much you pick up at a time and the larger prescription amounts seem to have, on the whole, positive results from everyone's point of view."

I don't think you are advocating for birth control here, however, would it not be similar to saying "It doesn't matter whether you tell a lie once or 1000 times, it's still equally wrong."

Darwin said...

I don't think you are advocating for birth control here, however, would it not be similar to saying "It doesn't matter whether you tell a lie once or 1000 times, it's still equally wrong."

Hmmm. That's an interesting point.

I guess my line of thought is -- if someone is regularly taking the pill, and leaves off for a couple days only because she runs out, then to the extent that she's committing a sin by using birth control (given that she might not know its a sin, etc.) the sin is more a continuity of action than a racking up of each time she actually takes a pill.

If someone knew that taking the pill was a sin, and stopped for a while, but then resumed, there would be a virtue in having exerted the effort to stop, and then a resumption of sin in falling into taking it again. But if someone means to keep taking the pill but simply runs out and so misses a few days, it's not like running out without any resolution to stop is itself virtuous.

Does that make sense?

Moira said...

Mrs. Darwin,

I am curious as to why you don't mention that contraception can and does cause what is considered to be a "chemical abortion".

Moira

Moira said...

Whoops - I obviously didn't read the comments first...:)

Kevin J. Jones said...

"controlling for age, race or ethnicity, and previous pill use"

Curious that income wasn't a control factor.

Jennifer Roback Morse has pointed out that very high success rates in contraceptive use can come from conflating the stats of older, less fertile women with much younger ones (who are also less responsible).

Breaking down the stat results by age and income could be useful.

Darwin said...

Moira,

Actually, you can't blame MrsD, I'm at fault for this post. :-)

Kevin,

I would assume that since all the women in the study were receiving subsidized birth control via public assistance, they were all of similarly low income, so the researches assumed they didn't need to control further for income.

Erin said...

Wow, I would love to be able to read the full study.

I spend 5 years working as a medical social worker among poor women on Chicago's west side. Before my work there, I was convinced that handing out birth control was the way to reduce the rates of unintended pregnancy and abortion.

However, as I worked at the clinic, and was assigned the same women over...and over...and over again, I be came increasingly convinced that contraception is exactly like communism--works in theory, but not in practice.

Every time I closed a client, I would have to aked what kind of contraception she planned on using. Clients almost always stated that they planned to use highly "effective" hormonal methods--yet a few months later, they'd turn up at the clinic, unintentionally pregnant again.

When asked what had happened, clients would state that they didn't like the side effects of the method they'd chosen, or learned from "a friend of a friend" that the method was dangerous or ineffective, so they'd decided to discontinue it.

I am shocked at the results of this study, and would love to read the full-test.

Darwin said...

Erin,

That's very much what I've heard in relation to effectiveness of birth control and income demographic.

As it happens, I just got hold of a PDF of the study. If you drop me an email, I can forward you a copy if you're curious.

Darwin said...

And speaking of having now read the article, it looks to me like this study is basically useless. The news articles had suggested that the study consisted of randomly giving some women 1 year supplies instead of one or three month supplies. Instead, it turns out that some clinics offer one year supplies as well as one month or three month supplies as an option. So the patient selected one of these three options, and the study just looks at how the results were different.

As the study authors admit at the end, this means their results don't really tell anything:
The cause of this reduction in pregnancies cannot be determined from these data. Most obviously, a greater supply of oral contraceptive pills may facilitate continuation of use by obviating the need for repeated time-consuming visits to a clinic or pharmacy for resupply; improved access and convenience may explain higher continuation among women given a 1-year supply. There is also a psychological explanation: each resupply visit is an opportunity to reconsider continuation of use. Being given a 1-year supply may enhance the expectation that the method is acceptable and safe, whereas fewer packs may suggest that the woman is likely to experience side effects and needs to reconsider use of the method at each resupply visit.

Kevin J. Jones said...

"I would assume that since all the women in the study were receiving subsidized birth control via public assistance, they were all of similarly low income"

Ha, I missed the obvious there.

Thanks for digging into this report.