Abstinence promotion and the provision of information about contraception in public school district sexuality education policies.

CONTEXT: For more than two decades, abstinence from sexual intercourse has been promoted by some advocates as the central, if not sole, component of public school sexuality education policies in the United States. Little is known, however, about the extent to which policies actually focus on abstinence and about the relationship, at the local district level, between policies on teaching abstinence and policies on providing information about contraception. METHODS: A nationally representative sample of 825 public school district superintendents or their representatives completed a mailed questionnaire on sexuality education policies. Descriptive and multivariate analyses were conducted to identify districts that had sexuality education policies, their policy regarding abstinence education and the factors that influenced it. RESULTS: Among the 69% of public school districts that have a district-wide policy to teach sexuality education, 14% have a comprehensive policy that treats abstinence as one option for adolescents in a broader sexuality education program; 51% teach abstinence as the preferred option for adolescents, but also permit discussion about contraception as an effective means of protecting against unintended pregnancy and disease (an abstinence-plus policy); and 35% (or 23% of all U.S. school districts) teach abstinence as the only option outside of marriage, with discussion of contraception either prohibited entirely or permitted only to emphasize its shortcomings (an abstinence-only policy). Districts in the South were almost five times as likely as those in the Northeast to have an abstinence-only policy. Among districts whose current policy replaced an earlier one, twice as many adopted a more abstinence-focused policy as moved in the opposite direction. Overall, though, there was no net increase among such districts in the number with an abstinence-only policy; instead, the largest change was toward abstinence-plus policies. CONCLUSIONS: While a growing number of U.S. public school districts have made abstinence education a part of their curriculum, two-thirds of districts allow at least some positive discussion of contraception to occur. Nevertheless, one school district in three forbids dissemination of any positive information about contraception, regardless of whether their students are sexually active or at risk of pregnancy or disease.

PIP: Descriptive and multivariate analyses were conducted to identify districts that had sexuality education policies, their policy regarding abstinence education and the factors that influenced it. A nationally representative sample of 825 public school district superintendents or their representatives completed a mailed questionnaire on sexuality education policies. Results revealed that 69% of public school districts have a district-wide policy to teach sexuality education, of which 14% have a comprehensive policy that treats abstinence as one option for adolescents in a broader sexuality education program; 51% teach abstinence as the preferred option for adolescents, but also permit discussion about contraception as an effective means of protecting against unintended pregnancy and disease; and 35% teach abstinence as the only option outside of marriage, with discussion of contraception either prohibited entirely or permitted only to emphasize its shortcomings. A growing number of US public school districts have made abstinence education a part of their curriculum; however, two-thirds allow at least some positive discussion of contraception to occur.

Capitol Hill forecast: the more things change.

PIP: In the US, election of a more balanced Congress in November 1998 has meant that few changes in family planning policy are expected. However, several areas continue to generate debate including whether research using human stem cells is included in the federal ban on research using human embryos. A measure passed by the House of Representatives to require parental permission for adolescents to receive federally funded FP services was dropped before final passage of the legislation and is unlikely to be revived, but there are rumors of impending attempts to introduce a new welfare reform measure that will expand "abstinence-only" sex education programs for adolescents. Supporters of contraceptive insurance coverage hope to expand on their victory last year that required the insurance program for federal employees to offer the full range of contraceptive drugs and devices. This year will see introduction of a similar measure that would apply to any private insurer that covers prescription drugs. Congress is also expected to consider attaching the "Mexico City Policy" to foreign aid bills. This policy is a gag rule that would prevent nongovernmental organizations receiving US funding from even mentioning abortion to clients, even in countries where abortion is legal.^ieng

Successful challenge with clozapine in a history of eosinophilia.

