I’ve probably studied more contraception that you have. Part 2.

You can find Part 1 here.

Continuing with my rebuttal of F’s concerns with the Guttmacher contraception video, this post deals with the economic questions. My work in health economics is fairly limited but I’ll do my best. Again, F’s complaints in green.

“reduces healthcare costs, like those associated with preterm births”
This is a pretty big claim to make. You’d have to know what health care costs would be like if contraception use was lower, which seems implausible. Even granting the claim, I don’t understand how contraception bears any relationship to preterm births. If anything I would have thought that delaying pregnancy, which contraception enables, would increase complications like preterm births. My ignorance in this area is substantial however, so I may well be wrong.
There is a lot of evidence for the cost-effectiveness of contraception (NB: The Trussell paper was corrected in 2012 to more current costs). Think about it logically. If contraception use was lower, there would be far more unintended pregnancies – look at the declining rates of number of children per family since the pill was introduced in the early 60s. More pregnancies means more health care costs (need more hospital staff for more visits, more resources, and then you have to take care them after). The relationship between contraception and preterm births can be found here, for those who had unintended pregnancies (ie not on or using contraception properly), the risk of preterm birth was almost double than those who had planned the pregnancy. Premature babies then have to spend time in the neonatal intensive care unit, which is hugely expensive(round the clock care, ventilators to keep them breathing, plus the cost of hospitalization for the mother). It’s true that delaying pregnancy past 35 can increase complications (due to ageing of genetic material, but this also contributes to infertility) but women have a reproductive window of about 40 years (start of menstruation to menopause), so it is very long time to have children. I for one, would rather have my child later rather than sooner.

“cost can be a major barrier”
They present no evidence for this claim. For this we would need to have some evidence for women who forgo use of contraceptives for primarily financial reasons. Again, this may be the case, but the video doesn’t give me any reason to think that it is.
Obviously coming from someone who has never had to purchase hormonal contraception. The cost varies quite a bit, you can see the wholesale price from 2009 in the Trussell paper, but I’ve put the 2012 figures in brackets next to each form. Oral contraceptives (OCPs) ($52.81/month USD, Planned Parenthood lists the price range from $15-50) are prescribed by a doctor (which can be expensive for a consult, plus transport), then off to the pharmacy which may charge a “handling fee” (which I don’t think they do in Aus but have experienced it in Canada). However, not every woman can take the most common OCP (usually the combined pill of estrogen and progesterone derivatives), so they switch to the more expensive progestin-only pill, or variations of the two. Sometimes those don’t fit their lifestyle – remembering to take a pill every day can be difficult, particularly with progestin-only pill as it has to be taken within a 3 hour window each day. So they’ll switch to another type – Nuva Ring ($49.81/month), injectable ($102/3months), the patch ($56.49/month), the implant ($791) various IUDs (Mirena $844, Copper $718)- all increasing in price (tend to be upfront costs but more cost-effective in the long run). And that’s only the cost of the drug. Factor  in things like transport to the doctor’s office for each visit (assuming you have insurance), then to the pharmacy (if the pharmacist distributes contraception, as some may have religious objections) and then multiply that 3-12x per year (as some may only distribute one pack at a time). If you live in a rural area, access to health care might be limited, and it’s probably even more limited if you’re a 16 year old girl and you don’t want your parents to know that you’re sexually active.

F might point out that the cost-effectiveness and cost barrier are contradictory. Not if you look at it from a population standpoint – helping someone to pay for something now to prevent something more expensive later is the entire point of cost-effectiveness.

“contraceptives covered without copays or deductibles”
Sounds like a horrible idea to me. There is evidence that even modest copays help to significantly reduce unnecessary healthcare usage. Also, note that this policy effectively means everyone with insurance (or who pays taxes) is paying for everyone else’s contraceptives – meaning that poor women pay, albeit indirectly, for the contraceptives of rich women. As a policy to help poor women gain access to contraceptives this is a poor one in my view. – Trying not to be offended that F has classified contraception as “unnecessary”, even if he doesn’t mean it. Particularly when it comes to sexual and reproductive health, those who can’t afford it need it most. Co-pays or deductibles can be fixed or a percentage of the drug cost, so it can vary quite a bit, and from what I understand, drugs are much more expensive in the US than in Australia or Canada.  According to the Cochrane Review, co-pays do reduce overall drug use and decrease third-party drug spending. But they also include reductions in life-saving drugs and drugs used for chronic conditions and notes that there isn’t a lot of data on the effects on health outcomes. Contraception is one of the few drugs taken regularly by young women (I know it’s a frequent topic of discussion among my age group), a group that generally doesn’t have a lot of disposable income. Don’t think I can answer the tax/insurance system question as I don’t know the US system very well . However, taxes are usually indexed to income, and paid by those who can afford it. Those who can pay (including men), effectively covering those who can’t afford to pay taxes. There’s about 45 million Americans without health insurance, so they wouldn’t be paying anything anyways.

I might have been willing to let all this go if it were not for that snarky little injunction at the end “please send this video to others to ensure that the debate about contraception is informed by facts, not misinformation”. I like the idea, but if its facts and an unbiased, nuanced presentation of the issue you are looking for, this video leaves a lot to be desired. Hence my initial reaction. – to get the kind of nuance you’re looking for is at least a couple hours in a documentary format, not a 3 minute video. Like I talked about in the other post, people who use contraception are demonized for it in the US, and so many are completely ignorant of how it works, and how it’s changed society as a whole. I didn’t go into but the Pill has a really rich history in affecting sexual and reproductive health, and opening up women’s roles in society. I think the video works for what it is – a short, informative ad to let people know that contraception isn’t evil.

