A new study in the journal Contraception reveals the power of a simple conversation: When trained counselors at family planning clinics ask young women if they have experienced reproductive coercion, it reduces the odds of their male partners forcing them to become pregnant.

The Family Violence Prevention Fund responded enthusiastically to the results of the study:

A brief intervention was associated with a 70 percent reduction in the odds of male partner pregnancy coercion among women who recently had experienced intimate partner violence. Study participants who were asked about reproductive coercion and then counseled about harm-reduction strategies — including switching to longer-acting contraceptives and contacting domestic and sexual-assault resources — were also 60 percent more likely to report ending a relationship because it felt unsafe or unhealthy.

“There is a strong, indisputable link between domestic and dating violence and unintended pregnancy. This study is extremely important because it identifies an effective solution that can be implemented relatively easily,” said Family Violence Prevention Fund President and Founder Esta Soler. “We need to build on these results by making this intervention the norm in health care settings throughout the nation as quickly as possible.”

The study was funded by the National Institute of Child Health and Human Development; the intervention was designed by reproductive health experts, UC Davis School of Medicine, the Harvard School of Public Health, and the FVPF.

An earlier study this year, also published in Contraception, concluded that 20 percent of women experienced pregnancy coercion and 15 percent experienced birth control sabotage.

The FVPF is calling for immediate action based on this latest evidence: “This study is extremely important because it identifies an effective solution that can be implemented relatively easily,” said Soler. “We need to build on these results by making this intervention the norm in health care settings throughout the nation as quickly as possible.”

Go to FVPF’s Know More Say More website for more information and opportunities for action. The site includes resources for healthcare providers, including suggestions on how to assess for reproductive coercion [PDF], including sample scripts, and how to integrate assessments into clinical practice [PDF].

In June, we wrote about the FDA’s Advisory Committee for Reproductive Health Drugs recommendation to approve ulipristal acetate (brand name “ella”) for emergency contraception. On Friday, the FDA did approve the drug, as a prescription-only emergency contraceptive to be taken up to 120 hours (5 days) after contraceptive failure/unprotected sex. Existing “Plan B”-type emergency contraception is currently approved for use up to 72 hours.

Despite the five-day use window for this drug (and the three-day window for others), some media outlets persist in calling it a “morning-after” pill. Ahem.

At the time of our June post, a transcript of the Advisory Committee meeting – which includes the text of presentations and detailed discussion of the drug – was not yet available. That transcript is now online [PDF], including comments from representatives of Planned Parenthood and the National Women’s Health Network.

See our previous post for further discussion of the new emergency contraceptive.

Via @NLIRH, we learned that the National Latina Institute for Reproductive Health, California Latinas for Reproductive Justice and the Colorado Organization for Latina Opportunity and Reproductive Rights have teamed up for the first annual Latina Week of Action for Reproductive Justice, starting today and running until August 15th.

As part of the week, the groups are asking supporters to contact their Congressional representatives “to ask the Department of Health and Human Services (HHS) to support comprehensive family planning services that include contraception as a key women’s health service under the Women’s Health Amendment.” As with many online action campaigns, you can put in your zip code to identify your Representative and Senators and send them a letter explaining that “Latinas, immigrants, and women of color will be disproportionately affected if contraception is not made affordable and accessible.”

There is also an online conversation about Latinas and contraception happening all week, with an inaugural blog post, My-So-Called-Sex-Education, up at Nuestra Vida, Nuestra Voz (NLIRH’s blog) on the need for information about and access to contraception. Further discussion will happen on Facebook, via Twitter (#latinaRJwk), and on partnering blogs such as VivirLatino. There are in-person events taking place in a few cities; check out this page for details.

Two aspects of recent health reform legislation may help expand access to affordable contraception and family planning services. The first of these is a provision that allows states – through their Medicaid programs – to receive federal funding to cover family planning and related services and supplies for individuals not otherwise eligible for Medicaid.

