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At a time when the medical community has been heartened by a decline in risky sexual behavior by teenagers, a different problem has crept up: More adult women are forgoing birth control, a trend that has experts puzzled -- and alarmed about a potential rise in unintended pregnancies.
Even as he cheered the news that a growing number of teenagers are using contraception, Santelli wondered whether doctors are neglecting women.
"Maybe we're failing with women over 21," Santelli said.
Physicians, statisticians and advocates who specialize in reproductive health had several theories for the rise in unprotected sex. They pointed to possible factors such as gaps in sex education, the cost of birth control, declining insurance coverage, fears of possible side effects of contraceptives and personal attitudes about childbearing.
It is possible, said Paul Blumenthal, that many more women are trying to conceive and thus have stopped using contraception. But the Johns Hopkins University professor said it is more likely that more women have found the cost of birth control burdensome.
Jeffrey Jensen, director of the Women's Health Research Unit at Oregon Health and Science University, said he regularly encounters patients who have trouble affording birth control, even if their private insurance covers it.
"It is absolutely unconscionable that women have a co-pay of $20 or $25 [a month] for contraceptives and men are getting off scot-free," Jensen said. Drug companies "have cut way back" on free samples and many women turn to less effective types of birth control because of cost, he said, "running a greater risk of pregnancy as a result."
Of the 34 million women in need of contraceptive services -- those who are not sterilized, pregnant or trying to conceive -- about 17 million qualified for publicly funded care, according to a 2002 report by the nonprofit Alan Guttmacher Institute. Of that number, 6.7 million received government-funded services, most through Medicaid or the Title X family-planning program.
Many physicians put partial blame on federally funded abstinence-only education programs that by law prohibit discussion of contraceptives, except to detail their failure rates.
Proponents of abstinence education played down concerns about unintended pregnancies.
"Pregnancy is not a disease. . . . The women making these choices are making a conscious choice. They are not stupid," said Leslee J. Unruh, president of the Abstinence Clearinghouse. "Women don't want to use birth control because of the side effects. And a lot of men refuse to use a condom."
Several recent studies found that as the abstinence-until-marriage movement surged, there was a "considerable drop" in comprehensive sex education from 1988 to 2000, Santelli said. "Women in their twenties have probably gotten less effective information about contraception," he said.
"It's clear that contraception is a service people use and want to use, judging by the almost universal use in America," Blumenthal said. "We're offering a service people find useful."
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