Written by Elizabeth Gregory for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Photo: See-Ming Lee / Flickr

New CDC birth data out Wednesday confirm that the U.S. birthrate dropped one percent to reach an all-time low in 2011, extending the downward trend begun with the recession in 2008. Put down your knee-jerk fears about smaller population. This drop is a good sign, foretelling not a diminished but a strengthened workforce down the line.

Historic lows make headlines, but the deep story here is the time-lag ripple effect of delay that this year’s data demonstrate. The big birthrate declines we’ve seen since the recent high in 2007 (down nine percent overall) have been sharpest among teens ages 15 to 19 (a 25 percent drop over the four years) and to young women ages 20 to 24 (down 19 percent). Both of those age bands hit historic lows in 2011. We’re talking framework change here.

On the other hand, rates among women ages 25 to 29 have fallen a much smaller nine percent since 2007; those among women ages 30 to 34 fell four percent between 2007 and 2010 and held steady in 2011; and those among women ages 35 to 39 also fell four percent between 2007 and 2010, but rose three precent in 2011. Rates among women ages 40 to 44 fell: they’d been rising steadily since 1981, and rose another seven percent between 2007 and 2011.

What we’re seeing here looks not so much like a big decline in the number of women who have kids over their lifetimes, or even necessarily in the number of kids they have, as like the time-lag effect of postponement. The big switch in the timing of when women have children was underway long before the recession of 2007 (see this CCF fact sheet), but the recession intensified it. We can see that in the chart below, in the rising birthrates for women ages 30 to 44, and the falling rates for women ages 15 to 29.

Already some women who stayed on the maternity sidelines in their thirties in the early part of this decline have jumped back into the game (visible in the rises among women 35 and older). Though the increases to date are not yet sizable, the scene is set for a flood of later mothers down the line. The overall rate of decline was lower than in the three previous years, suggesting that an overall upturn may be on the way in the next year or so. But though the recession officially ended in 2009, younger women’s rates are still dropping drastically in 2011 (down 8 percent from 2010). These indicators confirm that the recovery still needs to gain traction before people trust it with their families. They also tell us that the national birth timing dynamic is changing fast.

In their 25 percent rate plunge in just four years, young women today are enacting a sped-up version of the trend to delaying kids that’s been growing since the introduction of hormonal birth control, in 1960.[1]  Like millions of women before them, these citizens are refraining from having a first child early on (first births were also at an all time low in 2011), or sometimes a second, and choosing instead to invest in their educations (high school completion and college entry levels are up since 2007) and to build up their credentials at work. They may not be changing the number of kids they’ll have overall by much, but they are changing the economic circumstances into which those kids will arrive, for the better. Not all recession effects are problematic.

This sped-up delay effect has at least three overlapping causes. Most obvious is the recession/slow recovery (recessions are historically powerful contraception — before the Pill, the lowest recorded birth rate occurred in 1936). If people don’t feel they can afford kids, they become more vigilant about controlling fertility. A second cause lies in recent improvements in birth control methods and access, which make it easier to be vigilant.

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Written by Kees Rietjmeijer for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Editor’s Note: This article is part of a series developed by the American Social Health Association (ASHA) in celebration of Sexual Health Month 2012 during September. RHRC will be publishing articles by ASHA all month, see all the articles here and visit ASHA online throughout September for updates.

Cross-posted with permission from the American Social Health Association (ASHA).

(Photo: Portland Prevention/flickr)

One evening, during the week of the 2001 International Society for STD Research meeting in Berlin, I met with a couple of colleagues for beers after the day’s proceedings. We lamented the the narrow focus of many conferences was on disease and the lack of a broader sexuality framework. “It is time to put sex into STD prevention,” one of my colleagues said. The comment was a bit wistful at the time and I don’t think any of us could have foreseen that a decade later our field would be expressing so much more interest in sexuality and sexual health.

