With a bold investment of federal resources into clinician education during their academic training years and throughout their careers, we can improve reproductive health care—including family planning—and contribute significantly to the reduction of unintended pregnancy rates in the United States.

At the moment we lack a full picture of what students preparing for health professions are or are not learning about family planning. Understanding and improving education on reproductive health for clinicians-in-training will improve the care they can offer patients. Students have been strong advocates for these changes and are asking for more reproductive health training. For example, a 2006 study published in Contraception reported that “students requested that more time be devoted to teaching contraception.”^[2] This education should include the linked issues of contraception, sexuality, abortion, HIV and sexually transmitted infections, pregnancy, and maternal and child health, among others.

The time is right to transform provider education in reproductive health and family planning. The president has challenged all Americans to work together to help reduce the need for abortion by, among other complementary goals, reducing unintended pregnancies in the country.

This idea is not new to the core reproductive health community. In a 1999 lecture at the annual clinical conference of the Association of Reproductive Health Professionals, Dr. Daniel Mishell focused on the pressing need to expand family planning curricula at U.S. medical schools. More recently, the National Campaign to Prevent Teen and Unintended Pregnancy and ARHP jointly convened a panel of experts to review and discuss barriers to effective contraception among young adults.

After a thorough literature review and two intensive meetings, the panel concluded that there is not a clear picture in the United State of the amount of contraceptive education health care providers receive at all levels of their training. Worse, it appears that much education is minimal or nonexistent, in spite of family planning training requirements in various specialties and disciplines.^[3] The panel recommended expanding “broadly based, well-balanced and unbiased continuing education activities where practitioners could be exposed to evidence-based information in addition to practical hands-on experiences.”^[4] Other research supports this conclusion:

• A 2007 editorial published in Contraception reports that lack of training is the number one reason cited by health care practitioners for not taking a sexual health history from patients on a routine basis, followed by clinician embarrassment and a belief that sexual health is not relevant to the patient’s visit.^[5] Reasons for the small amount of time spent on contraceptive counseling, abortion care, and sexuality during training are listed as lack of time, competing curricular priorities, lack of trained faculty or appropriate training sites, and the belief that these issues are less important than training in other areas.
• A review published in the Journal of Sexual Medicine reinforces these conclusions, stating that “in all countries, medical students, house staff, and practicing physicians currently receive variable, nonstandardized, or inadequate training in sexual history taking and sexual medicine assessment and treatment. There remain significant physician–patient barriers to discussing sexual issues; and patients feel that their physicians are reluctant, disinterested, or unskilled in sexual problem management. There is a knowledge gap between developments in sexual medicine and the clinical skills of practicing physicians.”^[6]
• A study of contraceptive knowledge and attitudes among residents confirms that physician knowledge about contraceptives may not be optimal and is inconsistent across primary care specialties.^[7] The authors recommend that “health care providers need ongoing education about new and effective methods of contraception, including long-acting methods. Support should be given to higher education institutions to provide students in the health and medical field with evidence-based information on the latest contraceptive methods. Grants should be available so that health care providers can pursue ongoing continuing medical education on the latest contraceptive methods.”

Our priority should be to expand research and invest heavily into its translation into academic and continuing education for all health care providers. For the reproductive health and family planning field, this means increasing provider knowledge, skills and understanding of contraception, family planning, abortion, sexuality, prepregnancy health, HIV and sexually transmitted infections, maternal and child health, and other issues associated with reproductive health. But it also means incorporating key research about human behavior to improve patient consultation skills, develop cultural competence, and increase awareness of and sensitivity to the potential impacts of provider and patient biases on reproductive health care.

