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Contraception and Abortion

File this with the other studies that confirm what most people would have predicted.

Freebirth controlled to greatly lower rates of abortions and births to teenagers, a large study concludes, offering strong evidence for how a bitterly contested Obama administration policy could benefit womens health. The two-year project tracked more than 9,000 women in St. Louis, many of them poor or uninsured, who were given their choice of a range of free contraceptives.

If there's anything surprising about the finding, it is perhaps the magnitude. The study group's abortion rate was less than half that of the control group[women in the St. Louis Metro area] and a third of the national rate.UPDATE: Here's a link to the actual study. I also updated the language in the post because the original wording inaccurately referred to a "control group." The study did not use one.

About the Author

Eduardo Moisés Peñalver is the Allan R. Tessler Dean of the Cornell Law School. He is the author of numerous books and articles on the subjects of property and land use law.

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How is it that free birth control was available to teens for two years, if the contraceptive mandate wasn't even hatched until earlier this year?

It was available because people were able to provide free contraceptives before the Affordable Care Act. There is a space between prohibited and mandatory.

When you participate to a medical or social or whatever research you get free meds...

Wouldn't any rational consideration of these study results cause Catholic hierarchs to RETHINK their discredited ideology about contraception AND abortion??? [I purposely wrote HIERARCHS because the vast majority of Catholic women are far, far ahead in their thinking and values about contraception and choice.]In any sense, this opportunity for hierarchs to rethink their positions is a tremendous gift to the hierarchs, only if they were not so blinded by their lust for political power and misogyny. It really would be a twofer for them: 1. Dramatically drive down the number of and NEED for abortions - a very good thing for both women and the unborn! 2. Make peace with women by acknowledging their competency and self-agency to make choices about their reproductive lives.While I will always remain a happy-clappy optimist, I have to believe that the hierarchs are just too chained to their anti-feminine ideology to recognize a gift horse when they see it.Come on, bishops: Jump into the 21st century!

Here's what the study did: recruit 9,256 women in St. Louis to get free IUDs or implants. In order to join the study, they had to be sexually active but wanting to prevent pregnancy in the next 12 months. What's wrong with the study? 1. The women in the study were compared only to the rest of St. Louis and to women nationwide. That is not an actual "control group," contrary to Eduardo's misunderstanding above. It is also not a good comparison to make. 2. Why? The women who were so motivated to prevent birth that they were willing to sign up for such a study are almost certainly very different from all other women. This is a very bad thing; it introduces what we social scientists call "selection bias." 3. A good study would have taken the 9,256 women who signed up and randomly assigned half of them to get the birth control and half of them to get nothing, and it would have followed them over time to see whether their birth/abortion patterns changed. Then we would at least have known that the group of women who got the birth control had started out, on average, as very similar or identical to the group of women who got nothing. Then, if birth and abortion changed over time, it would be likely due to getting the free birth control, not to pre-existing levels of motivation or anything else. But with no control group and no before/after comparisons, this study provides literally zero information about the impact of a free birth control program. All the authors should have said is that the subset of women who are motivated enough to sign up for a study on IUDs/implants have relatively low birth rates and abortion rates, but even then they couldn't truthfully say that they had demonstrated a result the program per se, because such motivated women might well have found another way to prevent births even without the program. The study's conclusion may accord with one's intuitions, but it is still a bad study that should never have been published.

In reply to your lead question, Jim Jenkins, the answer is a firm "No!".Roman Catholic hierarchs are beholden to the Vatican. They were appointed by JPII for their firm (quote)orthodoxy(endquote). They are "Yes Men", "careerists", "sycophants" (a $20-word, as we all know, for "suckups").They don't aspire to William Morris' treatment by B16.They live in "La-La Land" or in fear.

Speaking of bishops:It has now been a day short of 30 calendar days since a U.S. bishop affiliated with Opus Dei has been convicted of failure to report possession of child pornography by one of his clerics. By definition, the guy --- the bishop, that is --- is a convicted criminal.And he's still the official bishop of a diocese.Not a peep (so far as I know) from the local church.Not a peep from fellow hierarchs.And not a peep from the Vatican.Go figure.

Stuart,I think you are missing some of the interpretations of the study. The significant finding, it seems to me, is that when women get good information and free contraceptives, they choose the more expensivebut also significantly more effectiveforms of birth control. It has been argued here (by you, as I recall) that birth control is cheap and that women can afford to buy it themselves. But that is true if you are talking about cheap generic oral contraceptives from Walmart, not the long-acting, reversible contraceptives (LARC). The criticism of the findings by conservatives in the version of the story I read was that contraception use results in more pregnancies because people using contraceptives have a false sense of security, engage in more risky behavior, and don't use contraceptives consistently and correctly. I don't find that particularly credible, but in any case it is not relevant to those using LARC, since one implant or IUD will work for years. I don't think the kind of study you outline would be workable or ethical.

The IUD is an abortifacient. Using the IUD does not reduce the number of abortions; using the IUD causes abortions.

"It was available because people were able to provide free contraceptives before the Affordable Care Act."Exactly right.While the results of this study are mildly interesting, and, as Eduardo says, not very surprising (it turns out that when there are fewer pregnancies, there are also fewer abortions), this study doesn't address what the Catholic Church finds objectionable about the contraception mandate. As Cupcake notes, and as many of us have noted here numerous times, subsidized and even free contraceptives have been available for years; and there are ways to increase that subsidy without forcing Catholic employers to cooperate.It is the forced cooperation that it objectionable.

Let's just bring it all out in the open, shall we? Let's speak plainly here.Are you advocating the distribution and use of contraception?

"Wouldnt any rational consideration of these study results cause Catholic hierarchs to RETHINK their discredited ideology about contraception AND abortion??? "I think this woman posited the best solution for dealing with Catholic lowerarchs: ""To the hard of hearing, you shout, and for the almost-blind you draw large and startling figures." (Flannery OConnor" "Are you advocating the distribution and use of contraception?" Not only YES, but HELL YES!!! Is that out in the open enough for you?"Come on, bishops: Jump into the 21st century!" A large number of us would be happy if they could make it into the 20th century, their medieval costumery, titles and pretense of authority notwithstanding.

A copy of the study link should be forwarded for information to the authors of the latest contribution to the Celibates for Marriage campaign. The Children of Mary order of nuns in Ohio has posted a YouTube video on the truth about contraception. They point out a number of undesirable effects associated with contraception, including confusion induced in male monkeys when (monkey) females were injected with birth control drugs. As often seems to occur, they apparently ignore (or are unfamiliar with) the large array of significant physical, mental, emotional, and social effects women experience over years when they have a child or several. http://www.dispatch.com/content/blogs/the-compass/2012/09/contraception-... http://www.youtube.com/watch?v=auv6c0-FsjU&feature=plcp

"Are you advocating the distribution and use of contraception?"I suspect the answer is "Yes." If I understand Church teaching corrrectly, the use of artificial contraception is intrinsically evil. If so, the results of the study are irrelevant to bishops.