This coverage would be available to individuals (women and men) who are not currently pregnant and whose income does not exceed an income eligibility level established by the state (similar to special eligibility rules for pregnant women who wouldn’t otherwise quality for Medicaid). Family planning-related services that may be covered include STI diagnosis and treatment, treatment of urinary tract infections, treatment of major complications from family planning procedures such as IUD insertion, and vaccines and other preventive services when provided as part of routine family planning visits.

States will basically have to opt in to this coverage by submitting some paperwork to the Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicaid. States will also set the eligibility guidelines for coverage up to a certain threshold. It is not yet clear how many or which states will be offering this coverage, which will expand access to family planning services for people who earn to much to qualify for Medicaid but who are having difficulty affording this care.

Another provision of the health care reform legislation that will take effect in late September, often referred to as the “Mikulski amendment,” requires that health plans cover preventive care and screenings (at no cost to the individual) for women. The coverage must be based on current evidence-based recommendations of the United States Preventive Services Task Force, and must includevaccines recommended by the CDC, and other care and services “as provided for in comprehensive guidelines supported by the Health Resources and Services Administration [HRSA]for purposes of this paragraph.”

What’s not clear is what guidelines the HRSA will support. Some have suggested that because HRSA doesn’t seem to have its own set of guidelines now, these will need to be created. I think another possible interpretation is that HRSA will identify an existing set of guidelines to support (such as from ACOG or another professional or governmental health organization). Whether new standards have to be created or HRSA simply designates some existing guidelines to support will determine how much room there is to advocate for services, but what will happen is not entirely clear at the moment.

A recent Guttmacher policy review has more on this issue, specifically on whether contraception might be included as preventive care. Guttmacher’s Adam Sonfield has also written about the issue for CNN, concluding:

In short, the case for ensuring family planning services are comprehensively integrated into women’s preventive care and insurance coverage is compelling. More and better contraceptive use will lead to more pregnancies that are planned and wanted, which will lead to more women who are healthy during their pregnancies and whose babies are born healthy. Who could argue with that?

The National Latina Institute for Reproductive Health is planning a “virtual cafecito” to discuss the issue of whether family planning will be included as a preventive service and to discuss strategies for ensuring that Latinas and other women have access birth control options as a preventive service. The call-in discussion will occur Wednesday, July 4 at 1pm EST; register online to participate.

by Kiki Kalkstein, Center for Health and Gender Equity (CHANGE)

Earlier this month, I attended the Women Deliver Conference in Washington, D.C ., on behalf of the Center for Health and Gender Equity (CHANGE). After a jam-packed three days of plenary sessions, chairman’s sessions, and more than 100 concurrent sessions, participants left the conference reinvigorated and ready to take action to work toward fulfilling Millennium Development Goal #5: Reduce maternal mortality and achieve universal access to reproductive health.

After speaking with hundreds of participants, one thing was made very clear to me — people not only want female condoms, but they believe that female condoms are a vital tool in decreasing maternal death, improving maternal health, and promoting sexual and reproductive health and rights.

I had countless conversations with participants from all over the world who were thrilled we were there talking about and promoting the female condom. As I shared information about the Prevention Now! Campaign (CHANGE’s initiative to increase access to existing prevention methods, especially female and male condoms), their message came through loud and clear — we want female condoms, and we want them now.

I spoke with men and women of all ages, and again and again they expressed interest in female condoms and inquired about how to increase access in their own countries. A doctor from Kenya said that women who come to his clinic consistently ask for female condoms, and he doesn’t have any to offer. A doctor from Nepal took all the information he could from our booth, and came back with his colleagues to get more. Some participants asked how they could launch a female condom program in their own countries. Female condoms are in demand.

Access to contraception is critical for preventing maternal deaths, but sometimes high-level decision makers do not make that connection. The female condom puts women in control of their own health by enabling women to delay pregnancy and space out births, all of which decrease the risk of maternal death and disability.