This has been accentuated by the Center for Disease Control’s (CDC) recent efforts in developing a sexual health framework signalling an overall shift from disease prevention to health promotion. Credit goes to Dr. John Douglas, the Chief Medical Officer in the National Center for HIV, Hepatitis, STD and TB Prevention, who spearheaded this effort in the past three years and has created a broad coalition of stakeholders across the political and cultural spectrum to endorse a national strategy for sexual health.

Of course, the CDC’s efforts did not arise in a vacuum and there have been a number of developments in the past decade that have fostered a broad-based discussion of sexual health. For me, one of the heralding events in the sexual health discourse was Dr. Amy Schalet’s presentation on teen sexuality at the Jacksonville STD Prevention Conference in 2006. I have always been taken by Dr. Schalet’s work — perhaps because as a chauvinist Dutchman (born and raised in Amsterdam) I liked her findings that a more liberal attitude towards sexuality among Dutch teens and their parents is associated with much lower rates of teen pregnancy and sexually transmitted infections (STIs) in the Netherlands compared to the U.S.  Her book: “Not Under My Roof” was published last year (a podcast interview with Dr. Schalet is available at this link).

However, association does not causation make. There is a lot to like about a more positive approach towards sexuality, but a causal link between better sexual health and lower pregnancy and STI rates ultimately requires scientific evidence that goes beyond intuitive reasoning. For example, it has been said that prevention messages that use a positive “gain” frame (i.e., focus on health) are more effective than messages that use a negative “loss” frame (i.e., focus on disease). Intuitively, this sounds good but what’s the evidence? Not much, at least not in the field of prevention. The only study that analyzed the use of negative versus positive approaches for ongoing prevention with patients, actually found greater efficacy of the loss frame (or negative) messaging. This study formed the basis of the Partnership for Prevention intervention, which has been widely disseminated by the Diffusion of Effective Behavioral Interventions (DEBI) program.

The point is that for a sexual health strategy to work, we must develop a sexual health science. For starters, we must determine what parameters best measure a person’s sexual health. How are these parameters assessed and how are they related to the outcomes we are interested in: unintended pregnancy, STIs, sexual violence? Finally, can interventions be designed to influence these parameters that can be shown to improve sexual health and reduce negative outcomes?

If our forays into sexual health do not yield something more than what we are already doing now (i.e., testing and treating for STIs (including HIV), counsel our patients to reduce numbers of partners and increase condom use), our journey may have been interesting, but ultimately proven to be a detour.

There is some good research at the interface of sexuality and STI/HIV/pregnancy prevention. One of the leaders in that field is Dr. Dennis Fortenberry (indeed: he of the “wistful” comment cited above) at Indiana University School of Medicine. He has become a frequent speaker at national and international STI conferences on sexual health topics. In one such presentation, he proposed a sexual health research paradigm that encompasses and links the full spectrum of sexual expression, including sexual abstinence, masturbation, and partnered sex. For example, he presented very interesting data on the linkage of masturbation and condom use (click here for a copy of this presentation). He has also proposed that in the context of sexual health, a much greater focus must be placed on pleasure and desire. Go read his blog entitled: “What is Sexual Health” posted at this link.

At the end of the day, I am still an STD prevention guy. And, while I am a strong believer in sexual health promotion, we need science not just good will to show that this approach is working.       

Written by Martha Kempner for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

When I was a peer sexuality educator at UMASS-Amherst back in the early 1990s we used to joke about the fact that the only gynecologist on staff at the health center was named Dr. Daniel Clap. At the time it seemed hilarious that the man charged with prescribing our pills and diagnosing our sexually transmitted diseases (STDs) seemed to be named after one of the most common STDs. None of us knew why gonorrhea was called the clap (more on that later). In truth, apart from making the joke about the gynecologist’s name, none of us thought much about this bacterial infection that had been reduced a nuisance by the advent of antibiotics long before we were born. Sure, we stressed how condoms can prevent gonorrhea and how important it was to get tested for it because it often has no symptoms but in the workshops we led we paid far more attention to the “4-H club” because these diseases—HPV, HIV, Hepatitis B, and Herpes—were ones you might have to live with for the rest of your life.