I've updated the post to respond to Stuart's correction regarding the control group. Thanks for pointing that out. I disagree that the absence of a control group makes the study worthless. Although there is surely a selection bias, the point of the study is, as David Nickols observes, to demonstrate that women with access to free medical advice and contraception will change their birth control methods in ways that cost and access to information would not otherwise have allowed them to do. In this case, the study authors note that among the criteria for inclusion in the study were that the participant not currently be using a long-term contraceptive method. The study results (75% adoption of long-term contraceptive methods) at least suggest that medical advice and free access increases use of long-term contraception (and therefore reduction in unwanted pregnancy and abortion) over the baseline provided by the prior behavior of the study group itself. I agree that you probably would not see such a large drop with a less motivated population, but unless you think access to information and cost are not barriers at all, it seems likely that you'd still see a significant reduction.

There seems to have been recently a Swiss study seeking t explain why Switzerland has an unusually low rate of abortions. "In 2011, the rate was 6.8 per thousand women aged between 15 and 44. This is remarkably low compared to the United Kingdom (17.5), France (15 in 2009) and the United States (16 in 2008), for example. . . . Sexual health experts point to three main factors: education, contraception and socioeconomic level."(that last refers to the relative wealth of Switzerland, and presumably to the fact that income inequality there is a good deal less than it is in the US, or the UK for example.)The rate of unwanted pregnancies is thus relatively low. Of course if one equates contraception and abortion morally (i.e., abortion is no worse than contraception, or if you prefer, contraception is no better than abortion), such a study will make no difference. Here is a news story on the subject, in any case. http://www.swissinfo.ch/eng/swiss_news/The_secret_of_Switzerland_s_low_a...

The problem with studies like this, other than the obvious technical problems pointed out by others, is that they try to use 'science' or 'data' to tell us how we should act. Unfortunately, science can really only tell us what is possible, we then have to use moral judgement to decide what we ought to do. This study provides no information in that regard.

Close, Eduardo, but still not quite. The relevant criteria were that women had to be: want reversible contraception, not be currently using such a method OR be willing to "switch to a new reversible contraceptive method," plus either be sexually active or plan to be sexually active in next 6 months, plus not want pregnancy in 12 months. Plus, implicitly, be motivated and willing to sign up for a study. I would grant, just as matter of common sense, that in such a tightly defined and selected group of women, giving them a thing for free that they already wanted, and perhaps were already using, results in them getting that thing. Yes indeed. But we do NOT know how much (if at all) giving out that free thing caused a "reduction in unwanted pregnancy and abortion." That is IMPOSSIBLE to know given the lack of a good study design. The study provides absolutely no way of knowing or guessing the counterfactual -- how much these particular women would have avoided pregnancy or abortion anyway. That's what a good randomized design would have revealed. Randomization would show how the same group of women, with the same motivation to avoid pregnancy and the same conscientiousness that led them to sign up for a study, would have behaved without the free IUD.

@ Bruce:As my sainted sixth-grade teacher, Sister Mary Adelaide, would often remind us: "Grace builds on nature, buddy! Science is just another way of knowing God."It has been my experience that when nay-sayers base their arguments on "obvious technical problems," it is a good indication that they have already lost the argument.

Jim,I think you misunderstood Sister Mary Adelaide. Science taught us how to build nuclear bombs; I highly doubt God wants us to use them. And moral behavior is not determined by who wins the argument or popular opinion.

"The women who were so motivated to prevent birth that they were willing to sign up for such a study are almost certainly very different from all other women"Stuart, even a non-"social scientist" can see that women who wanted to have a birth in the next twelve months are not pertinent to the study.

Jim -- the fact that this study is amateurish and weak, rather than careful social science, is not a mere technicality.

"I think you misunderstood Sister Mary Adelaide. Science taught us how to build nuclear bombs; I highly doubt God wants us to use them."Of course God does! After all, was not the Shining City on a Hill, this Most Favored of Nation of God given the gift of inventing and perfecting the very first one? Did God not allow the good old US of A to use one --- twice? Little atomic ones, admittedly. But that's like learning to crawl before you walk to the Really Big One.

Are you advocating the distribution and use of contraception?Bender,Our tax dollars have been supporting it ever since Richard Nixon signed Title X into law in 1970. I certainly think it is a good thing to make contraception easily and cheaply available to all who want to use it. It is a matter of public health and has been considered so for forty years.

It is worth being clear on the purpose of this exercise, given on p. 2 of the Peipert et al. article. This work was reasonably done in light of prior work, identified in the references, and the fact that few studies (p. 5) have investigated whether increasing the uptake of LARC methods decreases unintended pregnancy, as the authors explain. Their aim has everything to do with the sample population selection and characterization. Strengths and limitations of comparisons among various populations, of concern above, are discussed in detail on pp. 5-6. "The objective of the Contraceptive CHOICE Project was to promote the use of LARC methods and to provide no-cost contraception to a large number of women and adolescents in our region in an effort to reduce unintended pregnancies. The primary population-based outcomes for our study were the rate of teen births and the percentage of abortions that were repeat abortions."

A note for bishops (See p. 4) - 9256 study participants were given a choice of free contraceptive method after being briefed on alternatives. 3 chose NFP.

Abortion is thought to be a bad thing. The use of very effective kinds of contraception, like the IUD which does away with the worry that parients will not actually use the contraception as it's meant to be used (like m issing pills), reduces abortions because there are fewere unwanted pregnancies.If you want to reduce abortions, to refuse to use contraception, and thus to allow more abortions to take place, makes no sense, especially when the refusal is based on a Vatican doctrine that was almost flipped by V2, by the pope's own birth control commission, and which is disregarded by almost all Catholics. But I think the real issue for the Vatican and conservative Catholics is not reducing abortion. It is instead trying to control the lives of women. It won't matter to them that contraception reduces abortion.

As everyone here knows, I do not accept Catholic teaching on contraception, I had a tubal ligation in my 40s, and I pulled myself out of the communion line as required. However, I am uncomfortable with statements like Crystal's that they are "trying to control the lives of women." In my own view, strictures against artificial contraception are part of the Church's reverence for life and procreation.Sadly, however, where NFP is not deemed sufficient to prevent a pregnancy that would do real harm to a woman and her baby, the couple must forgo any sort of marital relation or sexual closeness that does not result in a "complete" act. Prayer and grace and separate rooms can help a couple kill that desire for sex (you "lose it if you don't use it").But the marriage will suffer as a result.And the Church must know that or Casti Connubi would not have put such a high premium on the unitive function of sex within marriage.(Please do not write me offline about this; I realize this is a heretical POV, and you can so so right on here.)

Sr. Mary Adelaide misunderstood the maxim. It's not that grace "builds on nature." That would be a two-story theory of salvation which everyone (Thomas, de Lubac, de Lubac's modern critics) would all reject.The maxim is "Grace elevates and perfects nature." Grace doesn't stoop down except to elevate. We're Catholics, after all.

