In This Issue:

New Ibis Research

Ibis Priority Areas of Work Recognized by Governmental Bodies

Dear Friend,

I am very pleased to share with you highlights of research released by Ibis and our collaborators over the past few months. This collection of articles will give you an idea of the breadth of our work, from analyzing data on the cost of unsafe abortion in Mexico City and documenting the impact of legal restrictions on abortion in the US, to critically evaluating the evidence on withdrawal as a legitimate contraception method. Other research identifies gaps in reproductive health instruction in nursing schools and how we can learn what people know about sexual health from emails sent to an emergency contraception website.

We are also delighted that two priority areas of work at Ibis, preventing unintended pregnancy and reducing maternal mortality, have been recognized by the US Institute of Medicine and the UN Human Rights Council, respectively, as critical areas for attention. We hope that these two influential organizations’ focus on these issues will help ensure that we will see increased resources—financial and human—brought to bear to improve women’s reproductive health around the world.

I thank you for your continued support and interest in our work.

Kelly Blanchard, President

New Ibis Research

The Cost of Unsafe Abortion Compared to Safe Abortion Alternatives
Reassessing the Evidence on Withdrawal as a Contraceptive Method
Strategies for Reforming Nursing School Curricula
Literature Reviews on the Impact of Legal Restrictions on Abortion
Can I Get Pregnant from Oral Sex? Sexual Health Misconceptions and Their Possible Sources

Ibis authors' names in bold text.

The Cost of Unsafe Abortion Compared to Safe Abortion Alternatives
Levin C, Grossman D, Berdichevsky K, Diaz C, Aracena B, Garcia SG, and Goodyear L. Exploring the costs and economic consequences of unsafe abortion in Mexico City before legalisation. Reproductive Health Matters July 2009; 17(33):120-132.
Hu D, Grossman D, Levin C, Blanchard K, and Goldie SJ. Cost-effectiveness analysis of alternative first-trimester pregnancy termination strategies in Mexico City. BJOG. May 2009; 116:768-779.

With PATH and the Population Council, Ibis undertook research to determine the cost of unsafe abortion to the health care system in Mexico City before abortion was legalized in 2007. The study used data collected at several public and private facilities in Mexico City in 2005. Before abortion was legalized, public hospitals treated women who presented with incomplete abortions by using safe abortion techniques including dilation and curettage (D&C) and manual vacuum aspiration (MVA); very rarely they also used these safe techniques to provide primary abortion care for women who qualified for legal termination of pregnancy. We also collected data on the cost of providing safe abortion care using MVA or medication abortion with misoprostol alone at a clandestine private clinic. The results of the study showed that hospital-based treatment of incomplete abortion was significantly more costly than outpatient, clinic-based care providing safe abortion. The per-patient medical costs of hospital-based D&C ranged from US$103 to US$192, while the cost of clinic-based MVA was US$53, and that of clinic-based medication abortion was US$69. The results also showed that the treatment of complications related to unsafe abortion, such as sepsis, uterine perforation, or hemorrhage requiring transfusion, was very costly to the health care system, ranging from US$600 to over US$2,100 per complication. The study also estimated the cost-savings that might be achieved by improving access to safe, legal abortion in Mexico City, if provided mostly through outpatient services. Assuming that complications would be reduced in the context of legal abortion, the estimation was that the health care system in Mexico City would save approximately US$1.7 million each year, reducing the cost per woman served by approximately 62%.

Using the findings from this cost study, as well as other published data, Ibis collaborated with researchers at the Harvard School of Public Health and PATH to examine the cost-effectiveness of the various safe abortion techniques compared to unsafe abortion. Consistent with the findings of the cost study, results of this study showed that any of the safe techniques was significantly more cost-effective than unsafe abortion, and that clinic-based MVA was least costly and most effective. Another finding was that enhancing access to medication abortion, especially in areas where surgical access is limited, can increase overall cost savings when the method is used in place of unsafe abortion. A shift toward safe abortion services appears to be one of the most cost-effective interventions that could be implemented in a country where unsafe abortion is prevalent.

While the public health benefits associated with reducing unsafe abortion are clear, the study also found that improved access to safe, legal abortion reduces costs to the health care system. While some of these savings might be offset by increased demand for public abortion services, per-patient costs would be dramatically reduced. [Click here to request the articles]

Reassessing the Evidence on Withdrawal as a Contraceptive Method
Jones RK, Fennell J, Higgins JA, and Blanchard K. Better than nothing or savvy risk-reduction practice? The importance of withdrawal. Contraception. June 2009; 79:407-410.