We were not alone in our complacency around gonorrhea. The disease is easily prevented by condoms, easily tested for in STD clinics, and easily cured. HIV got attention for being potentially life threatening. HPV got attention for being so widespread and leading to cervical cancer. Gonorrhea was annoying but not much of a menace. Deborah Arrindell, Vice President, Health Policy for the American Social Health Association (ASHA), explained it this way:

“We think of gonorrhea as a funny infection—the clap—that doesn’t kill anybody.  But the consequences of untreated gonorrhea are quite serious; infertility, increased risk of HIV, and a big impact on our national wallet…nothing to clap about there.”

Today, many in the public health community will admit that we collectively took our eyes off the ball because Neisseria gonorrhoeae is a very clever bug that has developed the ability to resist nearly all of the antibiotics that have been thrown in its path. It has steadily developed resistance to entire classes of antibiotics—as early as the 1940s it was resistant to sulfanilamides, by the 1980s penicillins and tetracyclines no longer worked, and in 2007 the CDC stopped recommending the use of fluoroquinolones (the class of drugs that includes Cipro, which we may all remember as the thing to stockpile in case of an anthrax attack). Today, the only class of antibiotics that remains effective are cephalosporins, but its susceptibility to these drugs is declining rapidly in the United States and other countries have already seen cephalosporin-resistant cases.

In February the Centers for Disease Control and Prevention (CDC) sounded the alarm about this growing threat and suggested that we need to change the way we screen for and treat gonorrhea in this country in order to respond to this wily germ. Last week, the World Health Organization (WHO) released a statement on this issue and, more importantly, a global action plan for stemming the spread of drug-resistant gonorrhea. As the resistant cases emerge, it is a good time to look at how we got here and what we can do to ensure that gonorrhea does not become a major public health threat.

Cephalosporin-Resistant Gonorrhea is Coming

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Written by Stephanie S. Arnold Pang for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

This article is published in partnership with the National Coalition of STD Directors (NCSD) as part of our joint series on STD Awareness.

Sexually transmitted diseases (STDs) remain a major epidemic in the United States. Each year, there are approximately 19 million new cases of STDs, approximately half of which go undiagnosed and untreated, making the United States the country with the highest STD rate in the industrialized world. STDs cost the U.S. health care system $17 billion every year — and that number doesn’t even take into account the costs to individuals of STDs, the short-term and long-term consequences, including infertility, increased risk of acquiring HIV, and certain cancers.

Photo by Fibonacci Blue

And it is because of this, I am here to make the case for increased funding for the Division of STD Prevention (DSTDP) at the Centers for Disease Control and Prevention (CDC).

Now I am not an advocate who lives under a rock. I know these are fiscally-challenging times, to put it mildly. I know that when a congressional staffer says (as I did when I worked for a Member of Congress), “Flat funding is the new increase” that he or she speaks the truth.

Yet, these statements chafe me.  It is not the factual basis of this statement that I take issue with, but the idea that this is something we should all accept. Investments in our country’s public health are investments in our country’s healthy future. These investments are crucial not only for maintaining healthy individuals, but these are the investments in the infrastructure that we rely on when there is an outbreak or an unforeseen disaster. And I refuse to believe that we live in a county where it’s okay to let people fall through the cracks.  Because in 2009, African Americans had 20 times the reported gonorrhea rates than whites. And that is just one alarming statistic. I could list many, many more that highlight the sexual health disparities in this country.

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Written by William Smith for RHRealityCheck.org – News, commentary and community for reproductive health and justice.