All hell breaks loose when a study doesn't confirm the liberal catechism (cf. the Regnerus study) but this St. Louis gem will no doubt win plaudits from Planned Parenthood and I expect it will be cited as authoritative by Obama, Pelosi, and Biden. I doubt if Washington U will question the expertise of the researchers and certainly will not investigate as closely as happened with the Regnerus study. "A sociologist whose data find fault with same-sex relationships is savaged by the progressive orthodoxy."http://chronicle.com/article/An-Academic-Auto-da-F-/133107

Jean, your honesty is refreshing.

I remember the first time I read about the history of the church's stance on contraception. I hadn't been a Catholic for very long and I hadn't any idea that the stance was so fraught with dissent until I read John O'Malley's book, "What Happened at Vatican II" (if anyone is interested, I quoted from the book here). What I found was that a majority of the bishops at the Council wanted contraception to be acceptable, that a Catholic doctor, John Rock, had been one of the creators of the birth control pill, that the problems of overpopulation and poverty, and the positives of unitive affection iregardless of childbearing, made a big impact on those present, and that the pope's own Commission on birth control advised that contraception be allowed. But the minority opinion won out and for shameful reasons ...."If it should be declared that contraception is not evil in itself, then we should have to concede frankly that the Holy Spirit had been on the side of the Protestant churches in 1930 [when Casti Connubii was promulgated) and in 1951. It should likewise have to be admitted that for a half a century the Spirit failed to protect Pius XI, Pius XII, and a large part of the Catholic hierarchy from a very serious error. This would mean that the leaders of the Church, acting with extreme imprudence, had condemned thousands of innocent human acts, forbidding, under pain of eternal damnation, a practice which would now be sanctioned. The fact can neither be denied nor ignored that these same acts would now be declared licit on the grounds of principles cited by the Protestants, which Popes and Bishops have either condemned, or at least not approved."Lives are at stake, women's lives and also the lives of those aborted. It just seems nutty to me to not take advantage of something that will help save them.

"based on our calculations in Table 3, changes in contraceptive policy simulating the Contraceptive CHOICE Project would prevent as many as 6278% of abortions performed annually in the United States."The paper implies a possible policy measure: at abortion clinics, at the time of an abortion, offer LARC contraception for free. The study suggests that this could be an extremely effective measure to prevent repeat abortions.Humanae Vitae prevents anti-abortion Catholics from lobbying for a measure along those lines.

Euthanasia and eugenics would result in a dramatically healthier population, too, Eduardo.

I note that in spite of the healthcare reform, IUDs are now considered "medical" devices, not contraceptive devices, so insurance companies can still refuse to cover them.

Hi Stuart Buck: I find your comments biased and inaccurate. You claim that the study lacked control groups and, therefore, was "worthless." In the first place, you mischaracterize the study. You claim that the study lacked control groups. This is incorrect. The control groups were women in the greater St. Louis area and also in the USA as a whole. You apparently feel that the definition of a "control" group is restricted only to control groups in prospective, randomized studies. While these latter studies are widely considered to be gold standard studies, it is utterly incorrect to assert that the only valid clinical trials are prospective, randomized trials. The overwhelming majority of peer reviewed clinical trials are not the type of prospective, randomized trial which you maintain are the only non-"worthless" trials. The study which you trash and dismiss out of hand was a peer reviewed study, performed at a top 10 US medical school, and published in a high impact factor medical journal (Obstetrics & Gynecology). The results obtained were, by any standard, simply stunning. Abortion rates were 1/2 to 1/5th those seen in the control groups. In the case of teenagers, the abortion rates were less than 1/5th of those seen in the control groups. You claim that these good results simply reflect "selection bias," by study participants who were "highly motivated." Motivated to do what? Abstain from sex? Kindly explain what type of "highly motivated" behavior in the study population in question could have produced these utterly stunning results?Let's look at the study population: "The women were aged 14 to 45, with an average age of 25, and ***many were poor and uninsured with low education***. ***Nearly two-thirds had had an unintended pregnancy previously***. Participants were either not using a reversible contraception method or willing to switch to a new one.* http://healthland.time.com/2012/10/05/study-free-birth-control-significa... Sagan said that extraordinary claims require extraordinary proof. The converse is that ordinary claims require only ordinary proof. No single scientific study ever answers all questions and all studies have weaknesses which can be criticized. So this study must be evaluated in the context of other available information. What is some of this available information?Half of all pregnancies are unplanned. Of the unplanned pregnancies, 40% end up with abortion. It is a very ordinary claim to assert that reducing unplanned pregnancies would, therefore, reduce abortion. It is a very ordinary claim to assert that providing contraception with a proven 99% effective rate (shown in other studies) would reduce unplanned pregnancies. The dramatically low abortion rates observed in this otherwise high risk study population, in comparison with entirely appropriate (if non-gold standard level) control groups, provides powerful support for a very ordinary claim, with the claim being utterly consistent with common sense. Other real world data include the extremely low abortion rates of native born Dutch. The Dutch have legal drugs, free love, legal prostitution, and free abortion on demand, but they also have not only free contraception, but free contraceptive counseling -- the latter two being components of ObamaCare. And they have an abortion rate on the order of that seen in the St. Louis study, or even a bit lower, which is a fraction of the rates observed in the USA, which has substantially greater restrictions on abortion - both legal and economic.You (Stuart Buck) refer only to IUDs (which do indeed work through a mechanism which meets the Catholic definition of abortion, though not the traditional definition, which is interruption of an established pregnancy, which doesn't occur until the micro-embryo has successfully implanted on the uterine wall). This leads me to seriously question your objectivity. Why you only mention IUDs. In point of fact, study participants were also given the option to use equally effective long term implants, which do not work through a "Catholic abortion" mechanism, and many did choose this latter option. Contraceptive techniques succeed when they are either used properly or when they are idiot-proofed (or, rather, libido-proofed). IUDs and implants are idiot/libido-proofed. Oral contraceptives and even condoms can work pretty well, when used properly, which requires instruction and counseling, including follow-up for reinforcement. Poor women can't afford the libido-proof methods and can't afford the counseling (especially with Planned Parenthood being targeted for shut down). I've pointed this out before, but Pope Paul's famous Humanae Vitae states explicitly that lesser evils may be tolerated to avoid greater evils. His Holiness did not conclude that contraception can be tolerated to prevent abortion, but, at the time of Humanae Vitae, abortion was not as widely available to the extent it is today. A little extrapolation of the results from the current study indicates the credible potential of reducing US abortions by over 800,000 per year, by expanding the St. Louis program nation-wide.And the study "was not worth publishing?" O.K. Your turn: what is your suggestion for a plausible method to reduce US abortions by 800,000 per year? Kindly propose a method and outline the design of a study to prove that your method works.I agree that a prospective, randomized, placebo controlled trial would be completely unethical, given the results of the St. Louis study, in the context of all other existing information and common sense expectations. You really think it's a good idea to kill all those babies in the control arm, just to satisfy your entirely unreasonable armchair objections?- Larry Weisenthal/Huntington Beach CA

Is "extraordinary" proof like being "very" pregnant? Proof be proof.Note, one of the first laws of logic is that just because Statement A is true, that does NOT imply that the converse of Statement A is true. For example, assume the following statement is true:All men are rational.The converse of that statement is:If you are not a man, you are not rational.Though there may be evidence for that, it is not a true statement.

