Like any energetic 7-year-old, your daughter loves running around outside, playing with her friends and kicking around a soccer ball. So you’re concerned when she starts losing energy. She looks pale and refuses to eat. You take her to the pediatrician, and her test results show the worst: she has leukemia. Once you work through the shock, you do you what any parent would do: find the best possible care to get her through it. But where do you go?
Health care for children is different from care for adults. Treating kids requires doctors who are experienced with their unique needs, and according to Stanford pediatricians Paul Wise and Lisa Chamberlain, this experience is developed and lives in children’s hospitals.
And these facilities are highly dependent on Medicaid.
“Children are the poorest segment of the United States population,” said Wise, a Stanford Health Policy core faculty member.
Nearly one out of every five children lives below the poverty line, according to the United States Census Bureau. Very few children need extensive health care, but of those that do, about 44 percent rely on Medicaid or other public insurance programs.
Because so many of their patients use Medicaid, these children’s hospitals need reimbursements from the program to support their services. Without this income, some might have to downsize or even shut down, and if they do, services would suffer for all children.
“If you want to kill rich kids, cut Medicaid,” said Wise. “If you’re a rich kid with a serious chronic problem, you’re going to want facilities that provide high-quality care. Those facilities are intensely dependent on Medicaid.”
If the American Health Care Act (the Republican replacement for Obamacare) passes Congress, Medicaid will convert to a per capita cap system. Instead of providing coverage to all who meet its criteria — which is primarily based on income and need — the federal government would cap how much money the federal government could provide each person.
Wise and Chamberlain worry that a set amount allocated for states or individuals would not be able to keep up with health industry inflation, causing payments to effectively decrease over time. They are also concerned that children would be particularly affected by these changes because their medical needs are so different from adults’.
“Caring for seriously ill children requires a wide range of services and specialists, from pediatric surgeons to speech therapists to hospital teachers who make sure kids don’t fall behind,” said Chamberlain. “In pediatrics we work as a team — and cutting Medicaid will reduce our ability to do that.”
Not only would the funds available for child health coverage erode, but according to Wise, the focus on adult health concerns in the emerging Medicaid changes could, without immediate attention, undermine 40 years of progress in developing strong, regionalized child health systems.
Providing for children’s needs should be simple because their expenditures are relatively low. Child health care makes up less than nine percent of all federal health expenditures in the United States.
But because the health policy debate in the United States focuses on older populations, children are often left out.
“I think it’s really important that we have these conversations about the unique needs of children,” said Chamberlain.
Wise and Chamberlain hope to alert policy-makers to the fiscal needs of children and how they affect care for all kids.
“Our elected officials have to cope with a wide range of issues, and they welcome engaged professionals exchanging ideas about active legislation,” said Chamberlain. “Those conversations really matter – now is the time to let them hear what we think.”
To hear more from Wise and Chamberlain about child health and Medicaid, listen to their podcast on World Class:
Sarita Panday has been selected as the 2017-18 Developing Asia Health Policy Postdoctoral Fellow at Stanford’s Shorenstein Asia-Pacific Research Center (APARC). She will join the center’s Asia Health Policy Program as it marks its 10th anniversary later this year.
“We’re delighted to welcome Dr. Panday as our first fellow from Nepal and in this important anniversary year,” said Karen Eggleston, director of the program and senior fellow in the Freeman Spogli Institute for International Studies. “Sarita also represents the first fellow from South Asia and the fourth fellow since we began our collaboration with the Asia-Pacific Observatory on Health Systems and Policies.”
“I am extremely honored and grateful to be awarded this prestigious fellowship and am very much looking forward to joining the Asia Health Policy Program,” said Panday. “I believe this fellowship will enable me to develop essential skills so that I can work towards helping some of the neediest women in South Asia.”
Panday completed her doctorate at the School of Health and Related Research at the University of Sheffield, which explores the role of female community health volunteers in maternal health service provision in Nepal. Her research interests include health service delivery, primary healthcare and human resources for health and global health.