Eosinophilia has been encountered from 0.2 to 61.7% in clozapine-treated patients, mostly with a transient course and spontaneous remission. There have been few reports, however, which have investigated a challenge with clozapine in patients previously showing eosinophilia. Two case reports are presented: the first with clozapine challenge after eosinophilia, the second under clozapine treatment and no previous haematological side effects. The challenge case showed eosinophilia with 1.2 10(9)/l (z = 1.79, p = 0.04) being followed by normalization despite clozapine continuation, whereas the maximum value reached 2.1 10(9)/l in the single episode case, with consecutive normalization and uninterrupted treatment. Eosinophilia caused by clozapine was observed in challenge, preceded by a faster neutrophil production and consecutive decrease (z = 2.27, p = 0.01). A challenge with clozapine was feasible and showed no clinical symptoms of eosinophilia.

Election-year session has Congress in spotlight.

PIP: In 1998, the US Congress will continue to grapple with the issue of funding for the Title X family planning (FP) program. Opponents to the program maintain that FP providers ignore state laws regarding statutory rape and other reporting requirements. Opponents also seek amendments that require parental consent before FP services can be offered. FP advocates are pressed to devise language addressing concerns about adolescents that protects the integrity of confidentiality. Funding for international FP programs was set at a decreased level of $385 million to be meted out monthly. However, international FP programs will continue to be allowed to provide information about abortion on request. In 1998, Congress will also debate whether to make reporting of HIV/AIDS cases mandatory as it considers reauthorization of the Centers for Disease Control. In late 1997, a Clinton Advisory Committee issued a draft Consumer Bill of Rights and Responsibilities that requires health insurers to give patients complete information about accessing coverage, to make sufficient numbers of providers available to ensure meaningful coverage, and to give women direct access to obstetrician/gynecologists for routine preventive care. It is likely that a bill will be introduced to codify these recommendations. Legislation will likely be revived to impel health insurers to cover prescription contraceptive methods.^ieng

Contraceptive parity: it's time for action.

PIP: In the US, lawmakers are attempting to address discrepancies in private health insurance coverage of contraceptive services and prescriptive supplies through legislative action. The proposed Equity in Prescription Insurance and Contraceptive Coverage (EPICC) Act was introduced to the Senate in May 1997 with the support of many leading health care organizations and the cosponsorship of approximately 30 senators. A companion bill was introduced into the House of Representatives in July with approximately 70 cosponsors. The sponsors were attempting to attach the bills to appropriate legislative vehicles because there was no time to achieve separate passage in the current session. The EPICC Act responds to the fact that many private insurance companies do not cover reversible contraceptive services. While 97% of plans cover prescription drugs, only 33% cover oral contraceptives. This forces women to spend 68% more than men on prescription medicine or to choose less effective or inappropriate, but less costly, methods. In April, Maryland became the first state to mandate contraceptive coverage (with an exemption offered to religious organizations). Virginia then required insurance plans to offer (but not mandate) coverage to companies purchasing plans for their employees. Hawaii had enacted similar legislation in 1993, and bills are pending in California, Illinois, New York, and Massachusetts.^ieng

Complacency, abortion politics obstacles to improved health of pregnant women and children.

PIP: Worldwide, the provision of family planning (FP) services is seen as essential for reducing incidence of maternal mortality and morbidity, which is especially high in developing countries. In the US, the maternal-child health advocacy community focuses almost exclusively on meeting the needs of children. During the past two decades, studies have revealed that nearly 600,000 women fall victim to maternal mortality each year, and 30 times that number experience debilitating morbidity. Thus, recent international conferences have promoted safe motherhood initiatives, including the provision of FP services. Despite the fact that the US has about 1000 maternal deaths each year and 800,000 cases of morbidity, with these adverse conditions more prevalent among Black than White women, the focus on children led Medicaid to expand its access to prenatal care to reduce infant mortality. Recently, states have sought permission to extend FP services to Medicaid recipients. This emphasis on the use of FP to time and space births in an optimal manner and, thus, reduce maternal mortality and morbidity in the US is welcome. However, when considered as a reproductive rights issue, FP is almost always regarded either as a service that increases abortion by promoting promiscuity or that reduces the need for abortion. To secure adequate levels of government financing, supporters of FP should promote all of its dimensions, rather than simply its impact on abortion.^ieng

Domestic, international family planning programs at risk.