Withdrawal is often not considered a legitimate contraceptive method and many believe it is not effective. However, in a review and commentary on recent research on the method, withdrawal was found to be almost as effective as condoms at preventing pregnancy. In perfect use—if the male partner withdraws before ejaculation every time a couple has vaginal intercourse—about 4% of couples will become pregnant over the course of a year. The failure rate with typical use is estimated to be 18%. These rates are only slightly less effective than male condoms, which have perfect- and typical-use failure rates of 2% and 17%, respectively. The authors found from survey and qualitative data that withdrawal use was much more common than is often cited, and that women and men often used withdrawal in conjunction with condom use or fertility awareness methods. Although not as effective as hormonal methods or long-acting methods, withdrawal use is significantly more effective than not using a method, and it is always available and does not cost anything or require a doctor’s visit. The authors recommend that providers talk with their patients about withdrawal so they have accurate information about its use. [Click here to read the paper]

This review has generated a range of reactions and opinions in news publications and the blogosphere:
Global Health, May 16
Feministing, May 18
Jezebel, May 18
Salon, May 20
ABC News, May 28
CBS News, May 28
The American Prospect, May 26
Advocate.com, June 3
Philadelphia Inquirer, June 8
Globe and Mail, June 11
Double X, June 16
AlterNet, June 22
New York Times, July 20
The Daily Beast, July 28
Double X, July 29
Washington City Paper, July 31
The authors respond to the blooming debate: RH Reality Check, June 3

Strategies for Reforming Nursing School Curricula
Simmonds K, Foster AM, and Zurek M. From the Outside In: A Unique Model for Stimulating Curricula Reform in Nursing Education. Journal of Nursing Education. March 2009.

This paper shares the strategies used and lessons learned by a group of advocates working to reform nursing program curricula in the United States. Reproductive health researchers and advocates created the Reproductive Options Education Consortium for Nursing (ROE Consortium) in 2002 to attempt to expand comprehensive reproductive health training for nurses in the US. Nurses may be expected to provide pregnancy options counseling, education, and referrals, or to assist with delivery of prenatal or abortion services, as a routine part of their work. However, educational opportunities in the epidemiologic, clinical, and ethical aspects of reproductive options are often unavailable in US nursing programs. The ROE Consortium identified several strategies to shape their model of curricula reform that enabled them to work efficiently, gain the trust of the nurses and school administrators they worked with, and remain in contact with participants to ensure follow through. For example, by engaging nurses and faculty to advise the project, they were able to build creditability among their broader audience. The ROE Consortium believes these strategies could be widely applied in curricula reform efforts. In using these strategies, the ROE consortium enrolled 114 nursing faculty participants for continuing education between 2002 and 2004, and 87% of these participants have incorporated the training materials they received into their teaching. [Click here to request the article]

Literature Reviews on the Impact of Legal Restrictions on Abortion
Joyce TJ, Henshaw SK, Dennis A, Finer LB, and Blanchard K.. The Impact of State Mandatory Counseling and Waiting Period Laws on Abortion: A Literature Review. Guttmacher Institute. May 2009.
Henshaw SK, Joyce TJ, Dennis A, Finer LB, and Blanchard K. Restrictions on Medicaid Funding for Abortions: A Literature Review. Guttmacher Institute. July 2009.

Ibis Reproductive Health and the Guttmacher Institute conducted a series of comprehensive reviews of the literature on legal restrictions to abortion. The final two reports, on mandatory counseling and waiting period laws and on restrictions to Medicaid funding, were recently released. (Click here to read the first review on parental involvement laws.)

The Impact of State Mandatory Counseling and Waiting Period Laws on Abortion: A Literature Review--Laws that require counseling and waiting periods before abortion, but that allow counseling to be delivered over the Internet, by phone, or by mail, appear to have little impact on birth and abortion rates. But these laws may postpone the timing of some abortions. These findings imply that counseling requirements do not cause women to change their minds about having an abortion, and that waiting period requirements do not impose significant barriers to abortion services. Currently, 24 states require women to wait, usually for 24 hours, between an initial counseling session and the abortion procedure. However, the laws in seven of these states require in-person counseling at least 18-24 hours prior to the procedure. Multiple studies of such a law in Mississippi have found that the requirement was associated with a decline in the state’s abortion rates, an increase in the number of residents going out of state for an abortion, and delays in accessing abortion services. These findings suggest that an in-person counseling requirement places an additional burden on some women by forcing them to take more time off from work, arrange child care, or stay away from home overnight when the distance to the clinic is great. This sometimes results in delaying the abortion to later in pregnancy, when the procedure is less safe and more expensive—if women are able to obtain an abortion at all. According to the study authors, these laws are intended primarily to block abortion access, and the most disadvantaged women, who already have trouble accessing services, are disproportionately affected. [Click here to read the paper]

