March 2, 2014

An Inconvenient Reality

Posted by calemed1 under Abortion Information | Tags: , , , , |
[12] Comments 

Pregnancy as an “inconvenience”

One of the greatest falsehoods of the pro-life movement is that pregnancy is merely an inconvenience, a period of temporary discomfort. This is more than a mere talking point; it’s a dangerous lie. Pregnancy is actually a life-threatening condition for many women.

The maternal mortality rate (MMR) is significantly higher in the US than in other developed countries, and the number gets even more pronounced when divvied up into demographics. The 2010 MMR in the US was 21 maternal deaths out of 100,000 live births, a number higher than 47 other countries listed by the CIA’s WorldFact report on maternal mortality. Compare this to the US Dept. of Health and Human Services’ goal for 2010 of 3.3 deaths per 100,000, and about seven times as many women are currently dying from pregnancy-related causes in the US than should be.

Shockingly, not only has the maternal mortality rate not fallen since the mid-1980s, it has actually steadily risen (the MMR in 1987 was 6.6!). But racial disparities in the MMR reveal even more appalling numbers: in 2007, black women were 2.7 times more likely to die of pregnancy-related causes than white women. A 2005 paper on the preventability of pregnancy-caused deaths in North Carolina showed that while 33% of deaths among white women were preventable, a full 46% of deaths among black women were preventable.  This is probably reflective of wider disparities: minority women are more likely to experience an unintended pregnancy, to be poor, and to receive care at lower quality medical centers than white women.

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Even worse, most of these figures are likely underestimated. A 2005 study compared actual rates of pregnancy-caused death to purported rates on death certificates in four regions and found a prevalent underestimation of pregnancy as a cause of death. In Massachusetts, death was inaccurately accorded to a cause other than pregnancy in 93% of the cases studied.

While the maternal mortality rate is increasing, the rate of severe pregnancy complications is also increasing. A 2009 study analyzing trends in the rates of severe obstetric complications showed a “20% increase in rates of renal failure, respiratory distress syndrome, shock, ventilation, and an approximately 50% and 90% increase in pulmonary embolism and blood transfusions, respectively” from 1998-2005. Although there was a correlation between increasing rates of (often unnecessary) caesarian section and severe complications, this only partially explained the dramatic rise in severe obstetric problems experienced by American women since 1998.

In addition, the infant mortality rate is also relatively high in the US compared to other developed countries. Despite substantial decline over the course of the 20th century, the rate of infant death has stagnated in recent years and the US international ranking for infant mortality fell from 12th place in 1960 to 30th in 2005. Abysmally, a Save the Children report recently showed that the US has the highest first day infant death rate of all industrialized nations studied in the report, 50% more than all other industrialized nations combined. And, as with the maternal mortality rate, racial disparities in the infant mortality rate are stark: according to the National Vital Statistics Reports for 2009, the mortality rate for black infants was 12.71per 1,000 live births, compared to 5.32 for white infants (and the report noted that the former is likely an underestimation).

And yet, as part of so-called “informed consent,” pro-life groups routinely tout the fallacious risks of abortion with pseudoscientific claims (e.g. increased risk of breast cancer, infertility, depression, and death) while understating the risks of childbirth. Among first trimester abortions, which comprise the vast majority of abortions, the risk of serious complications is less than .5%.  However, more than 50,000 women per year suffer from severe maternal morbidity (SMM), potentially life-threatening conditions associated with pregnancy. The rate of SMM is also increasing over time, more than doubling from 1998 to 2011. This does not include more minor complications, which are far more common in pregnancy (94.1% of the pregnancies in 2008) than first trimester abortion (2.5%).

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What should we be doing?

 First, and perhaps most importantly, we need to gather information. Why, besides increased caesarian sections, are the rates of severe obstetric complications increasing? Why is the maternal mortality rate increasing so steadily despite the $86 billion spent on pregnancy and childbirth in the US per year? How can we standardize data collection to ensure accurate information on maternal health outcomes across the board? What programs can hospitals institute to reduce the rate of mortality for women and infants?

Although we have some notion of risks associated with maternal and infant death, our data is far from complete. In 2011 the Maternal Health Accountability Act was introduced to provide grants to create state-level maternal mortality review committees to standardize data collection and eliminate disparities in health outcomes. The bill unfortunately died in a Republican-controlled committee.

