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Contraception that is used among married women in China ages 15 through 49:

•pill-1.7%
•iud-39.6%
•no birth control-14%
•modern methods-0.3%
•injection-0.1%
•condom-4.3%
•male/female sterilization-69%,33%

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"Carry out birth planning for the revolution."

The standard issue propaganda poster, along with its countless similar replications, was a patriotic call for birth control in the name of productivity and health. China was already short on food and resources, and with the country's population exploding, the future looked positively slim. The government's earliest efforts to control the burgeoning populace came in the form of these slogans and national dictums, which later expanded to include contraceptive use.

"20 years ago if you went to the rural villages, you could see the slogans on the wall that read, 'if you have one child, IUD please, if you have two children, sterilization please,'" describes Kaining Zhang, a research physician at the Yunnan Health and Development Research Association. "There is still a very strong influence [from that] policy."

Today, attitudes towards sexuality and reproductive health have dramatically shifted in China. The once taboo topics have been the subjects of national campaigns to increase sexual health awareness, and a survey by Renmin University shows that more than half of all respondents think premarital sex is acceptable.

Government policy and more traditional viewpoints remain deeply influential on Chinese attitudes toward contraception and birth control. Yet with rapidly changing world views and sexual habits among China's younger generations, outdated policies have created a shortage of free state health services for millions.
Methods and trends
China has one of the highest rates of contraceptive use in the world with 84.6% prevalence among women who are currently married or in union. In comparison, the United States has a 78.6% prevalence, and China's next largest neighbor, Japan, reports 54.3% prevalence. The high figures owe much to China's vast network of family planning centers and other government initiatives in local communities that followed the implementation of the One-Child policy in 1979.

China's family planning policies target married women, emphasizing permanent means of birth control, though a multitude of birth control options are available through retails stores. Individuals can visit family planning service stations in both urban and rural areas to access free birth control methods.

Sterilization has a 28.7% usage rate and is typically recommended to women following the birth of a second child. Intrauterine devices (IUDs) have a 40.6% usage rate, and though not permanent, are often promoted by state health services over temporary methods.

"There is a heavy emphasis on IUDs and sterilization, this may be a barrier [to contraceptive use] and people perhaps not wanting to use either of these two methods and finding themselves pregnant," says Amy Tsui, Director of The Bill & Melinda Gates Institute of Population & Reproductive Health.

You need to upgrade your Flash Player

The preference toward long-term methods of birth control is one that has contributed to gaps in sexual health awareness in younger generations of Chinese. The National Population and Family Planning Commission oversees China's population development and has made improvements in the access to birth control and sexual health education such as increased school initiatives and national campaigns about sexuality. However, the majority of these services are intended for married couples, leaving young, single individuals without free state coverage.

"For young people, they are not covered by the family planning program because they are not married, so they fall through the cracks in terms of sex education and contraceptive access," says Joan Kaufman, Distinguished Scientist at the Schneider Institutes for Health Policy at Brandeis University. "They can certainly purchase birth control at drug stores, but it is harder for them access services from China's free family planning program."

Temporary means of contraception such as condoms or hormonal contraception are used in low frequency in China. Among married couples, only 1.2% use pills and 8.5% use condoms. For adolescents who are likely to choose non-permanent contraceptive methods, the lack of usage could indicate a lack of knowledge of these methods or simple inaccessibility. According to Euromonitor, however, sales of emergency contraception grew by 8% in 2011 to reach almost RMB1.3 billion, a method that has seen a steady growth within the last decade.
Gaps in education and its effect

You need to upgrade your Flash Player

The inaccessibility of state services parallels a rapid rise in premarital sex rates among China's young people. A 2003 report by the China Family Planning Association showed that in most provinces, 60-70% of respondents engaged in premarital sex.

While abortion and its connection to China's family planning laws have long been a highly contentious issue, the high abortion rate among China's youth is thought to be a direct result of inadequate services and education. In 2009, Chinese health officials reported that 13 million abortions are performed in China annually. Of the total, 62% were among women between 20 and 29 years old, while most were single.

"Many young people don't use contraception at all and that is reflected in high abortion rates for youth," Dr. Kaufman says.

China's health care industry has taken note of the trend. The Beijing Modern Women's Hospital offers a government-subsidized "Safe & Easy A+" discount abortion package at RMB 880 or US$130, seemingly targeting Chinese students and young people.

While there have been increases in sex education, these improvements have been slow and targeted toward abstinence education. Chinese adolescents are hungry for information on sexual health and many turn to anonymous social media websites such as RenRen and Weibo for information on preventing unwanted pregnancy. Mary Stopes International, a UK based non-governmental organization providing sexual and reproductive healthcare services, even created a Chinese online resource called You and Me in order to create open dialogue on sexual health.

"Two decades ago it was so strange for parents and schools that there should be some marriage sex education," Zhang says. "Now we see more and more publications from the [Western] countries saying that we have to give children more information and choice before marriage."

Within the adolescent group, migrant youth in particular are excluded from the current system. Under the current residency registration system, or "hukou" system, an individual may only access state services in their home province or district, leaving most migrants with few options. For many young Chinese seeking work in urban areas, this creates a problem for free contraceptive access and sexual health education.