Restrictions on Medicaid Funding for Abortions: A Literature Review--Approximately one-fourth of women who would obtain a Medicaid-funded abortion if given the option are instead forced to carry their pregnancy to term when state laws restrict Medicaid funding for abortion, because they lack the money to pay for the procedure themselves. According to the report, Medicaid funding restrictions also delay some women’s abortion by two to three weeks, primarily because of difficulties women encounter in raising funds to pay for the procedure. Currently, 32 states and the District of Columbia allow Medicaid funds to be used for an abortion only in cases of rape and incest, or if the woman’s life is endangered, in accordance with the federal Hyde Amendment; only 17 states have policies to use their own funds to pay for all or most medically necessary abortions. Lacking insurance coverage, some poor women need a considerable amount of time to come up with the money to pay for an abortion, and may have to pull resources from other family necessities, like food or rent, if they are able to find the funds at all. As the cost of the procedure increases with gestation, many poor women become trapped in a vicious cycle of scrambling to raise enough money before the cost—and risk—increase further, while others are left with no recourse but to carry an unwanted pregnancy to term. The Hyde Amendment allows federal funding for abortion only in cases of rape, incest, or life endangerment. In addition, Congress has enacted legislation essentially banning coverage of abortion for women whose medical insurance is provided by the federal government, such as federal employees, military personnel, and women in federal prisons. The issue of federal funding goes to the heart of who has access to abortion in the United States and under what circumstances.  [Click here to read the paper]

Can I Get Pregnant from Oral Sex? Sexual Health Misconceptions and Their Possible Sources
Wynn L, Foster A, and Trussell J. Can I get pregnant from oral sex? Sexual health misconceptions in e-mails to a reproductive health website. Contraception. February 2009; 79:91-97.

“Not-2-Late.com,” a website providing medically accurate information about emergency contraception, allows readers to send in questions to be answered by a reproductive health expert. This paper examines the questions posed which offer insight into the knowledge, attitudes, and biases the questioners hold about reproductive health. Over 1,100 emails were sent to the site during the one-year study period from July 2003 to June 2004. Over a quarter of these emails were classified as containing a misconception (an incorrect belief or assumption) about reproductive health processes in one of five categories: sexual acts that could lead to pregnancy, the definition of protected sex, signs and timing of pregnancy and pregnancy testing, the dangers that hormonal contraceptives pose to women and fetuses, and confusion between emergency contraception and abortion. The authors identified as possible sources for these types of misconceptions: abstinence-only sexual education, health education websites with various degrees of medical accuracy, medical assumptions about pre-ejaculatory fluid containing sperm that are not evidence-based, public health campaigns which link STI protection to condoms, and the requirement at Catholic hospitals that a pregnancy test be administered before provision of EC (for which there is no medical justification). [Click here to request the article]

Ibis Priority Areas of Work Recognized by Governmental Bodies

In June, the Human Rights Council, a political body of the United Nations, adopted a resolution naming maternal mortality as a pressing human rights issue. The resolution, which was co-sponsored by over 70 UN member states, commits governments to increase their efforts to protect women and girls. It recognizes that protection and promotion of sexual and reproductive health and rights, such as reducing unsafe abortion and increasing access to contraception, are essential to eliminating maternal mortality, and that a human rights approach is the most sustainable one to take. Ibis applauds this important step in recognizing the global toll of unmet need for sexual and reproductive health services.

In addition, the Institute of Medicine recently convened a Committee on Initial National Priorities for Comparative Effectiveness Research to identify topics where comparative effectiveness research could make a significant impact in improving health care practice in the US. The committee released its report in June, and we are ecstatic that research on innovative ways to reduce unintended pregnancy was listed in the top quartile of the 100 priorities identified. These priorities will inform the allocation of the $1.1 billion for comparative effectiveness research that was included in the US federal economic stimulus bill passed earlier this year. The report mentions “over-the-counter access to oral contraceptives or other hormonal methods, expanding access to long-acting methods for young women, [and] providing free contraceptive methods at public clinics, pharmacies or other locations” as strategies to consider—all areas of research at Ibis.