PIP: The US government has subsidized family planning services domestically and abroad for three decades. For most of that period, the support has been provided with the broad-based backing of both US lawmakers and the general public. However, recent polling indicates that public support for family planning programs remains strong, but not necessarily among legislators. Since Republicans gained control of the US House of Representatives in 1995, a well-organized opposition to government-subsidized family planning has developed. The House leadership has launched attacks to defund and abolish Title X, the core domestic family planning program, and the US Agency for International Development's (USAID) population assistance program. Although these attempts failed, a parallel strategy is being pursued to raise anxieties about the programs and chip away at members' support for them. Family planning supporters in Congress and the White House are on the defensive. Rather than fighting for funding increases and new program initiatives, family planning advocates have been forced to try to just hold their ground. Even though they rest intact, Title X and USAID funding has suffered and the programs' base of congressional support has been seriously compromised. With the current Republican domination of the House, Title X and USAID face an uncertain future.^ieng

Congress delves into science with RU-486.

PIP: In June 1998, a conservative, Republican member of the US House of Representatives attempted to amend the 1999 bill authorizing funding for the US Food and Drug Administration (USFDA) to prevent government funds from being used to test, develop, or approve "any drug for the chemical inducement of abortion." This bill was designed to halt the approval process for RU-486, a drug that was deemed "approvable" by the USFDA in 1996. Arguments mounted against the amendment by medical, health, and research groups stated that 1) RU-486 is an advance because it permits abortions early in pregnancies, 2) it is improper for the US Congress to impose a scientific judgement on the USFDA, and 3) this amendment has adverse implications for a wide range of drugs and devices that might have an abortifacient effect but be approved for other uses. The House of Representatives passed the amendment but the Senate rejected it, and it was deleted from the final version of the legislation. The amendment is expected to resurface next year. The Congressional debate on RU-486 also spilled over into the appointment hearings for the nomination of Jane Henney as USFDA commissioner. During her confirmation process, Henney was grilled about whether she would grant final approval to RU-486. Henney's nomination was approved by committee but has not yet been considered by the full Senate.^ieng

Family planning at heart of political debate.

PIP: In the US, the efforts of Chris Smith, a Republican member of the House of Representatives from New Jersey, have led to Congressional approval of two restrictions on US aid to foreign family planning (FP) programs. The first restriction prohibits the US from funding any organization that performs abortion with its own funds, even in countries where abortion is legal (except in cases of life endangerment, rape, or incest). The bill specifies that President Clinton can waive this prohibition only at a cost of $44 million to the already reduced FP funding. The second restriction prohibits US funding of any group that engages in abortion-related lobbying and is, in effect, a "gag rule" that would punish organizations for engaging in activities that would be protected in the US by the First Amendment of the Constitution. Clinton has threatened to veto the legislation even though this means that he will risk losing his ability to pay dues owed to the UN or to provide backing to the International Monetary Fund. Smith's actions reflect efforts to eliminate federal funding of domestic and international FP programs despite the fact that polls continually demonstrate the widespread approval of the US public for such programs.^ieng

What methods should be included in a contraceptive coverage insurance mandate?

PIP: There is growing momentum in the US to require insurance plans to cover contraceptives and contraceptive services. One goal of such legislative action would be to redress the fact that many current insurance plans cover abortion and contraceptive sterilization, but do not cover reversible contraception. This failure of insurance plans to cover reversible contraception reflects the longstanding insurance practice of covering surgical and other remedial services, but giving very little attention to prevention. A second goal would be to ensure that a woman can use her insurance to choose contraceptives based upon whether they are the most appropriate methods for her, not whether the method or methods are covered by her plan. To achieve these goals, the Equity in Prescription Insurance and Contraceptive Coverage Act (EPICC) currently pending in the US Congress would require most private sector insurance plans to cover prescription contraceptive drugs or devices approved by the Food and Drug Administration, or generic requirements. Outpatient contraceptive services would also be covered. Should opponents to abortion in the US House of Representatives succeed in narrowing the scope of this contraceptive coverage mandate, the range of contraceptive options available to women would be severely limited. The author explains the conception of pregnancy and how contraceptive methods prevent pregnancy, and considers the debate over the issues in the US Congress.^ieng

Funding for international family planning attacked.