Larry -- there's no question that this study set-up is about as badly designed as one could imagine. Even short of randomization, they could have created a control group of sorts by finding women who were similar in all other respects, including pre-existing pregnancy and abortion rates, and then following both groups of women over a long period of time. Such a prospective cohort study would have been far better than what they did. Even that design is fairly weak, because it still doesn't do anything to address selection bias (which you purport not to understand: as I already said, women who are so highly motivated to avoid pregnancy that they sign up for a study like this are almost guaranteed to be different from women who are not so motivated, and women who are that motivated would behave differently even without the intervention). The point about the Dutch is silly, and further shows that you do not understand the basic scientific reasons that we want to have actual evidence rather than anecdotes. One might as easily point out that the abortion rate in Mississippi is already 4.6 per 1,000,* which is HALF the Dutch abortion rate that has for some reason impressed you.** Does that mean that we should all mimic the policies and economy of Mississippi? No. It's just an anecdote. * See http://www.guttmacher.org/pubs/sfaa/mississippi.html** See http://www.cbs.nl/en-GB/menu/themas/bevolking/publicaties/artikelen/arch...).

The discussion on this is wrong headed. If we give our girls oral contraceptives it precludes men from having to consider her as a person when making the deciision to have sex. In other words it makes her an object. If a man has to think about bringing a condom, will it break, will she get pregnant, what wil we do then, makes him at least consider the woman as more than an object. Of course there are men who will not care either way but seeing which men will consider these thing can actually clue a woman in to who the most desirable men are. If he cares enough about me to: Being a condom, delay sex, or dicuss possible pregnancy isn't he a caring man who will protect me and think of me as a person not an object. If we just give our girls birth control we give them tacit approval for incorrect behavior and send them the wrong message on spiritual growth. If we solve a problem from the physical end doesn't it preclude solving it fom the spiritual end.

Patricia--I think you've said many insightful and important things. But do women really view a male contraceptive as a sign of a man's love for her? I hope this doesn't come out wrong, but is that all it takes?

Hi Stuart,The Netherlands has 18 abortion clinics in a country of 16,000 square miles, with excellent public transportation, where abortions are free of charge, on demand. Mississippi has a single abortion clinic in a state of 48,000 square miles, and this clinic has had great difficulties in staffing. It is perfectly legal to cross state lines to have an abortion in the USA and the abortion rates in Louisiana, Alabama, Georgia, and Tennessee are all similar to the abortion rates in the local control group in the St. Louis study, while the abortion rates in Florida are much higher than those in both the local and national control groups in the St. Louis study.I asked you several direct questions, but you didn't address any of them. Your comments on this blogpost remind me of a politician -- ignore the questions and keep repeating the talking points.The medical journal which published the Washington University study (Gynecology & Obstetrics) accepts and publishes letters to the editor. Why don't you send in a comment there, concerning the present study, where your comment can receive actual peer review? In the meantime, we'll all have the opportunity to read comments from medical and public health professionals, which I'm certain will be shortly available.I stand by everything I wrote previously. - Larry Weisenthal/Huntington Beach CA

I think Patricia makes some sense re birth control for teenagers who aren't married. They're in a different situation than partners in a licit marriage.

P.S. (and this will be my final comment, as I don't think it's helpful when two readers start monopolizing bandwidth with back and forth debate): I forgot to address two of your statements. Firstly, I quoted the Dutch abortion rates for native born Dutch, which are, in fact, about 1/4 of those in the US as a whole and of a similar magnitude to the St. Louis "intervention" group. The Netherlands has a very large immigrant community, with poor language skills and without similar education and utilization of counseling as in the native born Dutch segment, but with access to the free abortion on demand. Doubtless both native and immigrant Dutch have similar access to and utilization of sexual opportunities. It seems very likely that differences in abortion rates are owing to differences in the utilization of effective contraception methods -- just as in the different groups in the St. Louis study.The prospective cohort study design you propose would have been prohibitively expensive (you'd have to recruit and pay volunteers and the process would, itself, introduce bias, in the control group). The excellent Washington University study we are discussing directly answers the following question: what is the abortion rate in a very large group of relatively poor, urban women when they are offered free access to effective contraception? The clear answer is that the abortion rates in such women ranks with the lowest abortion rates in any geographical jurisdiction in the world with legal abortion. This sets the bar for all other programs to follow; for example, abstinence based programs.- Larry Weisenthal/Huntington Beach CA

"I remember the first time I read about the history of the churchs stance on contraception. I hadnt been a Catholic for very long and I hadnt any idea that the stance was so fraught with dissent until I read John OMalleys book."As a fellow convert, Crystal, nothing in RCIA, as I experienced it, prepared me to live my life as a Catholic wife. The RCIA ladies took us women aside and told us that we could not, under any circumstances, have an abortion, and beyond that, "marital decisions" were up to our consciences.I lulled myself into thinking that there were probably caveats that allowed women to use artificial contraception or sterilization specifically to prevent pregnancy for health reasons. In truth, I should have looked this up in the CCC we were given. I would have realized that I was not ready to accept the no-contraception-ever rule, and would not have gone through the RCIA rite, which, given my beliefs then and now, was probably not even valid.Trying to be as Catholic as possible (which, of course is not really being Catholic) has made me a better person and Christian in many ways. But being married to someone for whom conversion "took" is not always a picnic. I try to hope God will understand and forgive more than those who promulgate rules for His people here on earth.

I didn't respond to most of your points because they are so wrong. But here goes: 1. You don't know what a good control group is if you think that the rest of a city or the country are a good basis of comparison. 2. You mention the academic prestige of the individuals and the journal. This may impress people who don't know anything about science. But anyone who has studied econometrics and causal inference knows that social science and even hard science journals are full of faulty articles that make causal claims far beyond what they can support. This occurs for many reasons (publication bias, etc.), and bad study design is just one reason. Nutrition and epidemiology are fields that are especially notorious for making causal claims that are unsupportable.3. As I already said, the study's finding is indeed "common sense" as you put it. Giving people a free thing results in them having more of that free thing. That still doesn't mean that the study has any basis for making a causal claim as to having actually REDUCED the abortion rate in anyone. In order to make a causal claim, you simply have to have some idea of what the counterfactual is. In the presence of selection bias, and with no valid control group, the study can't say what the counterfactual is. Given that these women were highly motivated to prevent pregnancy, they might have done so to the same extent anyway. Or maybe not. Either way, it's unknowable, and it is therefore irresponsible for anyone to claim that they know how much the free contraception actually reduced anything. 4. You keep trying to discuss the Netherlands and Mississippi, as if there's any reason to care. This is missing the point that none of that is relevant in any way whatsoever. You simply cannot determine such matters by cherrypicking one location and saying that you like their way of doing things. This would be as invalid as saying that a high-fat diet is the best, because look at the French. '5. One could learn a lot about causality by reading the following books: Morgan and Winship: http://www.amazon.com/Counterfactuals-Causal-Inference-Principles-Analyt... may be a bit too math-heavy, but Judea Pearl's book Causality is really good: http://www.amazon.com/Causality-Reasoning-Inference-Judea-Pearl/dp/05218...