I doubt that what I’ve just said will change F’s opinion about the video.

I’ve probably studied contraception more than you have. Part 1.

As usual, someone has managed to piss me off on the internet. I posted this video from the Guttmacher Institute

Guttmacher is a reproductive and sexual health organization/advocacy group that carries out research, policy analysis and education activities, mostly social science, and a lot of surveillance data (tracking numbers like number of abortions performed, rates of contraceptive use, etc). This is meant to be a short educational video, a general overview on the benefits of hormonal contraception from an American perspective (kind of like an advert). A facebook acquaintance (henceforth referred to as F) has quite a few issues with the video (although it has been clarified to me that his issue is with the video making the case for contraception, and not against contraception). I’ve reposted his complaints below (with his permission) in green. As there are so many, I’ve split them in two posts. Part 2 focuses more on the economic issues, and will post it when ready  posted here.

NB: The term “contraception” refers to hormonal contraception – the pill, intrauterine devices, the implant, injectables, NuvaRing (TM), etc.

It confuses facts with ideology a lot. “pregnancy that follows too soon from a previous one, or one that occurs after a family is complete”. These are not scientific statements.

A fact doesn’t necessarily have to be a scientific statement, just something that exists in truth. Anyways, the former is a scientific statement, as birth spacing can be an influential factor in family planning. Putting aside the fact that it takes awhile to recover from pushing out 2.5-3 kg out of a 10 cm hole (even if it was an uncomplicated pregnancy), there’s evidence that inadequate time between pregnancies can increase the risk of birth defects like gastroschisis (intestines sticking out of umbilical cord), increased risk of preterm birth, and less cognitive development in the previous child. Additionally, there are social and family reasons for waiting in between children, including having enough financial resources…babies are ridiculously expensive.

“women whose pregnancies are planned are more likely to receive prenatal care, etc” Correlation is not causation. I’m not familiar with this literature so it may well be that family planning is causal in this manner, however judging the video by its own merits, the facts it presents do not support this conclusion.
The use of the word “likely” is not considered causal, since you’re fairly limited in the randomized controlled trials run in pregnant women, so you can’t definitively link Effect X to Outcome Y. However, based on best available evidence, you can say someone is more likely to have experienced/exposed to this and had this outcome. Women who plan pregnancies in the first place generally have better outcomes as the sooner a woman knows that she’s pregnant, she can start monitoring her pregnancy, taking folate supplements to prevent neural tube defects, stop consuming alcohol, etc. This is also indicative of health care access. Contraception enables women to plan their reproductive health until they’re in a position to properly care for a child.

“Contraception use is universal… all religions, etc”
How is this a ‘benefit of contraceptive use’? Sounds like an argument from popularity to me.

Not sure why every line in the video has to be a benefit…this is just a comment on how religious groups are often against contraception but then their members use it anyway. About 90% of Catholics use contraception.

Note that the video moves immediately from saying “the impact (or this policy)…could be substantial” to “rolling back this major gain would be a huge loss”. In the latter statement they are making a presumption that the policy would be effective and helpful, which they themselves seem to have admitted in the former statement is, at best, premature to say. Again, lacking in evidence and overselling their case.
Contraceptive use varies between the states in the US, from that “Comparable population-based information on contraceptive use for states can be used to guide the development of state programs and policies to decrease unintended pregnancy and the spread of sexually transmitted diseases”. Using this data can tell us a lot about the effect of the policy but like a proper public health organization, they don’t deal in absolute statements.

“Isn’t it time we stopped playing politics with contraception?”
A loaded question that is irrelevant and also silly. If contraception is not a political question, then what is? If contraception is not a political issue, why do we need the law about insurance coverage for contraception just mentioned? Indeed, why need the video at all?
Not sure if F has been following the health care debate in the US recently but the Republicans demonize those who use contraception, like Rush Limbaugh calling Sandra Fluke a slut and a prostitute. Religious employers have been trying to insert a provision that exempts them from paying for contraception. The irony is that a lot of health insurance in the US covers Viagra, but not contraception. Let the men have their erection, but women can’t have a say in their own family planning. Don’t even get me started on the ridiculousness of a Congressional panel that included a bishop and a rabbi but not a single woman.

“contraception as … essential health care”
I find it interesting how they keep trying to sell contraception as health care. I can see the argument, but on the other hand it seems to me to be very different from the type of things we more traditionally think of as health care. This issue of things being ‘healthicised’ (to coin a word based on the concept of securitization) is more of an issue for sociologists of health and medicine than for me, but I find it interesting. Again, this is more about branding than providing evidence.
Ok. I’m calling penis privilege on this. The major difference between men and women’s health is that women can carry babies, and it always, always falls on the woman in a relationship to be the one concerned about pregnancy. And I don’t understand why it can be argued from a social science perspective makes it any less essential. One of the biggest issues in the developing world is the unmet need for contraception, where it would reduce the number of unplanned births, reduce the number of abortions and decrease maternal mortality. In the U.S., contraception has been linked to declining rates of teenage pregnancy. I think what confuses F here is that contraception is considered to be preventative health care, to avert bigger problems down the track for an individual. Is that really a hard concept to grasp – that preventative health is part and parcel with health care? In a check-up, doesn’t the doctor check your blood pressure, glucose levels, weight, eyesight, hearing, etc to prevent other problems? Also, contraception can be used for its non-pregnancy medical effects, like treating polycystic ovarian syndrome.

NB: I asked a male friend today if he knew anything about contraception, and his response was that he only knew what I told him. To be fair, hormonal contraception is somewhat irrelevant to him, as he is gay, and could only knock up a female-to-male transsexual.