PIP: US funding for foreign assistance has been jeopardized in recent years in the context of dwindling public support for foreign aid. To stymie the provision of international family planning program assistance and services overseas, Congressional opponents of family planning and abortion are offering amendments to foreign aid legislation at every possible opportunity. State Department reauthorization legislation is the current target of family planning opponents' efforts. Reauthorization is the process by which Congress indicates its ongoing support for a program, makes any necessary changes, and sets new funding ceilings. The global gag rule joined UNFPA funding cuts on the 1997 State Department reauthorization bill, H.R. 1757, which passed the House of Representatives in early June. If successfully appended to the State Department bill, the gag rule would prevent the US from funding any organization in a developing country which provides legal abortion services or communicates with its government on abortion-related policy, regardless of whether that organization used its own non-US funds. These restrictions and cuts to international family planning program assistance could adversely affect family planning programs, leading to less contraceptive use and higher rates of abortion, maternal morbidity, and maternal mortality. President Bill Clinton has promised to veto the bill if both houses of Congress accept the restrictions. These issues will probably arise on the annual appropriations legislation which funds US operations overseas.^ieng

Lawmakers use diverse strategies for targeting teen reproductive health.

PIP: During 1997, legislators in several US states have taken action to restrict or enhance the access of adolescents to contraceptive information and services. In Texas, a budget bill rider that mandates parental consent before minors can be given prescription drugs faces a legal challenge while, in Maine, a similar bill died in committee. Mississippi's welfare reform bill includes three adolescent pregnancy prevention programs: one meets federal abstinence-only sex education guidelines; one mandates employment of school nurses in each school district to coordinate health services, including reproductive health services; and the third is a school-based pilot program that seeks to reduce the incidence of adolescent pregnancy and to provide reproductive health education. Colorado created a voluntary school-based health program. The only family planning (FP) restriction in this program is that no funds may be spent on abortion (except as may be required by federal law). In Florida, legislation amended existing authorization of state-supported school-based health services and specified that state funds were not to be used for FP, immunization, or prenatal care. Similarly prescriptive measures died in Louisiana and South Carolina.^ieng

In welfare reform's wake, lawmakers take multifaceted approach to teen pregnancy.

PIP: In response to the 1996 US federal welfare reform law, states have prioritized legislative initiatives to reduce the incidence of adolescent pregnancy. By 1994, 31 states and the District of Columbia already had adolescent pregnancy prevention initiative in place, with most granting financial support to community-based efforts, conducting media or outreach campaigns, sponsoring education-related activities, and providing contraceptive services. Additional federal funding to reduce out-of-wedlock births to women on welfare has been almost exclusively channeled by states into programs for adolescents. The five states that achieve the largest decreases in numbers of illegitimate births without increasing numbers of abortions will receive a bonus of $20-25 million from the federal government. Louisiana and Arizona enacted measures that appear to respond to this incentive. In Louisiana, the initiative bonus would be passed on to the ten parishes with the most success, and Arizona allocated its entire federal portion of the new welfare block grant to the Department of Health for programs to decrease pregnancy without increasing abortion rates. While the federal government's program emphasizes proscriptive measures, such as abstinence-only education, a number of states have begun, continued, or expanded comprehensive programs to prevent adolescent pregnancy. These include Arkansas, Rhode Island, Iowa, Mississippi, New Jersey, and Connecticut. Efforts were made to improve public awareness about adolescent pregnancy in Florida, Louisiana, and Pennsylvania. Broad-based bills fell to gubernatorial vetos in California and South Carolina, and a measure to create an independent commission to develop a state plan to reduce adolescent pregnancy rates is pending in Massachusetts.^ieng

Adolescent use of Norplant implants: clinic services, policies and barriers to use.