Also, it's a bit odd to so firmly insist that a randomized trial would have been impossible and unethical, as if there aren't already randomized trials both of these devices, http://clinicaltrials.gov/ct2/show/NCT00653159, and of the idea of handing out free contraception, http://www.ncbi.nlm.nih.gov/pubmed/16202939.

Hi Jean,In my RCIA class, I don't remember sex ever even coming up. Me too, though - if I had realized then what I do now about being Catholic, I'm not sure I could have honestly made the committment. But the way I look at it all now has nothing to do with Catholic "rules" and everything to do with what Karl Rahner wrote (see Peter Nixon's more recent post above, Keryma) ... "The Christian faith is not simply teachings, wise sayings, a code of morality or a tradition. The Christian faith is a true encounter and relationship with Jesus Christ."

Hi Stuart, Although I'd promised not to continue our one on one debate, out of deference to other readers and commentators, I have now obtained and reviewed the full text of the article in question. I obtained this from the Gynecology & Obstetrics web site. I suggest that you do the same. I'll reference and further discuss this full text below.You say that you don't respond to my points and direct questions "because they are so wrong." It is unfair to make a charge like this; you do not give me the courtesy of considering a rebuttal. I have no idea how to respond to an unqualified statement that "my points are so wrong." I can only respond to your direct statements.I am prolonging this debate, because the issue is of self-evident and timely importance, and because I believe that your criticisms are completely unfounded. I don't know your background; I'd wager that you have either a master's degree or PhD in psychology. I say this because of your general reference to general trial design and statistical analysis, without explaining what relevance this has to the present study, and because of prior experience with discussing medical clinical trials data with psychologists.You are hung up on the possibility of "selection bias." This would, indeed, be a problem were this a study to, for example, demonstrate the effectiveness of Weight Watchers diet programs in weight loss. Women who volunteered might indeed be more motivated to lose weight than those who did not enroll. The present study, however, doesn't suffer in the least from this flaw. Quoting from the Methods section, the study design was a prospective cohort study (not merely an observational study). I find that the inclusion criteria consisted of: (1) age 14 - 45. (2) Desired contraception. (3) not currently using a method or willing to switch to a different method. (3) No desire to become pregnant for at least 12 months. (4) Currently sexually active or plan to be sexually active with a male partner, within 6 months. (5) reside in St. Louis region. (6) English or Spanish speaking.The 10,000 study subjects were 50% black, with a median age of 25. Comparison cohorts included age and race standardized population/abortion data from the St. Louis region, from the Kansas City region (which they show is, by demographic data, in their Table 1, almost identical to that in St. Louis, non-metropolitan regions of Missouri), and national USA data, from the year 2008. The data given the greatest attention in the press is simply the abortion rate for the total study population, relative to the control groups (and these are perfectly legitimate control groups, meaning that Eduardo Pealver needn't have amended the original article by saying "the original wording inaccurately referred to a control group. The study did not use one." This "correction," is, in fact, entirely INCORRECT, and Mr. Pealver should correct his "correction."). We have discussed these data. In this very high risk group, the majority of the study participants elected to receive a bullet-proof contraception method, and the group as a whole was found to have abortion rates far below those in the age and race-standardized cohorts and in the nation as a whole. The rates observed were astonishingly low, in comparison with not only the in study controls, but also in comparison with any other published data from large populations in regions where abortion is readily available.But the primary objective of the study wasn't even commented upon, possibly because it couldn't be explained in a one sentence sound bite. They looked at the incidence of REPEAT abortions, in study participants, in the greater St. Louis area, in the Kansas City area, and in non-metropolitan areas of Missouri. They also looked at the total number of abortions in these different regions. The purpose was to see whether the institution of a large scale program of free contraception, using bullet-proof methods, had a measurable effect on the overall and repeat abortion rates in a large metropolitan region (where the large majority of abortions are performed at Planned Parenthood clinics). The study showed that the incidence of repeat abortions went down over the time period of the study in St. Louis (P2=0.002), while it increased during the same period in Kansas City and non-metropolitan Missouri. In addition to showing decreased abortions, there were, not surprisingly, decreased teenage births, in the St. Louis group.The study discussion has a detailed consideration of the strengths and weaknesses of the study, and limitations in generalizing study findings. All studies have these strengths and weaknesses. But the authors conclude: "However, the weight of the evidence, including a marked reduction in teenage births, compared with regional and national statistics, provides evidence of a population effect of the CHOICE intervention." ("CHOICE" being the acronym for the study).Some data are very squishy and even counter-intuitive. In these cases, it is very important to have a prospective, randomized, and preferably placebo-controlled study design. But other studies have striking, clear-cut results, which are entirely consistent with the totality of existing data and also consistent with common sense expectations. The present ("CHOICE") study is one of the latter. The CHOICE study was a prospective cohort study, with entirely reasonable control groups. The results were completely clear-cut, and the implications are profound, if entirely in line with common sense expectations and consistent with the totality of existing data (also considered in the Discussion section of the full text paper).To assert that this important and timely study was "worthless" and "should never have been published," in the context of all of the other remarks made by Stuart Buck, shows that he is pursuing an agenda, as opposed to critically evaluating a peer-reviewed medical publication.- Larry Weisenthal/Huntington Beach CA

I subscribe to this magazine for one reason only and that is because I want to be informed as to what liberal Catholics believe. It is always disheartening to read Commonweal, however because I always feel saddened how many of my fellow Catholics believe they have moved into the 21st century when in fact they have moved closer to the secular, politically correct world. Since the beginning of the sexual revolution we have seen the rise in abortions, unwed teenage mothers, poverty, STDs, and in the 80s the scourge of AIDS in the homosexual and heterosexual communities. This adds up to millions of unhappy, sick and dying human beings. More and more couples are choosing to live together without marriage and now we have the extremely militant far left LGBT community trying to convince the world their way of life is good for the future of our children. These culture wars have been growing stronger with each passing day and in the process we are conducting one big social experiment with the future of our children. When I read Commonweal and many of the comments posted here, I realize the deep division liberal Catholics have with Rome and their fellow Catholics who stand with Rome. We are blessed with such a rich intellectual and spiritual tradition which has stood the test of time. The Church is not perfect and indeed is made up of sinners who with the grace of God are trying to be saints. But in all due respect, if you believe in artificial birth control, gay "marriage," Roe vs Wade, sex outside of marriage, and LGBT lifestyles you would probably be much happier in a liberal Protestant church. Your views would be accepted and welcomed and you would no longer have to try and convince the Vatican and your fellow Catholics who stand with Rome that we are out of touch with the modern world and it is we who should change.