During her fellowship at Shorenstein APARC, Panday will examine the relationship between payment and performance of community health workers in South Asia. She will also recommend strategies for systems that incentivize workers to contribute to healthcare improvement in resource-poor communities.
Supported by the Asia-Pacific Observatory on Health Systems and Policies (APO), the fellowship brings emerging scholars to Stanford to conduct research on contemporary health and healthcare in the Asia-Pacific region, particularly developing countries. The fellow gains access to resources at Shorenstein APARC as well as an APO network of researchers and institutions that spans the Asia-Pacific region.
Panday completed a Masters in Public Health and Health Management from the University of New South Wales and a Bachelor of Science in Nursing at the BP Koirala Institute of Health Sciences. Besides research, she has worked in various parts of Nepal, including in remote conflict-laden areas.
About two-thirds of American patients see doctors who receive payments from drug companies, but almost none of them know it.
In a collaborative study between Drexel, Stanford and Harvard, researchers found that 65 percent of participants had visited a doctor within the last year who had received payments or gifts from pharmaceutical or medical device firms.
Payments to physicians can take the form of meals, travel, gifts, speaking fees and research.
Only 5 percent of participants knew that their doctor had received these payments.
“The concern is that physicians with financial ties to drug and device companies may be more likely to recommend those companies' products to their patients, even when other choices would be better for the patient, or just as good but less costly,” said Michelle Mello, the Stanford author and a professor of law and of health research and policy.
Open Payments, which reports pharmaceutical and device industry payments to physicians, was set up as part of the Physician Payment Sunshine Act, a provision of the Affordable Care Act (ACA). The website exists to make industry payment information available to the public.
But the study found that only 12 percent of patients knew this information was accessible. The authors stated that the act’s impact is highly dependent on whether patients know about it.
“Transparency can act as a deterrent for doctors to refrain from behaviors that reflect badly on them and are also not good for their patients,” said Genevieve Pham-Kanter, the lead author and an assistant professor at Drexel’s Dornsife School of Public Health.
Drug and device companies tend to target “key opinion leaders” who are likely to influence the choices of other physicians. During the year studied, the average American physician received $193 in payments. However, the median payment for doctors visited by patients in the study was much higher, $510 for the year.
“We may be lulled into thinking this isn’t a big deal because the average payment amount across all doctors is low,” said Pham-Kanter. “But that obscures the fact that most people are seeing doctors who receive the largest payments.”
Payments vary widely across specialties. Among patients surveyed, 85 percent of those who saw an orthopedic surgeon saw a doctor who had received payments. The next highest was obstetrics and gynecology physicians at 77 percent.
“Drug companies have long known that even small gifts to physicians can be influential, and research validates the notion that they tend to induce feelings of reciprocity,” said Mello.
Despite potential changes to the ACA, Mello believes the Sunshine Act is here to stay. The current version of the American Health Care bill, which would repeal and replace the ACA, does not dismantle it.
This leaves the question of how policymakers can make information about payments to physicians more visible to patients. The authors suggested that the Centers for Medicare and Medicaid Services (CMS) could provide a one-stop shop for patients to view industry payments and other information about their providers online. Mello added that private insurers could make this information available on their “Find a Physician” websites.
“Finding the physician who is right for you depends on a lot of factors,” said Mello. “Whether a physician accepts money from industry may or may not be important to you, but my general view is that the more informed these choices are, the better they will be for patients.”
Non-communicable diseases such as heart and respiratory disease, cancer, obesity and diabetes are now responsible for some two-thirds of premature deaths around the world. And most of those are in low- and middle-income countries.
The United Nations has estimated that on top of the social and psychological burdens of chronic disease, the cumulative loss to the global economy could reach $47 trillion by 2030 if things remain status quo.