Effective family planning programs are not only fundamental to maternal health, they also allow women and families to better manage household and natural resources, secure education for all family members, and address each family member’s healthcare needs. Participants at Women Deliver conference acknowledged the benefits of the female condoms and recognized it as a vital tool for improving maternal health globally.

Related posts:
* Expanding the Female Condom Market
* FC2 Female Condom Available in the U.S.

Kiki Kalkstein is the program assistant at the Center for Health and Gender Equity (CHANGE). She previously designed and implemented public health education programs both domestically and internationally, including a rural community outreach program with the Uganda Village Project focused on increasing awareness around obstetric fistula. She also designed and implemented at the University of California at Berkeley “Sex and Sustainability: Reconnecting Population and Women’s Empowerment,” a campus program designed to increase awareness about unmet family planning needs in developing countries.

The FDA’s Advisory Committee for Reproductive Health Drugs yesterday reviewed a new drug application for ulipristal acetate, an emergency contraception that prevents pregnancy after intercourse. This particular drug has been available in Europe under the brand name ellaOne since May of 2009 and is intended for use up to five days after unprotected sex or contraceptive failure.

Most other emergency contraceptions sold over the counter in the United States are officially approved for use up to three days (72 hours), although it is widely accepted that these others drugs (such as versions of Plan B) are also effective for up to five days. See our previous post on the topic for further discussion of this aspect, as well as some fairly recent studies and anti-choice objections to the product.

The FDA committee voted unanimously to recommend approval; the Agency itself will now need to decide whether the drug is approved. The National Women’s Health Network released a statement [PDF] urging the FDA not to reverse the committee’s recommendation (as the FDA did in the initial, controversial Plan B decision in 2004), and commenting on anti-choice opposition, which has centered on whether the drug could be used for abortion or otherwise affect pregnancies:

As longtime drug safety advocates, NWHN would like to point out that there are hundreds, even thousands, of drugs approved by the FDA and prescribed by clinicians whose effect on pregnancy is unknown. The critics who are raising questions about ulipristal’s possible effect on pregnancy don’t raise those questions about other drugs that come before the agency, and there’s a reason for that. Their underlying agenda is to prevent women from having access to another contraceptive option by raising questions about abortion that are intended to confuse the issue. In this, they are out of step with the American public – rather than making more safe and effective options for preventing unintended pregnancy available, as the majority of people in this country would like to do, they are trying to block a new option.

A transcript of the advisory committee meeting is not yet available; we’ll update with a link when it is posted. We’ll also have discussion of flibanserin, the drug being reviewed today “for the proposed indication of the treatment of hypoactive sexual desire disorder (HSDD) in premenopausal women,” next week.

We recently wrote about the CDC’s new publication, the U S. Medical Eligibility Criteria for Contraceptive Use, 2010, which outlines specific characteristics or medical conditions that may interfere with safe contraception use. The July issue of the journal Contraception follows up on this topic, featuring articles from CDC and WHO authors on contraception use and specific medical conditions as well as current research gaps.

The authors identify the following issues as needing further research, among several others:

• Long-term effects of Depo Provera on bone mineral density and any relevant race/ethnicity factors
• Effects of postpartum oral contraceptives on infant health and breastfeeding
• Whether IUD expulsion rates vary by type of birth a woman has had (i.e., if the IUD is more likely to be come out if a woman has a vaginal or cesarean birth)
• Whether the risk of blood clots (venous thromboembolism or VTE) is greater and whether oral contraceptive efficacy is lower in obese women
• Whether use of hormonal contraceptives worsens depressive disorders (including postpartum depression)

Other issues identified as needing further research include questions about contraceptive use and efficacy in women with cervical cancer, uterine fibroids, HIV/AIDS, inflammatory bowel disease and rheumatoid arthritis.