Otherwise, we are aware of many of the risks and should be able to address at least some with public policy. Higher risk of infant mortality is associated with preterm birth, which is associated with teen pregnancy, unplanned pregnancy, and poor/minority mothers.

These risk factors overlap significantly; for instance, teen mothers are more likely to be poorer, less educated, and to receive less prenatal care than mothers in other groups, and 70% surveyed in a 2004-2006 North Carolina study indicated that their pregnancies were unintended. Similarly, poor and minority women are less likely to receive prenatal care, and minority women are more likely to be poor and have higher rates of unintended pregnancy than other women as well. As for maternal mortality, disparities in access to prenatal and labor care and family planning; poverty; and minority status are all major risk factors, and these also often overlap.

While the problem is systemic, it can be tackled in very specific ways. One of the most important steps in tackling poor health outcomes for mothers and infants is to reduce unplanned pregnancy, which is indirectly associated with both infant and maternal mortality, since the groups at highest risk of dying of pregnancy complications and/or losing an infant are also at very high risk of unintended pregnancies. The major means of accomplishing this goal are to offer comprehensive sex education to adolescents, to increase public funding to family planning clinics, and to make access to reliable contraceptives as universal as possible.

Every one of these things has been directly evidenced to reduce the rate of unintended pregnancy. Comprehensive sex education is associated with reduced rates of teen pregnancy. Conversely, abstinence-only education has not been correlated with lower rates of vaginal intercourse, and states with abstinence-only or non-requisite sex education programs consistently have some of the highest rates of teen pregnancy in the nation. But that doesn’t stop pro-life politicians from routinely insisting on abstinence-only programs, despite their marked failure year after year.

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For six in ten patients using publicly funded family planning services, it is their primary source of health care. An estimated 1.94 million unintended pregnancies and 810,000 abortions are prevented each year by use of public family planning clinics, but as I noted in my last article, they only meet a paltry 40% of the need. Increasing funding to family planning clinics, and therefore access to preventive services and contraceptives, would further decrease the rate of unplanned pregnancy. However, Republican politicians in numerous states consistently cut funding to family planning and women’s health services.

To give an example of the cognitive dissonance so prevalently present between stated pro-life ideology and the consequences of implementing pro-life laws, let us take Texas for an example. In 2011, as part of a sweeping pro-life agenda to shut down Planned Parenthood (the ultimate abortion scapegoat, despite 97% of its services being non-abortion related), Texas slashed family planning funds by 2/3 and barred Planned Parenthood from receiving funds from the Texas Women’s Health Program, resulting in a 77% reduction in the number of patients using family planning clinics, in a state that ranks first in the nation for the number of uninsured, 8th for poverty, and 3rd for teen pregnancy.

The maternal mortality rate has quadrupled in Texas in the last 15 years to 24.6, and even after improvement from 2009, the 2010 demographics are abysmal and much higher than the national average (27, down from 30.8, for white women, and 53.9, down from 66, for black women). For reference, that means black women are statistically better off giving birth in Mexico or Kazakhstan than Texas, and that white women would be better off in Saudi Arabia.

In addition, despite the incredibly high teen pregnancy rate, Texas schools stress abstinence education, do not require contraceptive education, and do not require that sex education be medically accurate. The budget cuts for women’s health care have also decreased the number of clinics that offer preventive healthcare for sexually active teens without parental consent or notification.

Every policy outlined above is one that increases the rate of unintended pregnancy, especially in populations more highly prone to infant mortality (teens) and maternal mortality (poor and minority women). Far from being “pro-life,” Texas has implemented a set of policies that will result in the unnecessary deaths of women and infants. It has instituted legislation that directly decreases access to contraceptives, preventive screenings, checkups, and prenatal care. These in turn lead to increased rates of poor health outcomes for pregnant women, as well as unintended pregnancy among the groups least likely to want or afford pregnancy or children. Simultaneously Texas has instituted sweeping anti-abortion policies that vastly remove access to abortion for women who can’t afford prenatal care or postpartum checkups.

The state ironically takes no responsibility for its own role in making women’s lives worse, exhibiting Orwellian double-speak about personal responsibility even as politicians systematically remove the resources women would otherwise use to BE personally responsible for their reproductive destinies.