April is National STD Awareness Month and sexual and reproductive health organizations throughout the country urge you to Get Yourself Tested!!  RH Reality Check has partnered with The National Coalition of STD Directors (NCSD) to produce a series of articles on the importance of STD prevention and treatment among populations throughout the United States.  Other articles in this series include one by Sandra Serna-Smith, Dana Cropper Williams and Peter Leone and a feature article by William Smith published earlier this week.

Last week, and as part of STD Awareness month (April), I and several other colleagues wrote about just how significant the STD situation is in our country. It might not be in the headlines everyday, but we’ve got very serious STD epidemics affecting the most vulnerable in our society. This week, I want to pick up on a theme from my own article and that of my colleague Peter Leone in North Carolina: The issue of the resurgent syphilis epidemic in the United States.

Headlines were made recently about the shockingly high rates of syphilis among men who have sex with men. These rates are indicative of behaviors—such as not using condoms–that put people at risk for other sexually transmitted diseases, including HIV. But that is just one aspect of the resurgent syphilis epidemic. Another is the equally disturbing trends of syphilis infection passed along to babies by their mothers, known as congenital syphilis.

On April 16^th, the CDC released new data about the rates of congenital syphilis (CS) and the trends are going totally in the wrong direction. From 2003 to 2005, there were roughly 339 cases per year in the United States. In 2008, however, nearly 100 additional cases of CS were reported for a total of 431 that year. That means nearly 500 children being born in 2008 with a totally preventable life-threatening illness.

CS is preventable. Treating maternal infection 30 days prior to delivery is highly successful in reducing or eliminating transmission. The CDC reports, however that in about a quarter of CS cases where maternal infection was detected within this 30-day window for treatment, an identified infection was left untreated. In another quarter of cases, infection was identified less than 30 days out from delivery and in about 30 percent of cases, no prenatal care was provided and infection was identified at the time of delivery.

What is worse: This isn’t just about babies born sick and easily treated with an “all’s well” ending. In 2007 and 2008, 54 babies born with CS were stillborn and another 7 died within thirty days of birth.

Drill down into the data a bit deeper and we find the same persistent and disturbing trends in terms of how this infection and its outcomes disproportionally affect the southern part of the country. Nearly 60 percent of all cases of CS in 2008 are in the South.

And of course behind the numbers of CS cases are also women whose sexual health is already compromised, particularly black women. Nearly 50 percent of all cases of CS were among those born to black mothers. An even more astonishing statistic provided by the CDC analysis that brings these two pieces of data to appalling convergence – 79 percent of those black mothers involved in CS transmission were from the South.

The current National Plan to Eliminate Syphilis sets a goal of reducing the rate of congenital syphilis to fewer than 3.9 per 100,000 births by 2010. It is highly unlikely that we will meet it. In 2008, the rate was 10.1 per 100,000 births. That is a huge gap to close when the evidence is all around that ground is being lost – not gained.

So, we have yet another window into a disturbing increase of syphilis in this country and it is part of a clarion call to renew and refresh our domestic commitment. This renewed effort must focus on greater efficacy of delivering treatment to pregnant mothers and the CDC recommends this going forward. The great success in preventing mother-to-child transmission of HIV is a good model to look to and the impact of health care reform may also hold promise. After all, good access to prenatal care could facilitate a dramatic drop in rates of syphilis and of CS. But we must focus these efforts and resources in the south where the ugly intersection of history and poverty allow syphilis to thrive.

A decade ago, we were on the precipice of a major public health success story in eliminating syphilis. In fact, syphilis rates in 2000 were the lowest since 1941 when it first became a reportable disease. Now, with insufficient resources and too much politics that has set back behavioral interventions and access to sexual and reproductive healthcare services, we have a big mess on our hands.

But it is a mess we can fix. And fix it we must.

Written by Brook Kelly for RHRealityCheck.org – News, commentary and community for reproductive health and justice.

On this Women and Girls HIV/AIDS Awareness Day 2010, we reflect back on the past year’s work around HIV/AIDS and women in the United States. The rate of HIV among women and girls has been steadily increasing over the years, with women of color the hardest hit.  HIV has now become the leading cause of death among Black women ages 25 to 34.