“That was a big whopper of a number and got a lot of attention, and that was good because it raised awareness,” said Rachel Nugent, vice president for global non-communicable diseases (NDCs) at the research institute RTI International.
“It’s an issue that is driven by a lot of different factors, “ she said. “And understanding how the larger social and economic factors affect NDCs, at a policy level, very little progress has been made — there’s been very little collaboration.”
Nugent was addressing the fourth annual Global Health Economics Colloquium at University of California San Francisco, with health experts, policymakers, students and researchers from Stanford, Berkeley and UCSF who gather every year to take a deep dive into the economics of a global health issue. More than 200 experts from 10 universities and public health departments attended the conference.
The daylong gathering focused on recent developments in the economics of NDCs, looking at case studies from around the world, and new guidelines for cost-effectiveness analysis and the role of economics in reducing health inequality.
“The donors are not convinced that there are cost-effective things that we can do in these countries; a lot of them are very skeptical that this is affecting the poor,” said Nugent, a member of the World Health Organization’s expert advisory panel on the management of NCDs.
In India, for example, much of the population still defecates outdoors, contaminating water sources and agricultural products, which can lead to malnutrition and physical and cognitive disorders. Many donors would rather see funds go to building latrines as they can see tangible results; NDC prevention is a long-term slog.
“But I don’t think we should necessarily think of NDCs as either-or,” said Nugent. “I think that integration of services and programming is very much at the forefront of what is the right way to go.”
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Cost-effectiveness Analyses
Nugent’s research has shown five cost-effective interventions would avert more than 5 million premature deaths from NCDs by 2030, or a reduction of 28.5 percent in projected mortality from chronic disease around the world. And the average benefit-cost ratio is 9:1, at a global cost of $8.5 billion a year.
The interventions are raising the price of tobacco products by 125 percent through taxation; providing aspirin to 75 percent of those suffering from acute myocardial infarction; reducing salt intake by 30 percent; reducing the prevalence of high blood pressure with low-cost hypertension medication; and providing preventive drug therapy to 70 percent of those at high risk of heart disease.
“There is a continued emphasis on transparency and comparability across analyses,” said Sanders-Schmidler. “And of course the big changes are that we’re now asking for a second reference case and using an ‘impact inventory’ table to clarify the scope of the findings.”
The independent panel of non-government scientists and scholars, which also included Stanford Health Policy’s Douglas K. Owens, focused on new ways to deliver health care effectively, yet with a focus on efficiency, as health care spending in the United States has reached 18 percent of GDP, much greater than the global average of 10 percent.
The first panel that convened in 1996 recommended that all cost-effectiveness analyses of health interventions include a reference case that uses standard methodological practices to improve comparability and quality. The second panel, which published its findings in September, now recommends that in addition to the societal perspective recommended by the original panel, that CEAs include a second reference case that looks at the health-care sector impact of an intervention. Additional guidance was given on what to include in the societal perspective reference case.
The panel wrote in its JAMA “special communication” that these societal reference cases should include medical costs “borne by third-party payers and paid out-of-pocket by patients, time costs of patients in seeking and receiving care, time costs of informal (unpaid) caregivers, transportation costs, effects on future productivity and consumption, and other costs and effects outside the health-care sector.”
They found most countries, including the United States, give greater weight to clinical evidence in their cost-effectiveness analyses. The panel now recommends an “impact inventory” that helps analysts and end-users of cost effectiveness analyses look at the impact of interventions beyond the formal health-care sector.
“We’re trying to ask people to be explicit,” said Owens, director of the Center of Primary Care and Outcomes Research and Center for Health Policy at Stanford.
“We want them to look at how to value outcomes in a societal perspective, not just the health-care sector, to look at all these other sectors such as productivity consumption, criminal justice, education, housing and the environment,” he said.
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Case Studies
Several case studies presented at the colloquium indicated that policy changes, government intervention and social factors are key to preventing obesity and diabetes and other NCDs.