In addition to learning about family planning essentials, clinicians need to improve their communication skills with their patients. Discomfort about discussing sexuality can interfere with effective reproductive health care. A 2003 ARHP survey of women and primary care providers in the United States concludes that providers can be as uncomfortable as patients when discussing specific issues such as sexuality, vaginal health, sexually transmitted infections, and other related issues. Sex and sexuality must be addressed in any discussion about pregnancy prevention.^[8] An analysis published in the Journal of the National Medical Association in 2006 on sexually transmitted disease prevention programs also addresses this point, concluding that “it is essential to train all healthcare providers to lead discussions, educate patients and provide treatment in hopes that sexual health promotion will become as important as other socially accepted healthcare concerns.”^[9]

But reproductive health care, including patient counseling, can be time intensive. A 2000 report focusing on contraceptive counseling for teens concludes that “prescribing and reviewing contraceptive methods with adolescents involves a significant amount of time and resources. Health care providers need to be familiar with how teens think about sex and birth control, what their beliefs are, and how individual teens may make different choices based on their lifestyles.”^[10] An investment in provider education on family planning and reproductive health is in order to meet these needs.

From the patient’s perspective, an untrained or unavailable health care provider can negatively impact contraceptive care. In an analysis of contraceptive use and nonuse published in Perspectives in Sexual and Reproductive Health, the authors found that many women experiencing problems with their contraceptive methods believe that contraceptive service providers are not readily available to answer method-related questions.^[11] Another study completed by Motivational Educational Entertainment Corporation in 2004 found that among a group of urban, African-American teens in the United States, experiences with the health system (including family planning services) were among the most distressing encounters they experienced with any human services system at all.^[12]

Of course, this work will not exist in a vacuum. The investment in provider education will only work in concert with an equivalent surge in new research, health care reform, patient education and advocacy, and a healthier economy. The concept of ramping up family planning education is only one of a handful of linked efforts that, when combined, can help reduce U.S. unintended pregnancy rates.

In a 2007 article on the state of U.S. family planning published in Obstetrics and Gynecology, the authors conclude that “a comprehensive approach requires policy change to improve funding for and access to family planning.”^[13] To accomplish this goal, the time is right for significant federal investment in provider training and continuing education on reproductive health and family planning.

Wayne C. Shields is president and CEO of the Association of Reproductive Health Professionals. This article is adapted from an editorial in the journal Contraception: An International Reproductive Health Journal.

Notes

^[1] Association of American Medical Colleges. AAMC Curriculum Management & Information Tool. http://www.aamc.org/currmit 2009.

^[2] Cwiak CA, Emmons SL, Khan IM, Edelman AB. A comparison of different contraceptive curriculums and their impact on knowledge retention and learning skills of medical students. Contraception. 2006; 73: 609–612.

^[3] Providers’ perspectives: perceived barriers to contraceptive use in youth and young adults, Final report, March 17, 2008. http://www.arhp.org/.

^[4] Brown S, Burdette L, Rodriguez P. Looking inward: provider-based barriers to contraception among teens and young adults. Contraception. 2008; 78: 355–357.

^[5] Lazarus C, Brown S, Doyle LL. Securing the future: a case for improving clinical education in reproductive health. Contraception. 2007; 75: 81–83

^[6] Parish SJ, Clayton AH. Sexual medicine education: review and commentary. J Sex Med. 2007; 4: 259–267.

^[7] Schreiber CA, Harwood BJ, Switzer GE, et al. Training and attitudes about contraceptive management across primary care specialties: a survey of graduating residents. Contraception. 2006; 73: 618–622.

^[8] Association of Reproductive Health Professionals. Vagina dialogues survey, August 8, 2003. /Publications-and-Resources/Studies-and-Surveys/Vagina-Dialogues. Accessed May 26, 2009.

^[9] Williams C, Wimberly Y. Sexually transmitted disease prevention in adolescents and young adults. J Natl Med Assoc. 2006; 98: 275–276.

^[10] Brill SR, Rosenfeld WD. Contraception. Med Clin North Am. 2000; 84: 907–925.

^[11] Frost JL, Singh S, Finer LB. Factors associated with contraceptive use and nonuse, United States, 2004. Perspect Sex Reprod Health. 2007; 39: 90–99.

^[12] In: Motivational Educational Entertainment, National Campaign to Prevent Teen and Unplanned Pregnancy. Key findings: this is my reality: the price of sex, an inside look at black urban youth sexuality and the role of media. 2004; p. 1–8.