Im a Catholic who appreciates the internally consistent logic of the Churchs teaching on contraception while respectfully disagreeing that such logic can or should be applied universally and without exception. (If any Christian ideal ever called for Niebuhrian realism, this does.) Im also a pediatrician who has prescribed adolescents contraception when medically appropriate. There are countless reasons medical, social, developmental, and moral why adolescents should not be having sex, but one doctors advice, however reasonable, is unlikely to persuade a teenager that s/he can wait when nearly everything else in American culture is saying otherwise. Ive come to see contraception in this age group as a form of harm reduction: intervening to make the harmful consequences of anothers actions. That said, its unclear whether the Washington University in St Louis study can or should be applied as policy. The results of this study fit the current theoretical paradigm (in the sense Thomas Kuhn used that word in The Structure of Scientific Revolutions) that easy access to contraception decreases abortions over the short and long term, but there are large-scale studies that contradict this. These latter studies are often messy, retrospective reviews of national data from European countries. Im often told, however, that Europe has teen sex all figured out and we Americans should learn from them, so I suppose it cant hurt to bring some examples up:K Erdgardh, Adolescent Sexual Health in Sweden, Sexually Transmitted Infections, 2002, 78:352-356 In Sweden, where abortion is free on demand, contraception is inexpensive and readily available, and teen pregnancy has been uncommon, teenage abortion rates increased from 17/1000 to 22.5/1000 from during the study period, 1996 - 2001, with an associated increase in sexually transmitted infections. The author proposes two causes for this: economic stagnation, associated with cuts in school funding and a decline in sexual education, and the exchange of the love script in adolescent sexual relationships for more openly experimental attitudes and behaviour. I dont know what the implications for an American post-Great Recession hookup culture are, but the economically poor adolescents I see increasingly tell me - much more so than their predecessors even ten years ago - that love or affection has little to do with their sexual behavior. Duenas, et al., Trends in contraceptive methods and voluntary interruption of pregnancy in the Spanish population during 1997-2007, Contraception, 2011, 83: 82-87 In Spain during the ten year study period, overall use of contraceptive methods increased from 49.1% t0 79.9%. During the same time, abortion rates doubled from 5.52/1000 to 11.49/1000. The authors propose as explanations: inadequate of inconsistent use of contraceptive measures, and a rising immigrant population. The authors further suggest that immigrants be targeted with unspecified culturally sensitive information campaigns to increase their knowledge and decrease their rates of pregnancy. Ill refrain here from commenting on the social and ethical implications of targeting identifiable ethnic groups for what amounts to fertility reduction. Nevertheless, to turn a small, voluntary intervention like the Washington University study into state or national policy inevitably raises questions about what techniques might be used to persuade economically vulnerable women, many of whom are women of color, to use long-term hormonal contraceptives. Since the Spanish study suggests that intensive education encourages contraceptive use and decreases pregnancies and abortions, however, it seems appropriate to consider this:Wiggins, et al., Health Outcomes of youth development programme in England: prospective matched comparison study, BMJ, 2009, 339:b2534 which used an intensive educational intervention described in a study from New York as increasing contraceptive use (in girls but not boys) and decreasing pregnancies. The after school intervention included youth development, sexuality education, and regular sexual health clinic check-ups. This approach was used in the British study of at risk teenagers, ages 13-15, with matched non-intervention comparison controls. Pregnancies in the intervention group were 16% compared with 6% in the non-intervention group, with similarly higher rates of early sexual activity and expectation of teenage parenthood. The authors note that other attempts to duplicate the New York studys success have been problematic, citing methodological problems with their study, including the unintended consequences of bringing at risk teens together. As I said, such studies contradict the current theoretical paradigm and, as Kuhn would predict in such circumstances, are usually marginalized as anomalies to be explained away methodologically or to be dealt with if time and funding permit. Whether these anomalies will necessarily accumulate and compel a shift remains unclear; Kuhn was not a Hegelian and neither am I. But technological interventions often have unintended behavioral consequences when applied to a large population, most of which are not appreciated until well after any study period is over. Who, for example, imagined that prenatal ultrasound would significantly change male : female birth ratios in Asia? With respect to contraceptive access there are, at least, theoretical reasons to be wary of basing policy decisions on short-term studies:Arcidiacono, et al., Habit Persistence and Teen Sex: Could Increased Access to Contraception have Unintended Consequences for Teen Pregnancies?, Journal of Business & Economic Statistics, 2012, 30:2 which uses a dynamic discrete choice model of teen sex and pregnancy that incorporates habit persistence. This theoretical economic model suggests that increased access to contraception will decrease teen pregnancies in the short run but increase teen pregnancies in the long run. Similarly, Cassell, et al. Risk Compensation: the Achilles heel of innovations in HIV prevention? BMJ, 2006, 332:605-7 and Richens, et al. Condoms and Seat Belts: the parallels and the lessons, Lancet, 2000, 355:400-403 consider the unintended consequences from risk compensation when attempting to alter the consequences of sexual behavior.I dont know what to do with these results, analyses, and theoretical suppositions. It may turn out theyre simply the anomalies the current paradigm considers them to be. I only bring them up in this thread to suggest two things that have been clear at least since Copernicus suggested the earth rotates while revolving around a stationary sun: commonsense isnt necessarily right and the ground on which we stand is always moving.

Larry -- you mean you just now got around to reading the actual study? Hmm. You still don't seem to comprehend the problem of selection bias. Without a way of accounting for selection bias, it isn't a solid study design. And if you don't understand that point by now, I'm not sure what else I can say except that reading several books on statistics and causal inference would be useful. Everyone else should be aware that the study was the exact equivalent of this: Suppose I want to do a study to find out about weight loss. I sign up thousands of people to go on a 500 calorie a day diet. But I don't have any actual control group with actual identifiable individuals who are being followed over time, and I don't even measure the dieters' starting weights. At the end of two or three years, I weigh the dieters, and then proudly announce that they weigh less than the rest of the city and country. The problem of selection bias would be obvious: the people who would sign up for such a study may be very different from everyone else, and the study design has zero ability to account for this. Indeed, I may have signed up people who were so motivated to lose weight that they would have done something to lose weight regardless. (Just so, this study probably signed up women who were so determined to avoid repeat abortions that they would have found some way of limiting pregnancy regardless, which is why one simply cannot claim that the rest of the city or country is a good idea for a control group.)Even in the field of nutrition, which isn't famed for its methodological rigor, that would be a laughable study. And this is true even though it is "common sense" that a radically calorie-restricted diet leads to losing weight -- it may well do so, but such a study is NOT good evidence of such a diet's effects. You have to learn to distinguish two points in your mind: 1) do I find the study's conclusion plausible? and 2) is the study itself actually solid evidence? It all goes back to logic: an argument might have a true conclusion even though the steps of the argument are invalid.

I don't doubt, by the way, that a program like this would have some effect (the progressive history of forcible sterilization undoubtedly had even more of an effect). But that is common sense, and a study isn't needed to show that there would probably be some effect. What a study would be useful for is answering the following question: exactly how big is the effect and under what conditions? But here's the rub: a study can answer that question only if it's good science, not junk science.

Pardon my double post, but my comment above includes:"Since the Spanish study suggests that intensive education encourages contraceptive use and decreases pregnancies and abortions, however, it seems appropriate to consider this..."The study itself suggests no such thing. The study authors, however, believe it to be the case and, I suspect, would cite other studies to support their belief.