Kristine Madsen, an associate professor of public health at UC Berkeley who focuses on childhood obesity, spoke about the nation’s first “soda tax” on sugar-sweetened beverages, which was implemented in Berkeley in March 2015.
The city has seen a 21 percent decline in the drinking of soda and other sugary drinks in low-income neighborhoods after the city levied a penny-per-ounce tax on sodas and sugary drinks. At the same time, according to a study in the American Journal of Public Health, neighboring San Francisco — where a similar soda-tax measure was defeated — and Oakland saw a 4 percent increase in the purchase of sweetened beverages.
“This decline of 21 percent in Berkeley represents the largest public health impact in an intervention that I have ever seen,” said Madsen.
Sergio Bautista of the Mexico National Institute of Public Health and UC Berkeley, said that Mexico’s sugary drinks tax implemented in January 2014 is expected to lead to a 10 percent reduction in sugary drinks consumption and prevent an estimated 189,300 cases of diabetes in a country famed for its sugary bottled cola.
William Dow, a professor of health policy management at UC Berkeley, shared his research on Costa Rica, where on average people live longer than Americans, despite the several times higher income and 10 times higher health expenditures in the United States.
Costa Rican men have a life expectancy of 77 and the women typically live until age 82; in Americans the numbers are 76 and 81, respectively. Obesity is low among Costa Rican men and few of their women smoke. Lung cancer mortality in the United States is four times higher among men and six times higher among women.
“It’s remarkable in so many ways,” Dow said, noting that deaths in the Central American country are due predominantly to infectious disease. “Does Costa Rica have any unique effective programs to emulate, or is there something going on upstream driving those health outcomes?”
He believes Costa Rica’s national health insurance and excellent access to primary care for nearly all its people are key. Having this guaranteed lifetime access to health care also reduces the stress and depression that can so badly harm physical health.
“And I would argue that probably diet is one of the most important things going on here,” said Dow, noting their diets are healthy.
Costa Ricans eat mostly unprocessed foods such as rice and black beans, corn tortilla, yam and squash, with little meat and plenty of fresh fruit.
“They also have the highest remaining life expectancy at age 80 of any country in the world, he said. “What we have learned in Costa Rica would be helpful in many other countries.”
When drug prices go up, does demand decrease? Not necessarily said Maria Polyakova, a professor of health research and policy and Stanford Health Policy core faculty member. In her study, "Out of Pocket Cost and Utilization of Healthcare among Elderly and Pre-elderly Adults," Polyakova used data from Medicare Part D — the prescription drug branch of Medicare, covered by private insurance companies — to determine how older people respond to price changes. In her preliminary findings, Polyakova discovered that people with acute conditions were less likely than patients with chronic conditions to change their drug usage when prices increased.
As the leading cause of death for young people in the United States, traffic accidents are a major risk to health. Around the world, they kill 1.3 million people per year and seriously injure more than 80 million. David Studdert, a professor of medicine and law and a Stanford Health Policy core faculty member, wanted to bring those numbers down. In his study, "Exploring the relationship between traffic citation history and crash risk among elderly drivers in Florida," Studdert looked for a way to find high-risk drivers based on demographics and driving records. He found that drivers who have a quick succession of traffic violations or have particular types of violations may be at a higher risk to cause serious accidents. Studdert hopes to use the study's results to make driving safer without encroaching on civil liberties.
The Institute for Public Policy at Hong Kong University of Science and Technology (HKUST) is soliciting papers for a workshop, “Reforming Public Hospitals in China: Emerging Models and Policy Options,” held in Hong Kong from Aug. 24-25, 2017. The workshop, led by an organizing committee with Shorenstein APARC’s Karen Eggleston, will result in an edited volume or a special issue of China Policy Journal, a new open access journal by the Policy Studies Organization.
Both quantitative and qualitative papers are welcomed; priority will be given to research that focuses on policy intervention of a specific locality or compares practices of multiple local initiatives. Selected paper presenters will receive economy airfare and accommodation paid for by HKUST’s Institute for Public Policy.