At the 2009 HIV/AIDS Prevention Conference in Atlanta, Secretary of Health and Human Services Kathleen Sebelius commented on the dramatic and disparate impact of the HIV epidemic on minority communities: "Today, African Americans make up just over one-tenth of the population. But they account for nearly half of new HIV infections. One in 30 African-American women will be diagnosed in her lifetime. One in sixteen African-American men will be diagnosed with HIV. The situation is also dire for Latinos. Think about that. Imagine if it were half the straight white women in Atlanta. Wouldn’t we be calling this a national emergency? Shouldn’t we be?"

The answer is, of course, yes we should be calling the HIV/AIDS crisis a national emergency.  

As the HIV Human Rights Attorney for the U.S. Positive Women’s Network, the only national membership organization for HIV-positive women, I have seen tremendous gains in advancing HIV-positive women’s issues to the highest policy levels. I have heard HIV-positive women’s voices where before there was only silence: in the White House, in Congress, at the tables where decisions are made.  But I am also struck by the continued blindness to the deeper structural challenges faced by women and girls affected and infected with HIV in the United States, a blindness that makes progress toward stemming the epidemic virtually impossible.

For the first time, the Center for Disease Control (CDC) in its Women and Girls HIV/AIDS Awareness Day 2010 statement called for the promotion of women’s human rights as a key factor in reducing “the burden of the epidemic among women and girls,” here in the U.S. They addressed the most challenging structural barriers that women face in preventing HIV transmission and in caring for themselves when HIV-positive: not only our biological vulnerability as women to HIV, which can be alleviated through safer sex tools, but the crux of the issue: gender inequity; lack of financial autonomy; and sexual and domestic violence that prevents women from demanding the use of safer sex tools.

While the CDC has taken a giant step in recognizing that the HIV epidemic among women is a human rights issue, beyond increased testing, they have yet to offer solutions that account for the complex barriers to HIV prevention and treatment women face. Yet, the implementation of a human rights based solutions that take a holistic approach to HIV prevention and care is necessary not only abroad but here at home.

For the PWN, a human rights based approach means that:

• Every woman has access to and education about high quality, culturally appropriate, accessible, and integrated HIV/AIDS and sexual and reproductive health services;

• Every HIV-positive woman can exercise her right to decide whether and when to have a child and has access to the information and services necessary to make an informed and voluntary decision; every woman’s right to confidentiality and dignity be respected;

• Stigmatizing laws and policies–like those that criminalize HIV transmission and exposure, or harm women in prostitution–are amended or repealed;

• Every woman has access to safe, adequate housing and meaningful employment, opportunities;

• HIV-positive women are meaningfully involved in all policy decisions affecting their lives; and

• Laws and policies that intentionally, or unintentionally negatively affect the prevention, or care and treatment of women living with or affected by HIV are changed.

Although the meaningful inclusion of HIV-positive women’s voices on issues most affecting their lives has been slow coming we see that progress has been made – voices have been heard.  For the first time the U.S. is in the process of drafting our first National HIV/AIDS Strategy.

As of today, however, the newly formed President’s Advisory Council on HIV/AIDS, which will review and monitor the Strategy has no Black HIV-positive woman member despite the fact that Black women carry the greatest burden of the HIV epidemic; as of today our U.S. foreign policy on HIV has a more woman-centered approach to HIV prevention and care than our own domestic policy – the PEPFAR Five-year Plan calls for the integration of HIV and reproductive health services and care as a mandatory component of HIV prevention and treatment; as of today we are still not calling HIV/AIDS among women of color in the U.S. a national emergency.

On this National Women and Girls HIV/AIDS Awareness Day, I hope our leaders will begin to listen to the resounding voices of HIV-positive women in the U.S. who know that the best solutions to the epidemic only begin with increased testing but succeed with the recognition of and work towards realizing women’s human rights to health, dignity, and equality.