In a commentary on the problem of gaps in the existing evidence base on contraceptive safety, CDC and WHO representatives write:

Absence of evidence regarding contraceptive safety may be equated by women or their providers with absence of safety and lead to use of less effective methods. Alternatively, absence of evidence may be equated with absence of risk, resulting in use of methods which may potentially place these women at increased risk of adverse events or complications.

Other articles in the issue review topics such as IUD use by women with uterine fibroids and contraception use among women who have had bariatric (weight loss) surgery.

The Women Deliver 2010 conference is happening in Washington DC today through Wednesday, focusing on global maternal and reproductive health and featuring great speakers from numerous U.S. and international agencies. I just listened to Melinda Gates wrap up and pledge $1.5 billion in new family planning and maternal/child health grants for next 5 years; an archive of these videos is expected to be posted as well.

The conference is streaming live at http://www.womendeliver.org/conferences/-2010-conference/webcast/. You can follow tweets using the hashtag #WD2010, which are also streaming on the webcast page. I’ve set up archives at Twapper Keeper and What the Hashtag? to save tweets with this hashtag for later review.

The CDC recently released the U S. Medical Eligibility Criteria for Contraceptive Use, 2010, adapted from World Health Organization recommendations and intended to outline specific characteristics or medical conditions that may interfere with safe contraception use.

The document is intended for use by health care providers when counseling individuals about contraceptive choices, but is freely available to the public and includes some useful tables of considerations related to numerous contraceptive methods. It also includes a table of contraceptive failure rates with perfect and typical use (i.e., what percent of women get unintentionally pregnant in the first year with each method), and how many women continue to use each method after one year.

The guide is a little bit opaque to navigate and read, putting data for each method in its own appendix and number-coding the recommendations. I’m linking directly to these appendices below – for each, the first column is the list of relevant conditions (like smoking status), and the second column, Category, gives a number code from 1-4 indicating how the risks/benefits of the method balance out for any particular condition. The third column provides any relevant explanation.

For example, use of combined oral contraceptives in those who are ≥35 years of age and who smoke ≥15 cigarettes/day is given a score of “4,” meaning “A condition that represents an unacceptable health risk if the contraceptive method is used.” The third column explains the cardiovascular risk associated with smoking and using the pill.

The guides:

• Appendix B: Combined Hormonal Contraceptives (including the pill, patch, and ring)
• Appendix C: Progestin-Only Contraceptives
• Appendix D: Emergency Contraceptive Pills
• Appendix E: Intrauterine Devices
• Appendix F: Copper Intrauterine Devices for Emergency Contraception
• Appendix G: Barrier Methods (includes male and female condoms, spermicides, and diaphragms with spermicide or cervical cap)
• Appendix H: Fertility Awareness-Based Methods (including symptom-based and calendar-based methods)
• Appendix I: Lactational Amenorrhea (i.e., breastfeeding for birth spacing/control)
• Appendix J: Coitus Interruptus (Withdrawal) (okay, looking at this topic, I can’t help giggling that the CDC has labeled all of these documents as “early release”)
• Appendix K: Male and Female Sterilization

The CDC also provides appendices summarizing the info for hormonal contraceptives/IUDs and limited data on possible interactions between hormonal contraception and antiretroviral therapies.

UPDATE: Interview got bumped for breaking news. It is scheduled to air Monday.

Our Bodies Ourselves Executive Director Judy Norsigian will be on “The Emily Rooney Show” on WGBH-FM (89.7 in Boston) today at 12 noon, discussing the 50th anniversary of the pill. You can listen live online.

Elaine Tyler May, a professor of American studies and history at the University of Minnesota and the author of “America and the Pill: A History of Promise, Peril and Liberation,” will also be on the program. Here’s an op-ed May wrote that appeared in the Washington Post this past Sunday: “The Pill: Making Motherhood Better for 50 Years,” and an interview she did recently at Feministing.

We’ll post more birth control-related stories, with comments from Judy, later today.