All of Texas’ legislative actions aimed at shuttering the Planned Parenthoods in the state are particularly cruel considering they have also declined to expand Medicaid, leaving many poor and minority women nowhere to turn for contraceptives, preventive healthcare, and prenatal care. The Texas Policy Evaluation Project’s survey of low-income women following Texas’ 2011 budget cuts found that “now more than ever disadvantaged women must choose between contraception and meeting other immediate economic needs.”

Texas, sadly, is not alone. Many other states are likewise instituting anti-abortion restrictions while failing to address the unmet need for family planning, expand Medicaid, increase access to prenatal and postpartum care, or offer comprehensive or medically accurate sex education. Far from being an “inconvenience,” pregnancy is a condition fraught with major risks of health complications for both mother and infant. And when legislators intentionally limit abortion access while failing to address the increased risks of maternal and infant death that accompany high unintended pregnancy in poor, uneducated, teen, and minority women, they really don’t deserve to be called “pro-life.”

 

Sources:

1) “Deadly Delivery: The Maternal Health Care Crisis in the USA.” Amnesty International.  http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf

2) Berg CJ, Harper MA, et al. Preventability of pregnancy-related deaths: results of a state-wide review. http://www.ncbi.nlm.nih.gov/pubmed/16319245

3) Hasnain-Wynia R, Baker DW et al. Disparities in health care are driven by where minority patients seek care: examination of the hospital quality alliance measures. http://www.ncbi.nlm.nih.gov/pubmed/17592095

4) MacDorman MF, Mathews, TJ. The Challenge of Infant Mortality: Have We Reached a Plateau? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728659/

5) “Surviving the First Day: State of the World’s Mothers 2013”. Save the Children: http://www.savethechildrenweb.org/SOWM-2013/files/assets/common/downloads/State%20of%20the%20WorldOWM-2013.pdf

6) CIA World Factbook rankings of countries by maternal mortality rate: https://www.cia.gov/library/publications/the-world-factbook/rankorder/2223rank.html

7) Kochanek, K., Xu, J., et al. Deaths: Preliminary Data for 2009; National Vital Statistics Reports. http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf

8) Xu, J., Kenneth, D., et al. Deaths: Final Data for 2007; National Vital Statistics Reports. http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf

9) Gaskin, Ina. Maternal Death in the United States: A Problem Solved or a Problem Ignored? Journal of Perinatal Education, 2008.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2409165/#citeref9 

10) Deneux-Tharaux, C, Berg, C, et al. Underreporting of Pregnancy-Related Mortality in the United States and Europe. 2005: http://opac.invs.sante.fr/doc_num.php?explnum_id=4060

11) CDC fact sheet on Severe Maternal Morbidity in the US: http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.html

12) National Abortion Federation fact sheet on the risks of abortion: https://www.prochoice.org/about_abortion/facts/safety_of_abortion.html#n5

13) Elixhauser A, Wier M. Complicating Conditions of Pregnancy and Childbirth, 2008. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb113.pdf

14) “Unintended Pregnancies: 2004-2006 N.C. Pregnancy Risk Assessment Monitoring System (PRAMS)”  http://digital.ncdcr.gov/cdm/ref/collection/p249901coll22/id/22589

15) An epidemiological review of the effects of comprehensive, abstinence-only, and lack of sexual education on the likelihood of teen pregnancy and rate of intercourse: http://www.jahonline.org/article/S1054-139X(07)00426-0/abstract

16) Teen pregnancy rates by state: http://www.livescience.com/27417-teen-pregnancy-rates-by-state.html AND, for comparison, a brief on state policies on sex education: https://www.guttmacher.org/statecenter/spibs/spib_SE.pdf

17) Guttmacher news release on unintended pregnancies and abortions prevented by the use of publicly funded family planning services: https://guttmacher.org/media/nr/2009/02/23/index.html

18) 77% fewer Texas clients for family planning clinics: http://rhrealitycheck.org/article/2013/11/21/after-budget-cuts-texas-family-planning-program-serving-77-percent-fewer-clients/

19) Texas has highest uninsured rate and ranks 8th for poverty: http://dfw.cbslocal.com/2013/09/17/texas-has-highest-uninsured-rate-high-poverty/