Written by Amie Newman for RHRealityCheck.org – News, commentary and community for reproductive health and justice.

For women who choose to go through pregnancy and childbirth, the freedom to choose where and with whom to birth is not always immediately accessible. Before childbirth in hospitals became the norm, women birthed at home, under the care of a midwife. It wasn’t until the 1950s that childbirth care shifted significantly from midwives and homebirth to physicians and hospital birth. However, birth for healthy mothers and their babies does not necessarily have to be medicalized.  And because it was becoming increasingly clear that birth was drifting, quickly, from the hearts and hands of women to the more medicalized, economic model put forth by hospitals, women’s health advocates interested in natural birth created a movement.

There is nothing inherently wrong with hospital birthing, of course (written from the heart of a mother who birthed two beautiful children in a hospital birthing center). It is the focus on economics, while having lost our sense of what birth is all about by straying far away from trusting women and women’s bodies, that is the "wrong." We now have a cesarean section rate in this country of 30 percent – one out of every three births in this country is via c-section -  that dangerously exceeds the World Health Organization’s recommended rate of 5 to 10 percent of all births. With a cesarean rate of over 15 percent, the WHO says, we’re in the realm of doing "more harm than good."

We are not providing women with the optimal enivornments for birthing, or giving women the chance to choose where they wish to birth and with whom. There are of course many reasons for this, not the least of which is access. Women who have no health insurance are not in a position to "choose." Pregnant women who live in a small town with one hospital that forces c-sections upon women who have had a previous c-section are not in a position to "choose." Women who live in a state where midwifery, essentially homebirth, is illegal are not in a position to "choose."

This cannot be what our mothers want or what we want for our mothers.

Things are looking up. According to a new report by the Centers for Disease Control (CDC) released this week, more women in the United States are opting to birth at home or out-of-hospital, when they are able, mostly out of a desire for a low-intervention birth or because of cultural or religious reasons, and sometimes because of lack of transportation.  

The report also identifies reduced costs associated with out-of-hospital maternity care as a factor in the increased demand. 

Over the last five years, out-of-hospital births (which includes home birth and birthing at a free-standing birth center) rose 3 percent and home births rose 5 percent after having sharply declined between 1940 and 1969 and then remaining static over the last few decades.

Approximately 17 percent of these home births recorded were unplanned – either because of transportation issues for women who live in rural areas or emergency scenarios.

The report acknowledges that home births were "less likely than hospital births to be preterm, low birthweight, or multiple deliveries."

Out-of-hospital birth and home birth has been treated with more than a raised eyebrow by the media as well as some professional medical associations (specifically the American Medical Association (AMA) and American Congress of Obstetricians and Gynecologists (ACOG)) over the last few years.

The AMA passed a resolution in opposition to home birth stating that hospital births are the safest route for mothers and babies.

In a poorly reported segment on The Today Show a few months ago home birth was treated as a perilous fad spurred on by celebrities who birth at home with hordes of pregnant women clamoring to "do what Ricki Lake did."

However, the report makes a point to note that in contrast to the AMA and ACOG, the organizations that represent physicians who facilitate birth in hospitals, "the World Health Organization, the American College of Nurse Midwives, and the American Public Health Association all support home and out-of-hospital birth options for low-risk women."

As for midwives who attend home births and birth center births around the country?

The Big Push for Midwives Campaign Manager, Katie Prown, says, “Those of us who have been advocating for increased access to Certified Professional Midwives and out-of-hospital maternity care have long known that the research shows that AMA and ACOG statements about the safety of home birth and the reasons why women choose out-of-hospital delivery have no basis in the evidence,“ said Prown. “It’s great to be able to cite even more research on the safety of out-of-hospital birth and to be able to point to data showing that women in the United States do not, in fact, make decisions about where to have their babies for frivolous, selfish, or trendy reasons.”