Stuert the "scientist' wants a control group with no pills and he will count their abortions.PHEW

we are conducting one big social experiment with the future of our children.You are forgetting what I think is the most important social experiment, the one with the largest impact on the largest number of children: parental divorce.

In response to Claire:You are so correct concerning divorce and the disastrous effect it has on our children and the family. And once "no fault" divorce came on the scene, many couples no longer felt the need to work out their problems when they could just walk away convincing themselves along the way (when there were children involved) that it was the best thing for the kids! Is it any wonder so many young people are afraid of marriage and say they don't believe in it. They are afraid to trust anyone. Unfortunately, they can thank their parents for that.

WAY off original topic now, but even when parents make an effort to establish the detente that allows them to stay together for the sake of the children, the kids are still "swimming in the soup" of a society that sanctions easy divorce. Kids are quite quick, if they witness any marital discord, to say, "Why don't you just get a divorce?"One reason NOT to get a divorce were the number of "turtle" children I met at my kid's middle school while volunteering--kids who lived out of huge back packs packed full of toiletries and extra clothes as well as school work because they were shuttled to and from one parent to another. These were bright, affectionate kids for the most part, who simply accepted this as a way of life. But it broke my heart to see how much of their own care and organization they had to shoulder for themselves. I have to wonder how much this affects the ability of a child to focus, learn, and develop.

My parents were divorced when i was a baby and then a few years later another divorce, and another divorce again when I was in college. I can only imagine how different I would be now if I'd had two normal happily married parents, but I don't think people should stay together when they don't love each other - don't think that's good for kids either.

Brian Volck --Thank you for a very reasoned consideration of the problem. Only when we are willing to recognize all the evidence -- the possibly pro and the possibly con -- will the solution become possible.

I recommend Brian Volck's detailed and reasoned response to all.

To Dr. Volk,Perhaps you missed the point of the St. Louis study, but the purpose of the study was to see if *bullet-proof* contraceptive measures would reduce re-abortion rates (primary objective), overall abortion rates in the study population (secondary objective), and even reduce overall abortion rates in the St. Louis area, in comparison with those in a comparable metropolitan area (Kansas City) and in non-metropolitan Missouri (secondary objective). The study met all three objectives, in a fashion which can only be described as spectacular. Swedish and Spanish studies you quote did not study populations in which bullet-proof contraceptive measures were utilized and, thus, are not directly relevant to the current study.Both abortion and teen pregnancy rates have fallen dramatically in the USA since 1984. At one point, it was estimated that 25% of this effect may have been owing to abstinence education and 75% to contraception education (*I'll provide a 1998 reference at the end of this comment; I didn't make the effort to determine if there is an updated estimate). These reductions continue to persist up to the present time, despite an environment of continuing sexual permissiveness. The point is that there need not be a conflict between teaching moral behavior to those who are open to such teaching, and also making available effective contraception methods to those who wish to use them and who are actively participating in either "licit" and illicit" sex -- if most of us can agree that contraception is a far lesser evil than abortion, as also concluded by the large majority of the Magesterium and theologians on Pope Paul's Pontifical Commission on Birth Control. I want to repeat my point that the Pope himself acknowledged in his encyclical that lesser evils are preferred to greater evils and that this encyclical was written just before the world-wide emergence of what is essentially abortion on demand.* reference: http://www.guttmacher.org/pubs/or_teen_preg_decline.html- Larry Weisenthal/Huntington Beach CA

"I dont think people should stay together when they dont love each other dont think thats good for kids either."Maybe it's not optimal, but if you can manage some mutual respect and common decency, I think that's better than shuffling your kid from house to house. Frankly, I think divorced couples should be required to leave the kids in a family home, with the parents doing the moving in and out when it's their custodial time. Why should the kids be messed up?

Hi Jean, Did you happen to catch yesterday's mass Gospel (Mark 10:2-16)? Although we can (in my opinion) argue contraception in good conscience, in the matter of divorce (particularly with children), there's simply no wiggle room. My parents were divorced when I was 12. 53 years older, I still haven't gotten over it and neither has my father, who's shortly turning 99 (my Mom died three years ago). Your story of the "turtle" children really is heartbreaking. I personally think that divorce in the case of a couple with children is infinitely worse than contraception, which is why I think that couples should strongly consider practicing contraception until both woman and man are certain that they'll be able to honor their marriage vows.- Larry W/HB

Crystal --Maybe in some cases divorce is better, but I certainly couldn't condone a woman staying with a man who beat her regularly in front of their children. But maybe I'm wrong. I've read more than once that there are studies showing that even into adulthood divorce is terribly painful for most children even when the divorce happens and the children are in their 20s and 30s. Be sure to read Larry's post directly above this one. I suspect the only solution is to help people not to marry the wrong person or not to marry at all. Years ago a French sociologist proposed that divorce be prohibited entirely. That would certainly discourage people from marrying for immature reasons. But . . .

Mr. Wiesenthal:Thank you for your kind response. No doubt I miss a great deal. Let me clarify: My comment did not critique the study done at Washington University (the institution from which I received my medical degree). I am familiar with what the study did and did not do and its level II evidence (presumably II-2) is worth some attention, though neither that evidence, nor the long term, user-independent contraceptive methods the study strongly encouraged the volunteers to choose, can be properly described as "bullet proof."Perhaps I did not make clear that I have prescribed a variety of contraceptive measures to young women, in much the spirit you suggest, as a lesser evil than abortion. Furthermore, I cited other studies to suggest that moving from a voluntary study (consistent with a paradigmatic approach) to governmental (or ecclesial) policy does not always have the population effect one hopes or imagines. For example, even the Guttmacher Institute's explanations for reduced teen pregnancy rates in the US require assumptions for which, to my knowledge, hard data don't exist. I'm confident available contraception plays a role, but I have my doubts that relationship is simple, straightforward, or entirely benign. That's all I meant to say. Pardon me if I seemed to suggest otherwise.

For those searching for the latest Guttmacher data ( released 2010 with data through 2006), see:http://www.guttmacher.org/pubs/USTPtrends.pdfWhile the data is about as hard as one will find, the report includes this under the heading "interpreting the data":Because health department abortion statistics are incomplete or nonexistent in many states, care should be used in interpreting the teenage abortion and pregnancy data. For the states with no information on the age of women having abortions, the rate of abortion among teenagers was estimated. Similarly, error is introduced by the assumption that teenagers have abortions out of state in the same proportions as older women. Therefore, one cannot draw inferences about the effects of parental involvement requirements on the number of abortions obtained by minors.