20) “Republicans Offer an Obamacare Alternative,” Time Healthcare online: http://swampland.time.com/2014/02/03/obamacare-republican-alternative/

21) The Texas Policy Evaluation Project, “Low-Income Women’s Attitudes About Affordable Family Planning Services” http://www.utexas.edu/cola/orgs/txpep/_files/pdf/TxPEP-ResearchBrief-WomensAttitudesAboutFPServices.pdf

 

January 28, 2014

Grasping at Straws: “Racial Genocide” and Other Lies

Posted by calemed1 under Abortion Information | Tags: , , , , , |
[18] Comments 

In the last several years it seems that there have been increasing efforts to portray abortion as a form of racial genocide, with pro-life institutions claiming the relatively high percentage of abortions among black and Hispanic women compared to white women is apparently evidence of some conspiracy to “kill off” minorities.

This effort has gained major traction among the general pro-life community in what appears to be an effort to appeal to the “rights” of minorities (at the same time as it advocates the restriction of women’s rights). The cry has even been taken up by certain black pundits and clergymen.

Herman Cain came under attack for blatantly false accusations he made about Margaret Sanger in 2011, when he referred to Planned Parenthood as a bastion of “planned genocide” and claimed that Margaret Sanger’s motivation for founding PP was “to prevent black babies from being born.” Pastor Clenard H. Childress, Jr, quoted as saying that “the most dangerous place for an African-American is in the womb,” founded blackgenocide.org specifically to bring awareness to the plight of black Americans under a regime of extreme genocide.

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It’s too bad that this genocide is completely imaginary.

The black genocide argument usually brings up one of several points:

1) Margaret Sanger was a racist and a proponent of eugenics.

Ah, the Margaret Sanger argument. Only rarely does any debate involving the merits of Planned Parenthood’s mission fail to bring up controversy over Sanger’s motives in founding it, her involvement with the eugenics movement, or something very loudly touted by pro-lifers as “the Negro Project.”

Doubts pertaining to Sanger’s supposedly racist motives usually center around one of several quotes widely disseminated on pro-life websites. First is the claim that Sanger described blacks (in some cases this is expanded to include other groups such as Jews, Catholics, and Hispanics) as “human weeds,” a term she purportedly used in her book “The Pivot of Civilization.”

Fortunately, this book is available for free online, and nowhere does it include the term “human weeds.” There is one section in which Sanger uses a similar term (“human undergrowth”) but it doesn’t actually refer to any minority. Sanger uses it as a metaphor to describe how it is unfair to blame the victims of overpopulation (the poor in particular) for “the indomitable but uncontrolled instincts of living organisms.” This is in keeping with Sanger’s career advocacy for birth control education and use.

Another quote commonly espoused by the pro-life movement to discredit Sanger is the following, disseminated widely via pro-life websites and texts as evidence that “The Negro Project” meant to annihilate the black race: “We do not want word to go out that we want to exterminate the Negro population…if it ever occurs to any of their more rebellious members.” This was taken from a letter sent by Sanger to a doctor in reference to her plans to educate black communities with sex education and to provide them birth control. It was also taken out of context, to imply the precise opposite of her meaning in the original letter. Here is the entire quote, in its full contextual glory:

“I note that you doubt it worthwhile to employ a full time Negro physician. It seems to me from my experience where I have been in North Carolina, Georgia, Tennessee and Texas, that while the colored Negroes have great respect for white doctors they can get closer to their own members and more or less lay their cards on the table which means their ignorance, superstitions and doubts. They do not do this with the white people and if we can train the Negro doctor at the Clinic he can go among them with enthusiasm and with knowledge, which, I believe, will have far-reaching results among the colored people. His work in my opinion should be entirely with the Negro profession and the nurses, hospital, social workers, as well as the County’s white doctors. His success will depend upon his personality and his training by us.



“The ministers [sic] work is also important and also he should be trained, perhaps by the Federation as to our ideals and the goal that we hope to reach. We do not want word to go out that we want to exterminate the Negro population and the minister is the man who can straighten out that idea if it ever occurs to any of their more rebellious members.”

Clearly the quote, when taken out of context, implies that Sanger’s intent was to “exterminate the Negro population.” With the context, however, it is clear that she feared her attempts to educate blacks about sex and to provide them with birth control might be perceived as an attempt to exterminate them, and so wished to hire black physicians and ministers to preemptively discourage such unwarranted suspicions.