Abstract submissions should be 300 words in length and provide a summary of the paper’s main arguments and conclusions. The deadline for submission is April 15, 2017, to Eliza Tang at eliza@ust.hk.
For more information, please click to view the PDF below.
I remember two things about my patient, Maria, a tiny baby who was born a little early. One was her large, beautiful eyes. The other was that when I put my stethoscope on her chest, I heard an enormous heart murmur. Maria had been born with a serious heart condition that would change her life and the life of her mom.
Good patient care at a time like this involves much more than treating a child’s heart. At that first appointment, Maria (not her real name), her mother and I began a long journey punctuated by multiple hospitalizations, surgeries and procedures.
Maria was born at Lucile Packard Children’s Hospital Stanford and lived with her mom in East Palo Alto. As her general pediatrician at Ravenswood Family Health Center, I came to know them both well. I focused on helping the tiny infant gain weight, so that she would be strong enough to undergo her heart surgeries. We brought in the Women, Infants and Children program to support her nutrition. I explained to her mom what the surgeries would do. I reviewed what Maria’s medicines were for, and when her mother couldn’t pay for them I helped gain authorization from county staff, who were able to get them dispensed at the pharmacy. When I realized Maria’s mom didn’t have enough money for food (due to many absences at work), I made sure she applied for food stamps.
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My experience with Maria coincided with my research at Stanford involving access to care for kids in California. As a result of the research, I spent part of my time in Sacramento, working with legislators on changes to the California Children’s Services program. This program is critical to the care of low-income children with serious medical conditions. My research, which involved analyzing data on publicly insured pediatric care like Maria’s, showed that access to high-quality care for low-income kids was pretty good in California compared with other states, but that there was variation among its 58 counties.
While working on the program’s reform in Sacramento, I spent time in countless staff meetings, public hearings and hallway discussions. I often thought about Maria, whose life depended on CCS. The research data I brought to these negotiations were as important as sharing Maria’s story — how her mother lost her job because of time spent caring for her fragile daughter, how the family sank more deeply into poverty and how services needed to be more focused on families. As changes to the CCS system were being discussed, I imagined how they would benefit or hinder Maria’s care and her future.
In a shack that now sits below sea level, a mother in Bangladesh struggles to grow vegetables in soil inundated by salt water. In Malawi, a toddler joins thousands of other children perishing from drought-induced malnutrition. And in China, more than one million people died from air pollution in 2012 alone.
Around the world, climate change is already having an effect on human health.
In a recent paper, Katherine Burke and Michele Barry from the Stanford Center for Innovation in Global Health, along with former Wellesley College President Diana Walsh, described climate change as “the ultimate global health crisis.” They offered recommendations to the new United States president to address the urgently arising health risks associated with climate change.
Bangladeshi children make their way through flood waters.
The authors, along with Stanford researchers Marshall Burke, Eran Bendavid and Amy Pickering who also study climate change, are concerned by how little has been done to mitigate its effects on health.
There is still time to ease — though not eliminate — the worst effects on health, but as the average global temperature continues to creep upward, time appears to be running short.
“I think we are at a critical point right now in terms of mitigating the effects of climate change on health,” said Amy Pickering, a research engineer at the Woods Institute for the Environment. “And I don’t think that’s a priority of the new administration at all.”
Health effects of climate change
Even in countries like the United States that are well-equipped to adapt to climate change, health impacts will be significant.
“Extremes of temperature have a very observable direct effect,” said Eran Bendavid, an assistant professor of medicine and Stanford Health Policy core faculty member.
“We see mortality rates increase when temperatures are very low, and especially when they are very high.”
Bendavid also has seen air pollutants cause respiratory problems in people from Beijing to Los Angeles to villages in Sub-Saharan Africa.
“Hotter temperatures make it such that particulate matter and dust and pollutants stick around longer,” he said.