Monday’s episode of NPR program “On Point” focused on “The Pill’s Impact, Past and Present.” A transcript doesn’t seem to be available, but you can listen to the program online. The “On Point” site also links to a recent Time magazine piece on the topic, The Pill at 50: Sex, Freedom and Paradox.

Last Friday, “On Point” also covered the status of women in the workforce and pay equality. I haven’t heard either piece yet myself, but plan to listen soon. Let us know what you thought in the comments.

In this difficult economy, many states are struggling to balance their budgets, often resulting in controversial decisions and cuts. Last month, New Jersey Governor Chris Christie (R) released a 2011 budget plan for the state which continues to generate considerable discussion. An astute reader brought one line in particular to our attention from the proposed budget: “Funding for grants to support clinical family planning and related services is eliminated.”

A representative of the ACLU of New Jersey writes:

Without state funding next year, the centers would serve 40,000 fewer patients, leaving an already vulnerable population with even less. In the midst of a recession, these services are more critical than ever. The recently passed health care legislation may offer some assistance in the coming years, but it won’t keep the lights on in the only medical centers serving neighborhoods that need them the most.

A piece in the Daily Princetonian urges students to contact Christie about the proposed cuts, arguing that the cuts will lead to poorer health for both men and women, and already vulnerable populations, ultimately costing the state more: “These cuts are not just shortsighted, misogynistic and classist — they’re completely nonsensical. And they will result in devastating consequences for public health.”

What’s going on in your state’s budget related to women’s health? Let us know in the comments.

View all Women’s Health Heroes. Voting closes May 14. Background info here.

Entrant: Joan Z. Spade, Ph.D.
Nominee: Karen M. Hicks, Ph.D., Adjunct Professor, Lehigh University and Lafayette College

I am nominating Dr. Karen Hicks for her on-going dedication to improving women’s health and well-being, particularly as it relates to sexuality and reproductive health.

Dr. Hicks has been a sexuality educator for more than 20 years. She teaches Human Sexuality and Women’s Reproductive Health as an adjunct professor at both Lehigh University and Lehigh University.  In 1994,  Dr. Hicks authored one book on women’s health, “Surviving the Dalkon Shield IUD: Women v. the Pharmaceutical Industry,” and edited another, “Misdiagnosis: Woman as Disease.”

She started a kitchen table action grassroots action group of survivors of the Dalkon Shield IUD, which grew to 15 chapters across the United States and became the chief claimant’s voice in the courtroom during the A. H. Robbins bankruptcy case.  More than 200,000 women ultimately received modest settlements from the Dalkon Shield Trust Fund.

In 2004, she published an online Medscape CME course titled “Women’s Sexual Problems — A Guide to Integrating the New View Approach.” She also developed a successful online course titled “Ministry, Sexuality and Congregations” for the Center for Sexuality and Religion. She is currently a member of the New View Campaign, which advocates against the medicalization of women’s sexuality. She is also a member of the consortium on sexuality and aging.

Dr. Hicks is an activist, researcher and educator whose work has impacted the health and well-being of many women.  Her work on the Dalkon Shield IUD took her from the kitchen table to courtrooms and Congress. In addition to the classrooms and online courses noted above, she has also facilitated workshops on many topics related to women’s sexual well-being, including body image, teenage pregnancy prevention, menopause, and sexuality in aging and aged populations.  I believe she deserves to be called a “Women’s Health Hero.”

The Center for Reproductive Rights has launched a campaign to raise awareness of the continuing prescription status of emergency contraception for young women, while older women have over-the-counter access – and they’re doing it with bunnies.

As the bunnies note:

Bunny 1: Wait, I thought you didn’t need a prescription anymore.
Bunny 2: You don’t. But you still have to go to the pharmacist, show your ID, and if you’re lucky, escape without the Stares of Shame.
Bunny 1: Yikes. Why can’t you buy it like a condom?
Bunny 2: Excellent question. Scientists say there are no medical grounds for limiting access to emergency contraception. But instead of putting our health first, the Food and Drug Administration overruled their own scientists and bowed to political pressure.
Bunny 1: Whoa.