^[13] Espey E, Cosgrove E, Ogburn T. Family planning American style: why it’s so hard to control birth in the US. Obstet Gynecol Clin North Am. 2007; 34: 1–17 vii.

The incident simply points to a larger problem: Federal policy regarding comprehensive reproductive health care is inadequate.

Last week, researchers at the University of California, San Francisco, uncovered this ironic situation while trying to “connect” to “reproductive health literature.” Health care providers, researchers, and advocates around the country were alarmed to learn that POPLINE (POPulation information onLINE), had rendered the search term “abortion” a stopword—which directs the database to ignore the term when used in a search. UCSF librarians discovered this deliberate restriction when they were unable to find a single document containing the word “abortion” in POPLINE’s database, and contacted the administrators at the Johns Hopkins Bloomberg School of Public Health to ask them why. Simply put, the UCSF librarians were told that “abortion” was eliminated as a search term by the POPLINE administrators so that the latter could examine the database for information “that might not have been consistent” with guidelines from a government agency that funds the project. And our UCSF colleagues were then given some mystifying, convoluted search term suggestions for finding medical literature on the subject, including “fertility control, post-conception” and “pregnancy, unwanted.”

By Friday morning, news of the self-censorship had spread like a virus. Countless members of the medical, scientific, and advocacy communities responded and by early Friday evening, Hopkins Dean Michael J. Klag issued a statement unequivocally denouncing the administrators’ decision to censor the word abortion and promising to get to the bottom of it. By Tuesday, he issued a follow up statement citing his opposition to the decision and his speedy response, while blaming “an overreaction on the part of POPLINE staff” to a search by USAID [United States Agency for International Development] officials who “found two items in the POPLINE database that advocated for abortion.”

So let’s pause for a moment and review what happened: a vigilant literature search on the word “abortion” by unidentified Federal employees at USAID resulted in finding two abortion articles in the POPLINE database that they deemed to feature inappropriate advocacy. Once notified by the Feds, Hopkins administrators immediately made abortion a stopword—an additional step not requested by USAID, but implemented to allow administrators to search for other material that might have been inconsistent with the agency’s guidelines—effectively ending access to abortion research to health professionals and the public on their 30-year-old database.

While giving credit to Dean Klag for his quick response to an untenable situation, there are two important questions that remain: Why are Federal employees at USAID so attentively monitoring scientific research articles on the POPLINE database for the word “abortion”? And why are Hopkins administrators so afraid of them? The Dean states that USAID is prohibited by law from funding any abortion activities or supplies. This is all the more reason for concern by researchers, civil libertarians, health care providers, and patients who deserve the best possible care. But the incident simply points to a larger problem: Federal policy regarding comprehensive reproductive health care is inadequate.

The Real Impact of Limiting Access to Information

The medical and scientific needs of the reproductive health professional community were impeded by POPLINE’s decision to remove abortion as a search term on its publicly funded database. If this action had gone unchecked, the decision would have limited the medical and scientific community’s ability to access information on a range of patient care scenarios, including women experiencing both wanted and unintended pregnancies.

A clinician seeking information while providing abortion care services would have been unsuccessful in accessing key medical and scientific literature on the topic—potentially endangering the patient. Women with wanted pregnancies and their health care providers looking for information on spontaneous abortion (miscarriage), inevitable abortion, incomplete abortions, missed abortions, and related medical information would have also been denied this key data.

Unsafe abortion practices claim thousands of lives worldwide every year and any public health student, policy maker, or provider seeking vital information on the topic of unsafe abortion would have also come up empty-handed.

Ideology Trumping Science Is About More Than Just Abortion

The specter of ideology trumping science goes way beyond POPLINE and abortion. There is more visible political opposition to important health classifications like family planning, sexuality, and reproductive health than we have seen in years. Political posturing can get in the way of science, public health, and patient care—even POPLINE’s reputation is potentially at risk.

Even self-censorship of a specific term like “abortion” in a scientific setting—especially as a result of Federal government monitoring—sets a dangerous precedent.