Another effort to discredit Sanger often lies in linking her to the eugenics movement of her period.  Sanger was associated with the eugenics movement, and her appointment of several prominent members of the movement to a predecessor of Planned Parenthood might raise eyebrows, if she had given any indication that the movement targeted minorities. Sanger did support sterilization of people with low intelligence, deformity, other incapacities, and those “who have as many children as they believe they can rear” (Sanger, “Sterilization”). But her writings give no indication that she viewed blacks or other minority religious or ethnic groups as genetically inferior. She also vehemently opposed programs of forced sterility.

In “Pivot of Civilization” she writes of the merit of the eugenics movement that it is “valuable in its critical and diagnostic aspects, in emphasizing the danger of irresponsible and uncontrolled fertility of the ‘unfit’ and the feeble minded” (104). She speaks rather extensively of “the menace of the moron to human society…[a problem which requires] an immediate, stern and definite policy” (97).

Lastly, the idea that Sanger supported eugenics of any kind via abortion is simply not the case. Sanger not only never advocated for abortion whatsoever, she actually wrote against it.  An ad for the first clinic Sanger opened and secretly operated, in Brooklyn, included the text “Mothers: Can you afford to have a large family? Do you want any more children? If not, why do you have them? Do not kill, do not take life, but prevent.” The full extent of the mission of the clinics she opened was to educate and provide birth control only.

Her first clinic had to operate secretly because birth control education and the provision of contraceptives for reasons other than STIs were illegal at the time. It was forced closed by authorities and re-opened three times between October 26 and November 16, 1916, when her landlord was forced to evict her and her staff. Nonetheless, it was extremely popular during its brief stint, serving an estimated 400 patients in its first ten days.

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Unless the proponents of the idea that the founding of PP was a conspiracy to commit black genocide, including Herman Cain (who claimed that Sanger’s “objective was to put these centers in primarily black communities so they could help kill black babies before they came into the world”) conflate contraceptives with abortion, their case simply has no leg to stand on. It should be noted that Cain was also wrong about the locations of the clinics. The first, in Brooklyn, catered to Jewish and Irish women; the second, in Harlem, catered to a half-white, half-black clientele.

While it is important to note that the reasons used to justify Sanger’s (and, by proxy, Planned Parenthood’s) vilification are actually false, in the end they are actually irrelevant to the abortion argument today. Even if these false accusations were all true—that Sanger was a racist, that her eugenics goals targeted minorities, that she viewed minorities as “human weeds” and abortion and forced sterilization as a means to eliminate “inferior” races—it would not have any bearing on Planned Parenthood’s mission today.

It is an organization that does not discriminate based on race or ethnic background, and which provides far more STI screenings and treatment, cancer screenings, women’s health services, and contraceptives than abortions. It benefits the poor the most, with 75% of its clientele having “incomes below 150 percent of the poverty line” (“What Planned Parenthood Actually Does”).

 2) A far higher rate of abortions among black (and Hispanic) women compared to white women points to racial genocide.

It is absolutely true that Hispanic and black women have higher rates of abortion than white women. For women aged 15-44, that means an incidence of 40/1,000 for black women and 29/1,000 for Hispanic women, as opposed to 12/1,000 for white women.

Not only is it extremely disingenuous to say that this is reflective of some sort of racial genocide, it also betrays a severe lack of critical thinking ability. Portraying abortion rates as a form of racial decimation (blackgenocide.org directly compares it to slavery and to Hitler’s “Final Solution” and asks “Are we [black people] being targeted?”) necessarily assumes that the agent of action in any abortion is someone other than the mother.

This is anything but the case. Forced abortions and sterilizations are not a problem in the U.S., and it is routine medical practice to give pregnancy options counseling to women considering abortions.

Rather, the higher rates of abortion among black and Hispanic women reflect higher rates of unintended pregnancies in these groups. In addition to having more than twice as many abortions of unintended pregnancies as white women, minority women also have more than twice as many births of unintended pregnancies as white women.