The video further explains that “On March 23, 2009, the Center won a major victory when a judge ordered the FDA to reconsider making emergency contraception available over-the-counter to women of all ages. A year later, the FDA still isn’t moving forward. Even though there is no scientific basis to continue restrictions on emergency contraception.” The full decision in that case is available online from the Center, and includes the judge’s conclusion that:

…no useful purpose would be served by continuing to deprive 17 year olds access to Plan B without a prescription. Indeed, the record shows that FDA officials and staff both agreed that 17 years olds can use Plan B safely without a prescription. The FDA’s justification for this age restriction, that pharmacists would be unable to enforce the prescription requirement if the cutoff were age 17, rather than 18, lacks all credibility.

This can be a bit confusing (as we noted in this previous post), but Plan B was initially approved for non-prescription access only for women 18 and older. A generic version of Plan B (called Next Choice) and Plan B One-Step have since been approved for OTC status for women 17 and older, but all forms are prescription-only for women 16 and younger. The judge’s ruling mentioned above concerns the continuing lack of OTC access to the original Plan B for 17 year old women.

The Government Accountability Office, in its 2005 report [PDF] on irregularities in the FDA’s initial decision to deny over-the-counter status for Plan B, also identified the approach to access to the drug for younger women as one of the unusual aspects of the decision-making process. The report disputed the behavioral rationale used in the denial as well as the claim that it was invalid to extrapolate data from older to younger adolescents, and  noted that there are no age-related marketing restrictions for any other FDA-approved contraceptives and no identified safety issues that would require age-related restrictions.

Supporters are being asked to contact the FDA and ask the agency to remove restrictions on access to emergency contraception for young women.

A recent ABC news piece and two new journal articles (in The Lancet and Obstetrics and Gynecology) have drawn attention to an emergency contraception drug that is not currently available in the U.S. but apparently has been submitted to the FDA for review.

Emergency contraception pills (EC) currently available in the U.S.  are intended to be taken within 72 hours (3 days) of unprotected intercourse or contraceptive failure.  The drug new drug, ellaOne (ulipristal acetate), can be taken within 120 hours (5 days), providing a longer period in which to prevent pregnancy. [It's worth noting here that women have long been advised that existing EC options can also be taken up to 5 days after intercourse, although that's not the "official" approved recommendation on the drug inserts].

Anti-choice groups such as the American Association of Pro-Life Obstetricians and Gynecologists argue that the pill could cause abortions and be an OTC abortion pill in the U.S., using a definition of “pregnancy” that includes a non-implanted fertilized egg, a definition that is generally not medically or scientifically accepted. These arguments were also presented during debate over the approval of Plan B.

The Lancet study compared ulipristal acetate (30 mg) with levonorgestrel (1.5 mg, the drug in Plan B) among adult women in the US and UK seeking emergency contraception within 120 hours of unprotected intercourse.

The women were followed for pregnancy outcomes, and both drugs significantly reduced the expected pregnancy rate, with the outcomes demonstrating that ulipristal was not inferior to levonorgestrel at preventing pregnancy.

The researchers also looked at rates of pregnancy among those 203 women who received one of the drugs 72-120 hours after unprotected intercourse. They found reduced rates of pregnancy: 0 in the ulipristal group, and 3 pregnancies in the levonorgestrel group, a statistically greater reduction in the ulipristal group (although a couple of changes either way might make a big difference in this result).

The second study, in Obstetrics and Gynecology, also looked at efficacy of ulipristal acetate over various time periods, up to 120 hours, and seemed to demonstrate continuing efficacy beyond 72 hours.

Both studies were funded by the company that owns ulipristal acetate.

A librarian note: searching PubMed for ulipristal acetate only returns a few citations; a search for “CDB 2914″[Substance Name] OR “CDB-2914″ OR “ulipristal acetate” OR “ellaone” is more comprehensive.