Over the last seven years, we have witnessed an intentional blurring of the lines between opposition to abortion and a more general objection to contraception. For example, many of President Bush’s anti-choice family planning political appointees have been openly anti-contraception as well. Bush’s 2002 appointment to a key FDA panel, Dr. Joseph B. Stanford, complained about contraceptive use even among married couples. And more recently Bush appointed Susan Orr as the acting deputy assistant secretary for population affairs to oversee family planning funding for clinics serving poor women, even though she previously worked to limit access to contraception as the senior director for marriage and family care at the Family Research Council, an organization well-known for its anti-contraception stance.

And now the term “reproductive health” is being targeted. At the United Nations, there are unbelievably rancorous debates about whether or not to include the terms “sexuality” and “reproductive health” in treaties because many politicians view them as faux terms for abortion.

It may have been that POPLINE staff made the decision based on fear of losing their USAID funding. USAID does have a history of basing reproductive care funding decisions at least partly on ideology and politics. For example, they have withheld funding from developing countries if potential grantees provide abortion services or give abortion referrals to women.

It’s also possible the suggestion came from above. With the Bush administration’s history of attempting to (and often succeeding in) restricting access to abortion services and information at every possible turn, it’s not so unlikely they’d attempt to scrap the word altogether.

The bottom line is that even self-censorship of a specific term like “abortion” in a scientific setting—especially as a result of Federal government monitoring—sets a dangerous precedent. We must follow the example of our UCSF colleagues and make preserving access to reproductive health science a part of our own work plans. It’s scary enough to consider the possibility that ideological searches are being performed by anonymous government employees who troll our scientific databases for the word “abortion.” “Contraception,” “sexuality,” and “reproductive health” are the next stopwords, unless we remain vigilant and protest loudly.

Pablo Rodriguez, MD, is the Board Chair of the Association of Reproductive Health Professionals. Wayne C. Shields is the President and CEO of the Association of Reproductive Health Professionals. Jennifer Aulwes is the Media and Policy Manager for the Association of Reproductive Health Professionals.

Dr. Orr does not have a medical degree and has no direct experience in family planning. Her public statements indicate a lack of experience and an ideologically-based commitment to extreme points of view that bring into question her qualifications for the job and her ability to objectively assess and apply accepted best practices in health care to Federal policy.

Americans value their right to decide when and whether to have children, and sound public policy supports their ability to make those decisions.

What’s worse, this is the second time in a year that the administration has appointed an anti-contraception activist to the position. In November 2006, the administration appointed Dr. Eric Keroack, a non-board certified gynecologist, who received “two formal warnings from the Massachusetts board of medicine ordering him to refrain from prescribing drugs to people who are not his patients and from providing mental health counseling without proper training,” just before he resigned in March amid Medicaid fraud allegations.

Dr. Orr’s appointment is only the most recent example of a trend that will take years to repair. The administration’s unapologetic long-term political strategy of diminishing the value of scientific integrity to create doubt and achieve ideologically-driven political goals is becoming more widely recognized. Unfortunately this appointment is another clear-cut example of an administration appointee whose background and ideology are at odds with the majority of reproductive health professionals.

In Title Only

Dr. Orr’s appointment highlights some particularly difficult challenges that will likely have negative implications for people in America who don’t have full access to health care. Her position oversees Title X, the federal family planning program that serves more than 5 million low-income Americans annually through more than 4,400 community-based clinics. Seventy-five percent of U.S. counties have at least one clinic that receives Title X funds, and it is estimated that over 1 million unintended pregnancies are prevented each year through contraceptives made available for low income Americans by Title X services each year.

Application of Dr. Orr’s position on family planning places undo hardship on those least able to pay for contraception.

But the controversy of her appointment is about more than the possible subversion of policies that have proven effective for preventing unintended pregnancies and abortions. Few would question that the person filling this position should have a commitment to evidence-based science and to all aspects of reproductive health care including disease prevention and family planning. Title X-supported clinics provide patient education and counseling; breast and pelvic examinations; breast and cervical cancer screening; sexually transmitted disease (STD) and Human Immunodeficiency Virus (HIV) prevention education, counseling, testing and referral; and pregnancy diagnosis and counseling.