In addition to respiratory issues, air pollution can have long-term cognitive effects. A study in Chile found that children who are exposed to high amounts of air pollution in utero score lower on math tests by the fourth grade.
“I think we’re only starting to understand the true costs of dirty air,” said Marshall Burke. “Even short-term exposure to low levels can have life-long effects.”
Low-income countries like Bangladesh already suffer widespread, direct health effects from rising sea levels. Salt water flooding has crept through homes and crops, threatening food sources and drinking water for millions of people.
“I think that flooding is one of the most pressing issues in low-income and densely populated countries,” said Pickering. “There’s no infrastructure there to handle it.”
Standing water left over from flooding is also a breeding ground for diseases like cholera, diarrhea and mosquito-borne illnesses, all of which are likely to become more prevalent as the planet warms.
On the flip side, many regions of Sub-Saharan Africa — where clean water is already hard to access — are likely to experience severe droughts. The United Nations warned last year that more than 36 million people across southern and eastern Africa face hunger due to drought and record-high temperatures.
Residents may have to walk farther to find water, and local sources could become contaminated more easily. Pickering fears that losing access to nearby, clean water will make maintaining proper hygiene and growing nutritious foods a challenge.
Climate change will affect health in all sectors of society.
All of these effects and more can also damage mental health, said Katherine Burke and her colleagues in their paper. The aftermath of extreme weather events and the hardships of living in long-term drought or flood can cause anxiety, depression, grief and trauma.
Climate change will affect health in every sector of society, but as Katherine Burke and her colleagues said, “….climate disruption is inflicting the greatest suffering on those least responsible for causing it, least equipped to adapt, least able to resist the powerful forces of the status quo.
“If we fail to act now,” they said, “the survival of our species may hang in the balance.”
What can the new administration do to ease health effects?
If the Paris Agreement’s emissions standards are met, scientists predict that the world’s temperature will increase about 2.7 degrees Celsius – still significant but less hazardous than the 4-degree increase projected from current emissions.
The United States plays a critical role in the Paris Agreement. Apart from the significance of cutting its own emissions, failing to live up to its end of the bargain — as the Trump administration has suggested — could have a significant impact on the morale of the other countries involved.
“The reason that Paris is going to work is because we’re in this together,” said Marshall Burke. “If you don’t meet your target, you’re going to be publicly shamed.”
The Trump administration has also discussed repealing the Clean Power Plan, Obama-era legislation to decrease the use of coal, which has been shown to contribute to respiratory disease.
“Withdrawing from either of those will likely have negative short- and long-run health impacts, both in the U.S. and abroad,” said Marshall Burke.
Scott Pruitt, who was confirmed today as the head of the Environmental Protection Agency (EPA), is expected to carry out Trump’s promise to dismantle environment regulations.
Despite the Trump administration’s apparent doubts about climate change, a few prominent Republicans do support addressing its effects.
Secretary of State Rex Tillerson, the former chairman and CEO of Exxon Mobile, supports a carbon tax, which would create a financial incentive to turn to renewable energy sources. He also has expressed support for the Paris Agreement. It is possible that as secretary of state, Tillerson could help maintain U.S. obligations from the Paris Agreement, though it is far from certain whether he would choose to do so or how Trump would react.
More promising is a recent proposal from the Climate Leadership Council. Authored by eight leading Republicans — including two former secretaries of state, two former secretaries of the treasury and Rob Walton, Walmart’s former chairman of the board — the plan seeks to reduce emissions considerably through a carbon dividends plan.
Already an issue, malnutrition will increase with droughts in Sub-Saharan Africa.
Their proposal would gradually increase taxes on carbon emissions but would return the proceeds directly to the American people. Americans would receive a regular check with their portion of the proceeds, similar to receiving a social security check. According to the authors, 70 percent of Americans would come out ahead financially, keeping the tax from being a burden on low- and middle-income Americans while still incentivizing lower emissions.