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The unintended pregnancy rate in North America—across all subgroups—is significantly higher than that of Northern, Southern, and Western Europe, and it is the only region (counting both developed and developing regions) in which unintended pregnancy rates have not declined between 1995 and 2008. In the US specifically, rates of unintended pregnancy among poor to low-income women have increased to some of the highest levels of all subgroups, a trend that is especially troubling considering that taxpayer-funded family planning clinics only meet “about 40% of the need for publicly subsidized care” (Singh, “Unintended Pregnancy”).

The Contraceptive CHOICE study showed that when financial hurdles are removed as a barrier to care and women are educated on the relative efficacy of different birth control choices, they are most likely to use long-term methods (e.g. the IUD) which are up to 20 times more effective than short-term contraceptive methods like the pill, vaginal ring, and condom.

What do all of these things mean? For one, they mean that when given a choice and financial capability, women opt for the most efficacious birth control methods, leading to lower rates of unintended pregnancy and lower rates of abortion. It also means that many women aren’t currently given that education, that publicly funded family planning clinics don’t meet the needs of a whopping 60% of the women in income brackets at very high risk of experiencing an unintended pregnancy, and that the US has not only fallen behind most of the developed world, but has stagnated for decades in its progress addressing the needs of women–even as undeveloped nations improve.

Lastly, it means that any accusations of racial genocide are myopic and ignorant at best. The abortion rate among minorities in the US is a reflection of the unintended pregnancy rate in these populations, something that can and should be addressed not by restricting abortion but by addressing the needs of women—especially poor women and minorities. That means increased sex education and increased access to the most effective, long-term forms of birth control, both incidentally things provided by the very organization being smeared as a proponent of “genocide” in the US. It means we do have a problem, but abortion and racism aren’t at the root of it.

 

Sources:

 1) A Politifact Georgia article tackling Herman Cain’s remarks regarding Planned Parenthood’s mission of “planned genocide” (it got a “Pants on Fire” rating): http://www.politifact.com/georgia/statements/2011/apr/08/herman-cain/cain-claims-planned-parenthood-founded-planned-gen/

 2) The “Planned Parenthood” page of blackgenocide.org: http://blackgenocide.org/planned.html

 3) “The Demonizing of Margaret Sanger,” an entry from the blog “Fundamentalist Deceit: an American Tradition,” which goes into much more detail than I have debunking lies and edited misquotations attributed to Sanger: http://fundamentalistdeceit.blogspot.com/2008/01/demonizing-of-margaret-sanger.html

 4) A free, full online-available text of Sanger’s “The Pivot of Civilization”, which is also searchable by keywords (if anyone wishes to double-check that it does not, in fact, include the term “human weeds,” much less as a reference to blacks): https://openlibrary.org/books/OL7206135M/The_pivot_of_civilization

 5) Copy and transcript of Sanger’s letter to Dr. Gamble regarding “The Negro Project”: http://news.rapgenius.com/Margaret-sanger-letter-from-margaret-sanger-to-dr-cj-gamble-annotated

 6) The Margaret Sanger Papers Project, including information on the first clinic Sanger opened: http://sangerpapers.wordpress.com/2010/10/26/sangers-first-clinic/

 7) “Sterilization (A Modern Medical Program for Health and Human Welfare)” by Margaret Sanger, from NYU’s collection of Sanger’s public writing and speeches: http://www.nyu.edu/projects/sanger/webedition/app/documents/show.php?sangerDoc=239501.xml

 8) “Repost: What Planned Parenthood actually does, in one chart,” from the Washington Post: http://www.washingtonpost.com/blogs/wonkblog/post/what-planned-parenthood-actually-does/2011/04/06/AFhBPa2C_blog.html

 9) Guttmacher’s “Facts on Induced Abortion in the United States”: http://www.guttmacher.org/pubs/fb_induced_abortion.html

10) Finer, Zolna, “Unintended pregnancy in the United States: incidence and disparities, 2006,” Guttmacher: http://www.guttmacher.org/pubs/journals/j.contraception.2011.07.13.pdf

11) Singh, Sedgh, Hussain, “Unintended Pregnancy: Worldwide Levels, Trends, and Outcomes”: http://mpts101.org/docs/SinghSFP-UnintendedPregnancy.pdf

12) Paper detailing the results of the three year Contraceptive CHOICE project: Winner et al, “Effectiveness of Long-Acting Reversible Contraception,” New England Journal of Medicine: http://www.nejm.org/doi/full/10.1056/NEJMoa1110855