Hi Dr. Volck,When I used the term "Bullet-proof," I was referring to contraceptive methods with a 99% reliability rate -- namely the IUD and implants. I did not label the study itself as being "bullet-proof," although I believe that the study, in the context of the totality of existing knowledge, was both credible and impressive. It certainly rises well above the level of being "worthless" and "not worth publishing," which was my original criticism of an earlier comment made by someone else (not by you).I'm a medical oncologist myself, and there are many situations where prospective, randomized trials are required (for example, to show a 5% improvement in 10 year survival with the addition of a taxane to cyclophosphamide/doxorubicin in stage II breast cancer). There are other situations where a prospective, randomized trial is not required. For example, here is a single institution experience using historical controls, in chronic myelogenous leukemia (not even concurrent, cohort controls, as in the presently described study): "The median survival was 15% before 1983, 42%-65% from 1983-2000, and 87% since 2001." These improvements were owing to (a) bone marrow transplantation (1983 - 2000) and (b) the introduction of a new drug, Gleevec (since 2001). In the latter situation, not only is a randomized trial not required, but even a concurrent, cohort control study is not required (and, indeed, would be unethical). Reference to the leukemia study:http://bloodjournal.hematologylibrary.org/content/119/9/1981.fullNow, in the present study, the authors reported the following: "The rate of teenage birth within the CHOICE cohort (50% African-American) was 6.3 per 1,000, compared with the U.S. rate of 34.3 per 1,000." This represents a hazard ratio of 0.18! And the raw number (6.3 per 1,000) would be impressive in any group of subjects, including white middle class adult women of child-rearing age.You brought up levels of evidence, stating that the present study represented Level II (which is, you'll agree with me, well above "worthless"). Let me ask you to answer a question, once you've reviewed the following (from Wikipedia), which is a related topic, namely "Categories of Recommendation:"Categories of recommendationsIn guidelines and other publications, recommendation for a clinical service is classified by the balance of risk versus benefit of the service and the level of evidence on which this information is based. The U.S. Preventive Services Task Force uses:[19] Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweigh the potential risks. Clinicians should discuss the service with eligible patients. Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients. Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations. Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients. Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.Now, my question to you (in your capacity as a pediatrician) is the following: For a teenage girl, who is either sexually active or who intends to become sexually active within 6 months (despite whatever counseling efforts have been made), what would be your "category of recommendation" regarding the totality of available information (including the present study), regarding the advisability (or not) of the teenager being offered the same range of contraceptive choices as were offered to participants in the St. Louis study?A, B, C, D, or I ?- Larry Weisenthal/Huntington Beach CA

To bring the current discussion around to a relevant and timely topic, extensively discussed on Commonweal in the recent past, many conservative critics of ObamaCare object to the mandate to cover contraceptive counseling and services. These critics state that contraceptives are either free or inexpensive, and that it is an unnecessary assault on religious freedom to have a regulation that insurance companies are required to offer private, third party contracts to employees for a rider to their employer-provided policies to pay for these contraceptive services.However, the current study confirms reasonable expectations that "bullet-proof" forms of contraception are dramatically effective in reducing both teenage pregnancy and abortion rates. It should be recalled that this contraception mandate was not a nefarious assault on religious liberties hatched by the evil Sibelius/Obama duo, but was rather the unanimous recommendation of the doctors on the evaluation committee tasked by the highly-respected (and independent/non-partisan) Institute of Medicine to carry out this evaluation. The Obama administration was simply following this recommendation.The "bullet-proof" contraception methods do not have trivial costs, which is why the Institute of Medicine recommended that coverage for contraception be included.Those who are very concerned about the high incidence of abortion in this country should seriously consider the claim that prohibiting employers from preventing their employees from entering into private third party contracts is really a serious infringement on religious liberty. They should then consider the relative degree of evil associated with contraception on one hand and abortion on the other hand.- Larry Weisenthal/Huntington Beach CA

Larry Weisenthal -- Thank you for your effort and careful detail in shedding light on this important topic. An ACOG discussion of Levels of Evidence I, II-1,2,3 is included in "Reading the Medical Literature - Applying Evidence to Practice" and may be useful. The article under discussion says Level II.http://www.acog.org/Resources_And_Publications/Department_Publications/R...

Dr. Wiesenthal:I regret that my comments above apparently lead you to believe that I am your adversary. What can I do to persuade you otherwise? While I am well aware of the use-effectiveness of non-user dependent methods of contraception, describing them -- or, indeed, any therapeutic technology -- as "bullet proof" is new to me. Forgive me for stumbling over this novelty in terminology. I agree with you that preventing pregnancies with contraception is preferred to ending pregnancies with abortion. Shall I write for a third time in this thread that I prescribe contraception to adolescents and will do so again? I teach residents how to evaluate evidence AND engage in the terribly inexact process of applying that evidence to the patient before them. No doubt I have much to learn. My reference to Level II evidence above was drawn from the study's abstract, using United States Preventive Services Task Force classification. At no time did I write that the study's evidence was worthless. If you believe I was misusing the very classification scheme referenced in the study, I regret that any imprecision on my part. My point all along -- at which, judging from your response, I have failed -- has been to suggest that applying studies to policy is never simple and almost always have unanticipated, unintended consequences. My comments have not been about evidence, but application. Perhaps we are talking past each other. Perhaps my experiences in Native American health, US poverty medicine, and global health have made me overly suspicious of government programs designed to help. In any case, there's not much more for me to add.

However, the current study confirms reasonable expectations that bullet-proof forms of contraception are dramatically effective in reducing both teenage pregnancy and abortion rates. Larry, the question isn't whether particular types of contraception work, but what are the society-wide effects of a social policy of handing out those types of contraception. The study does nothing to resolve that question. As you cannot dispute, selection bias contaminates the study from top to bottom. This means, for example, that the women who signed up for such a study may be quite different from everyone else, and perhaps they would have found a way to avoid pregnancy regardless. It would be intellectually dishonest to suggest that this study tells us anything about women who were not study participants.

Larry -- I just realized that the fundamental confusion here may be that you're thinking about the question, "Do IUDs and implants work in preventing pregnancy," to which the answer is obviously yes, whereas I'm thinking about the question, "What exactly will happen if there is a social policy of handing out free IUDs and implants," which is a very different question, as it depends entirely on exactly how many people are enticed to sign up and how seriously those people would have tried to avoid pregnancy even in the absence of the program. The latter question, which is more relevant to the HHS mandate, is not answered by this study. That much is indisputable.

Hi Stuart,No, what I was "thinking about" was the following: In a group of women who are motivated to ask their doctors to prescribe "bullet proof" contraception, what is the impact, with regard to teen pregnancy and abortion, of providing free contraceptives? Isn't this precisely the question most relevant to the likely impact of the contraception-coverage mandate?Under ObamaCare, coverage for contraceptive services is not automatic. Rather, the individual woman must enter into a private contract with her health insurer to add a no-cost rider to her policy to cover payment for contraceptive services. Women who are not proactive in obtaining this rider do not receive coverage for contraceptive services.Thus, the study is directly relevant to the question at hand. The study conclusively shows that when poor minority women who want to utilize bullet-proof contraceptives are provided with these contraceptives at no cost to them, the observed rates of teenage pregnancy and abortion are extremely low -- far lower than ever previously reported in these demographic groups and lower than presently reported in the USA in more favorable demographic groups.These data provide powerful support for the unanimous recommendation by the physician members of the (independent, non-partisan) Institute of Medicine panel that coverage for contraceptive services be a mandated component of the Affordable Care Act. - Larry Weisenthal/Huntington Beach CA

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