Steering the ship responsible for funding such services requires respect for the value of providing people with informed options for their health care. Americans value their right to decide when and whether to have children, and sound public policy supports their ability to make those decisions. The Centers for Disease Control and Prevention included family planning in its list of the “Ten Great Public Health Achievements in the 20th Century,” yet Title X funding has declined by 60 percent since 1980, when adjusted for inflation, even though 17 million U.S. women rely on public funding to obtain contraception.

With almost half of all pregnancies in the United States being unintended—80 percent of teen pregnancies fall in this category—any neglect of basic services can be directly linked to failures in education and public policy. The American public will benefit from a significant increase in funding to make all methods of contraception available to all who want and need them, to research new approaches to family planning, and to provide comprehensive, evidence-based reproductive health and sexuality education in schools and communities.

Steering the ship responsible for funding such services requires respect for the value of providing people with informed options for their health care.

Application of Dr. Orr’s position on family planning places undo hardship on those least able to pay for contraception. Further restriction on these funds will inevitably result in more unintended pregnancies and more abortions, an outcome that runs directly counter to the stated goals of the program she is supposed to be directing.

While most private insurers cover contraception, it is ethically and fiscally sound public policy to ensure that all Americans have equal ability to decide what is best for them and their families. Dr. Orr’s position as senior director for marriage and family care at the Family Research Council, an organization that advocates restricting access to family planning, makes her entirely unsuitable to run the agency whose mandate is to provide access to needed family planning care for our nation’s men and women.

One Tired Finger

Americans deserve a deputy assistant secretary for population affairs who will advocate for increased access to contraception for all who need and want it, and for the full range of reproductive health services that enhance quality of life. We believe that we must communicate the value of reproductive health services to individuals first and, second, to society as a whole.

Simply put, we are advocating for reproductive health professionals to compensate for the inability of Dr. Orr, her predecessors, and this administration to achieve those goals. As scientists, we must learn to appeal to the positive aspects of belief systems outside of our experience to communicate scientific values, to change minds and to affect public policies.

But it is insufficient to simply point our finger at the administration and Dr. Orr. We also must accept responsibility for failing to effectively communicate with the public and policymakers.

It isn’t completely clear why it’s been so easy to take anti-science policy positions in the United States in the last decade. One answer lies in the U.S. public’s ambiguity about science and the role it plays in their lives. In the most recent survey of public perceptions about science by the National Science Foundation, 55 percent of the respondents agreed that “we depend too much on science and not enough on faith,” and 70 percent agreed that “scientific research these days doesn’t pay enough attention to the moral values of society” and that “scientific research has created as many problems for society as it has solutions.”

These findings indicate that the anti-science faction that has taken root in Washington of late has reason to cheer. This unfortunate trend is not merely the result of overzealous ideologues; there seems to be a level of indifference among much of the lay public to the importance of science and the policies that directly affect them. For many, “science” is a necessary but somewhat remote, dusty, and godless venture that has no direct impact on their everyday lives. These findings should also serve as a warning that regime change in Washington 15 months from now will not be enough to turn the tide of public sentiment.

We also know that lecturing the public about scientific principles and research outcomes in the desire to convince them about our correctness is oftentimes a wasted effort; our intended audiences often consider this approach condescending and patriarchal, despite our opposite intention. If our goal is to change minds, this approach just does not work and should be abandoned as a primary course of action.

Behavioral science theory tells us that most people operate from the screens of their own interests and beliefs; they are not going to listen to or be swayed by data that contradict their belief systems, regardless of accuracy. Without getting overly academic (we tried that), we have to reinvent the way we communicate the value of applying science to health policy in the context of the values that we share with an angry and doubting but concerned public.

The scientific community and the general public have a lot more in common than not. That’s why we as scientists must be prepared to channel the public’s skepticism of science toward a broader understanding of the progressive values that should always underpin scientific inquiry and public policymaking.

Wayne C. Shields is the President and CEO, Association of Reproductive Health Professionals. Rivka Gordon is the Director of Strategic Initiatives, Association of Reproductive Health Professionals.