INTRODUCTION: The purpose of this article is to review the experiences of family planning clinic providers in making Norplant available to adolescents. We look specifically at the proportions of women receiving the implant from these providers who are teenagers, the policies adopted regarding implant education and whether or not parental consent is required for minors. Pricing policies and the implications of high method cost for teenagers are discussed. Finally, some of the policies adopted by state agencies related to adolescent use of the implant are reviewed. METHODS: The data come from two national surveys conducted by the Alan Guttmacher Institute (AGI). The first, a survey of family planning agencies, collected data from 616 family planning providers of clinic services (response rate 69%). The second surveyed the Medicaid, health and welfare agencies in all 51 jurisdictions about policies related to Norplant. RESULTS: Over one-quarter of all contraceptive implants inserted by family planning agencies were provided to teenagers. Teenagers were routinely informed about the implant in about 85% of those clinics offering implant services. Few state agencies notify women about the implant. Twenty-three percent of all family planning agencies providing implant services report that parental consent must be obtained prior to implant insertion. The Medicaid program has paid for a majority of implant insertions at family planning agencies. CONCLUSIONS: Teenagers who rely on publicly funded family planning clinics for contraceptive services face a variety of barriers in obtaining Norplant. High method cost, parental consent requirements and issues related to Medicaid eligibility are likely to deter some teenagers who might otherwise choose Norplant.

PIP: Data from two national surveys conducted by the Alan Guttmacher Institute--the Family Planning Monitoring Survey and the Norplant Accessibility Survey of State Agencies--enable a preliminary assessment of the extent to which US family planning programs have succeeded in making Norplant available to teenagers. By September 30, 1992, 40% of US family planning agencies provided Norplant and another 13% were about to begin distribution. During the first 18 months of Norplant availability, teenagers were recipients of 27% of all contraceptive implants inserted by family planning agencies. By the end of 1993, about 75,000 teens had obtained Norplant from family planning agencies by the end of 1993 and another 60-65,000 received the implants from private providers. The median cost of Norplant insertion is US$500, but 60% of insertions are funded by Medicaid. Although 85% of clinics routinely inform teenagers about the Norplant option, state health and welfare departments and Medicaid have made little effort to promote Norplant use. 23% of agencies that offer Norplant require parental consent for minors; this requirement varies, however, from a low of 6% of Planned Parenthood affiliates to a high of 40% of hospital-based programs. Potential deterrents to continued high use of Norplant by teenagers include a lack of confidentiality, Medicaid limits on the number of funded insertions, and loss of Medicaid benefits when a teen leaves home or is more than 60 days postpartum.

Welfare reform hearings begin with focus on out-of-wedlock births.

PIP: Congressional representatives across the political spectrum agree that the US welfare system needs to be reformed, but no consensus exists on how to do it. Central to the argument in support of making major changes is the high number of out-of-wedlock births, especially among low-income teens. Looking for ways to discourage such pregnancies and births, some people argue that the welfare system itself promotes the births. Republicans are calling for punitive action to regulate fertility such as cutting off welfare payments to unwed teens who give birth. Opponents counter that little evidence exists demonstrating that welfare change will reduce rates of out-of-wedlock births or unintended pregnancy. Few in Congress, however, have stepped forward to point out that many unplanned pregnancies and out-of-wedlock births could be avoided if poor and low-income women had better access to voluntary family planning and abortion services. In failing to provide such services for poor women, Congress is failing to act as reality demands.^ieng

Title X may get 10% funding increase despite cutbacks for deficit.

PIP: The politics of the US budget deficit and President's Clinton proposed health budget are described. The proposed health budget included the following items and expenditure levels: Title X planning with a 10% increase to 199 million; abstinence-based programs deleted and funding directed to the Office of Adolescent Health for $6.8 million; Community Health Centers with a 1% increase to $604 million; WIC with a 12% increase to $3.7 billion; Title IIIb of the Ryan White CARE Act on AIDS prevention with a 40% increase to $67 million; National Institute of Child Heath and Human Development, including contraceptive research, with a 5% increase to $581 million; Sexually Transmitted Disease Prevention for $100 million; Breast and Cervical Cancer Screening for $78 million; and Maternal and Child Health Block Grant with a 1% increase to $679 million. Abortion funding for poor women was an item deleted from the appropriations budget for the next fiscal year, because of its inclusion in health care reform. Final funding levels may diverge greatly from Clinton's proposed budget outlined above. Appropriations subcommittees will consider funding for each of the departments. There is no certainty on how the administration will support the proposed budget, or what actions on health care reform will impact on appropriations. If the cost of health care reform is enough, it may be that other health funding will be cut. The president's budget was sent to Congress on February 7, 1994, and included mandatory entitlement programs, which are 66% of the entire federal budget, and discretionary spending, such as for family planning. The prior Bush and Reagan administrations reduced discretionary funding, and Clinton is in the awkward position of having politically supported both increased health funding and federal budget reduction. The agreement between Congress and President Clinton in 1993 to cut federal spending over the next 5 years has reduced the ability to include new spending.^ieng

