Contraceptive Development and Family Planning
TABLE OF CONTENTS
I. INTRODUCTION
Better contraceptives and improved family planning service delivery systems have great potential to help stem the global epidemic of unintended pregnancy. Every year, of 179 million pregnancies, 79 million are unplanned or unwanted—a number about equal to annual world population growth.
The Global Health Council estimated that between 1995 and 2000 there were more that 300 million unintended pregnancies in developing countries that led to nearly 700,000 deaths from unsafe childbirth and unsafe abortion.
Unintended pregnancies also contribute to the rapid population growth that impairs desperately needed social and economic progress. If family planning programs are not strengthened and more successful, and if current fertility were to remain unchanged, world population would increase in size from the current 6.2 billion to 13 billion in 2050, rather than to the 8.9 billion estimated by the UN.
The reasons for high fertility in developing countries are complex but past experience makes it clear that improved contraceptive technology and improved delivery of family planning information and services can help lower fertility and make an important contribution to reproductive health in all countries.
As is the case in developing countries, almost half of all pregnancies in the U.S. are unintended. And, as in poor countries, unintended births often deprive young women of educational and occupational opportunities.
An important goal of the Center is to conduct sound research to allow evidenced based decisions relating to contraception, family planning and other preventive reproductive health methods.
I.A.The Potential of Expanded Contraceptive Choices
Many women and men will not use contraception because of their fears about contraceptive safety or side effects. Many others discontinue use because they did not find a method suitable—often because of unpleasant side effects. And many others have an unintended pregnancy because of contraceptive failure relating to difficulty of proper use or unreliability of the method.
Development of new and improved contraceptives that are more effective, safer and free from undesirable side effects would make an important contribution to helping individuals gain full control over the number and timing of childbearing. Experience shows that each new contraceptive method increases overall use because a greater variety of options increases the odds that every individual will find a method that meets his or her needs.
I.B.The Role of Improved Contraceptive Delivery Systems
An extensive body of research to evaluate family planning service delivery systems has brought about improvements in both the efficiency and effectiveness of family planning and reproductive health programs.
II. RESEARCH
The Center is contributing to a 25-year record of clinical research at UCSF to develop new contraceptives and to ascertain their effectiveness, safety, patient acceptability and best use. New ways of distributing emergency contraceptives, of reaching male clients, and of serving immigrants and other diverse populations are just a few of the many important advances developed and proven by the Center through delivery system research.
II.A. Contraceptive Development
Studies have made major contributions to the development and introduction of most of the new contraceptives that have been introduced since 1970. They have included:
- A decade of study of vaginal contraceptive rings that contributed to recent FDA approval of the first ring to be introduced for general use in any country, NuvaRing®.
- Studies of contraceptive steroids that can be delivered transdermally through skin patches resulted in approval of Ortho Evra®. A current study is comparing use of the patch and oral contraceptives when used by adolescents.
- A comparison of the cervical cap to the diaphragm that led to FDA approval of the cavity-rim cervical cap.
- A study of the acceptability and effectiveness of the polyurethane condom.
- Studies of various types of contraceptive implants, two of which are approved by the FDA (6 capsule Norplant® and 2 rod Jadelle®) and a third implant which should be approved soon (single rod Implanon®). Long-term studies are evaluating use of implants.
- Studies that led to FDA approval of a once-a-month injectable contraceptive with improved bleeding control, Lunelle®. Studies of the self-administration of injectables are underway.
- Center clinicians have helped to evaluate a frameless copper IUD that is now in use in Europe, that should increase use of the IUD, a safe and effective method that is underused.
II.B. Family Planning Research and Programs
- Emergency contraception (Plan B®) reduces the risk of pregnancy by 89% if taken within 72 (or even 120) hours of unprotected intercourse. The Center demonstrated that distribution of emergency contraception to high-risk adolescent and young adult women in advance of need (advance provision) increases use of the method and does not lead to higher rates of unprotected intercourse. These findings encouraged the American College of Obstetrics and Gynecologists (ACOG) and the American Medical Association (AMA) to support advance provision of emergency contraception. Recent State of California legislation that makes emergency contraception directly available to women through pharmacies without a doctor’s prescription is being evaluated by the Center.
- Center studies demonstrated that provision of oral contraceptives without a mandatory pelvic exam does not appear to substantially place women at higher risk of cervical cancer. This streamlined policy for access to oral contraceptives expands access to this effective method. These finding have been widely disseminated and are changing clinical protocols and policies.
- Involving young men in family planning and reproductive health programs has never been easy but by offering culturally appropriate services, a Male Clinic at the New Generation Health Center has successfully attracted increasing numbers of male clients.
- Innovative Center programs in San Francisco and elsewhere are also meeting the needs of diverse populations.
II.C. Family PACT (Family Planning, Access, Care and Treatment)
The Center provides evaluation, monitoring, and technical support for Family PACT, the California state family planning program. Legislation to establish the program was enacted in 1997 with the goal of by expanding access to contraception, basic reproductive health education and services for low-income women and men. Prior to Family PACT, state-funded family planning services were provided through a small network of public clinics, serving approximately 525,000 women annually and rates of unintended pregnancy, abortion, and teen births were high. This program met about 30% of the need for publicly funded family planning services.
Evaluation data and analysis of the first four years of the new program, found that the number of clients served increased to almost 1.2 million, and unmet need was reduced from 70% to 37%. Annually, approximately 1.2 million clients receive services from approximately 6,500 private providers and public clinics. The dramatic improvement in contraceptive use attributable to Family PACT services resulted in at least 108,000 fewer unintended pregnancies during fiscal year 97/98 in the state, and consequent cost-savings of almost $400 million in state and federal expenditures on medical, social and educational services that would have been needed as a result of these unintended pregnancies. Based on these findings, the state applied for and obtained a federal Medicaid waiver expected to provide more than $900 million over five years.
It is planned to provide assistance to policy makers in other states now planning to develop and implement programs similar to Family PACT. Current evaluation activities for the California program will continue to measure overall program effect on unintended pregnancy, cost of services, and will also assess the (relative) effectiveness of new “demonstration” models for outreach to three hard to reach population groups: adolescent women, low-income men, and low-income women living in areas of high unmet need.