“A tax on carbon is exactly what we need to provide the right incentives and induce the sort of technological and infrastructure change needed to reduce long-term emissions,” said Marshall Burke.
Pickering added, “This policy is a ray of hope for meaningful action on climate.”
It remains to be seen whether the new administration and congress would consider such a program.
What can academics do to help?
Meanwhile, academics can promote health by researching the effects of climate change and finding ways to adapt to them.
“I think it’s fascinating that there’s just so little data right now on how climate change is going to impact health,” said Pickering.
Studying the effects of warming on the world challenges traditional methods of research.
“You can’t create any sort of experiment,” said Bendavid. “There’s only one climate and one planet.”
The scholars agree that interdisciplinary study is a critical part of adapting to climate change and that more research is needed.
“If ever there was an issue worthy of a leader’s best effort, this is the moment, this is the issue,” said Katherine Burke and her colleagues. “Time is short, but it may not be too late to make all the difference.”
The Trump administration’s reinstatement of a policy that bans U.S. foreign aid to agencies that provide abortion counseling abroad was a predictable move that could have unintended consequences, Stanford researchers say.
The move freezes funding to nongovernmental organizations that provide abortion services or discuss abortions as a legitimate family-planning option. It revives what is known as the “Mexico City Policy,” so called because it was announced by President Regan in 1984 during a U.N. population conference in Mexico City. It’s a highly partisan policy, which has been implemented under Republican administrations and suspended by Democratic presidents.
From that standpoint, the move to revive the policy was no surprise, said Grant Miller, PhD, an associate professor of medicine at Stanford and core faculty member at Stanford Health Policy. But Miller’s research has shown that the policy actually appears to have the unintended effect of increasing, not decreasing, abortions in the developing world.
“The bottom line is that it doesn’t matter what you think about abortion and the morality and ethics of it,” Miller told me. “I don’t think either side of the disagreement would think a good policy is one that leads to an increase in abortions. Neither side wants to see more abortions.”
In 2011, Miller published a study with Eran Bendavid, MD, on the impact of the policy between 1994 and 2008 in sub-Saharan Africa, a region in which family planning services are heavily financed by U.S. foreign aid. Family planning agencies provide a range of family planning services, including contraception, so when their funding is cut, the availability of contraception declines, said Bendavid, the study’s lead author and another faculty member at Stanford Health Policy. This results in declining use of safe contraception and an increase in abortion rates, the researchers found.
“Sure enough, where you see this relative decline in use of contraception is where you see this uptick in abortion,” said Bendavid, an assistant professor of medicine. “Our theory of what is underlying this is this notion that when women have more restricted access to modern contraception, they rely on abortion. If the intention was to curb abortion, then what we observe is that cutting support to family planning organizations led to the opposite effect.”
Miller followed that up with another study published in 2016 that focused on Nepal during the period when the government legalized abortion, making it more widely available. The policy change gave him the opportunity to test the idea of abortion and contraception as substitutes — i.e. that use of one method to limit family size reduces use of the other. In fact, as the number of abortions rose, use of contraception declined, he found.
“What is remarkable is that this is clear evidence on this interchangeable use that women make in use of contraceptives and abortion services,” Miller said.
In other words, women are trying to control the number of children they have and will use one or the other, depending in part upon what is most available. “If contraception is available, they won’t have to resort to abortion,” Bendavid said.
He said these results have subsequently been corroborated in other studies in sub-Saharan Africa.
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A woman sits by her stall in the Jorkpan market at Sinkor district in Monrovia, on May 2, 2016. Family planning services, like contraceptives and counselling are available in the markets in Liberia, an initiative that is aimed at tackling the high adolescent pregnancy rate in the younger population. | Marco Longari/AFP/Getty Images
Bangladeshi children make their way through flood waters.
Climate change will affect health in all sectors of society.
Already an issue, malnutrition will increase with droughts in Sub-Saharan Africa.