Public funding and policies for provision of the contraceptive implant, fiscal year 1992.

According to results of a survey of state Medicaid, health and welfare agencies, these agencies spent $61 million in federal and state funds on the provision of the contraceptive implant to low-income women in FY 1992. Some $57 million of this was federal funds, with Medicaid accounting for 84% of all public funds spent on the implant; only nine states committed monies from their own coffers. The Medicaid agencies of 13 states reported restrictions on the number of subsidized implants a woman could receive over her reproductive lifetime. No Medicaid agency has provisions to cover required or requested removals of the device among users who become ineligible for Medicaid while the implant is in place; only eight health departments have policies ensuring subsidized removals for such women.

PIP: Made available to the public for the first time in February 1991, Norplant is the first contraceptive implant approved for use in the US. The implant provides women with continuous contraceptive protection, is fully reversible, and is not coitus-dependent. Data from Wyeth-Ayerst Laboratories, the distributor for the US, indicate that 750,000 kits had been inserted as of July 1993. People, however, question the degree to which users may be dependent upon providers, particularly for implant removal, and about the potential for coercive public policies targeted to members of lower socioeconomic classes. By January 1993, all fifty states and the District of Columbia had approved the implant for reimbursement under their Medicaid programs. This paper reports findings of a survey conducted to assess levels of public funding for the provision of Norplant and the development of policies under which these funds are made available. The survey found that state Medicaid, health, and welfare agencies spent $61 million in federal and state funds providing Norplant to low-income women in fiscal year 1992. $57 million of the outlay was federal, with Medicaid accounting for 84% of all public funds spent on the implant; only nine states committed state funds. Medicaid agencies of a woman could receive over her reproductive lifetime. Further, no Medicaid agency has provisions to cover required or requested removals of the devices among users who become ineligible for Medicaid while the implant is still in place. Only eight health departments have policies ensuring subsidized removal for such women.

Questions of balance: issues emerging from the introduction of the hormonal implant.

PIP: The Alan Guttmacher Institute takes a critical look at the practical aspects of obtaining and providing the hormonal implant Norplant in the US service delivery system. It focuses on financial accessibility of the implant and raises questions about the role of service providers in implant counseling and removal. In the US, access to a complete range of contraceptive options usually hinges on income and insurance coverage. Since the initial price of Norplant is high ($365), the public sector cannot assure a full range of methods. The price precludes most low-income women who do not quality for Medicaid from using Norplant. Many people want the price to be reduced, particularly because a private foundation and public funds shouldered much of its development costs. In some cases, the private company and publicly funded contraceptive development organizations have negotiated a price reduction for public sector family planning providers. The current debate over national health care financing must result in coverage of contraceptive services and supplies for all methods. Safeguards must be in place to make sure that women voluntarily choose the implant and continue to use it. Providers need to counsel women about all the risks and benefits of each contraceptive method, potential side effects, and how to obtain financial and clinical access to start, continue, and discontinue method use. Family planning providers need to put as much attention on access to removal as on access to insertion. For example, the initial fee could include the cost of removal. The Population Council and health agencies in California, Florida, and North Carolina provide guidelines for implant provision and on informed and voluntary method choice. Public policy needs to uphold equal access to use and to discontinuation of methods, especially when public funds have been used.^ieng

Contraceptives. On their own.

Despite the need for more safe and effective contraceptive drugs and devices, enormous barriers to contraceptive research and development have been raised in the United States. The designation of contraceptives as orphan drugs, with concomitant incentives, may be warranted to encourage private manufacturers to reenter the field.