In a study published in the Journal of Adolescent Health, 63.6% of urban non-migrants reported unprotectedintercourse compared to 83.1% of rural-to-urban migrants in Shanghai. Though lack of access to free contraceptives is high for both groups, urban migrants face significantly higher barriers.
Changes in Family Planning Oversight
One facet of China's family planning measures does seem to be relaxing.

"The vigilance and implementation of the One-Child policy, while it is centrally decided, is less stringent in the rural areas instead of the cities," Dr. Tsui says. "The implementation is not [as] coercive as the Western media makes it out to be."

While urban families with additional children will easily draw unwanted attention, rural areas have seen a easing of enforcement in recent years. Nationwide, individuals who have no siblings, and marry another single child, may have two children under the current policy. Members of China's 55 ethnic minority groups are also exempt from the One-Child policy.

The policy shift is partially fueled by increased abortions for couples unwilling to pay second child fines or participating in selective sex abortions, hoping to conceive a male child. Further, reports of forced abortion for women with multiple children add gravity to the situation.

"When you read their laws, definitely they do talk about issues of quality of care and access to resources," says Sai Sulo, of the Asian-Pacific Research and Resource Centre for Women. "But in terms of what we've observed, we are not exactly sure of how that whole policy is translated."

China has made strides in recent years to creating a more open dialogue and adhering to the prevailing rhetoric of the international health community regarding contraceptive use. The nation still can improve in terms of providing universal state coverage and increasing sexual health education initiatives.

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united states ãƒâ¢ã¢â€šâ¬ã¢â‚¬å" china relations

# data[].attributes.attachment_link.keywords[]
united states of america ãƒâ¢ã¢â€šâ¬ã¢â‚¬å" peopleãƒâ¢ã¢â€šâ¬ã¢â€žâ¢s republic of china relations

# data[].attributes.attachment_link.keywords[]
president jimmy carter diplomatic relations

# data[].attributes.attachment_link.keywords[]
chairman mao zedong president richard nixon

# data[].attributes.attachment_link.description
US-China Today is a student-driven publication of the USC U.S.-China Institute. The magazine focuses on the multidimensional and evolving U.S.-China relationship and on significant trends in contemporary China. The magazine offers coverage of and commentary on a wide range of political, economic, social, and cultural issues.

# data[].attributes.body
•China's shifting cultural norms and views on contraception/sexuality are changing.
•now a days 84.6% of women in China use contraceptions

# data[].attributes.attachment_link.readable_text
"Carry out birth planning for the revolution."

The standard issue propaganda poster, along with its countless similar replications, was a patriotic call for birth control in the name of productivity and health. China was already short on food and resources, and with the country's population exploding, the future looked positively slim. The government's earliest efforts to control the burgeoning populace came in the form of these slogans and national dictums, which later expanded to include contraceptive use.

"20 years ago if you went to the rural villages, you could see the slogans on the wall that read, 'if you have one child, IUD please, if you have two children, sterilization please,'" describes Kaining Zhang, a research physician at the Yunnan Health and Development Research Association. "There is still a very strong influence [from that] policy."

Today, attitudes towards sexuality and reproductive health have dramatically shifted in China. The once taboo topics have been the subjects of national campaigns to increase sexual health awareness, and a survey by Renmin University shows that more than half of all respondents think premarital sex is acceptable.

Government policy and more traditional viewpoints remain deeply influential on Chinese attitudes toward contraception and birth control. Yet with rapidly changing world views and sexual habits among China's younger generations, outdated policies have created a shortage of free state health services for millions.
Methods and trends
China has one of the highest rates of contraceptive use in the world with 84.6% prevalence among women who are currently married or in union. In comparison, the United States has a 78.6% prevalence, and China's next largest neighbor, Japan, reports 54.3% prevalence. The high figures owe much to China's vast network of family planning centers and other government initiatives in local communities that followed the implementation of the One-Child policy in 1979.

China's family planning policies target married women, emphasizing permanent means of birth control, though a multitude of birth control options are available through retails stores. Individuals can visit family planning service stations in both urban and rural areas to access free birth control methods.

Sterilization has a 28.7% usage rate and is typically recommended to women following the birth of a second child. Intrauterine devices (IUDs) have a 40.6% usage rate, and though not permanent, are often promoted by state health services over temporary methods.

"There is a heavy emphasis on IUDs and sterilization, this may be a barrier [to contraceptive use] and people perhaps not wanting to use either of these two methods and finding themselves pregnant," says Amy Tsui, Director of The Bill & Melinda Gates Institute of Population & Reproductive Health.

You need to upgrade your Flash Player

The preference toward long-term methods of birth control is one that has contributed to gaps in sexual health awareness in younger generations of Chinese. The National Population and Family Planning Commission oversees China's population development and has made improvements in the access to birth control and sexual health education such as increased school initiatives and national campaigns about sexuality. However, the majority of these services are intended for married couples, leaving young, single individuals without free state coverage.

"For young people, they are not covered by the family planning program because they are not married, so they fall through the cracks in terms of sex education and contraceptive access," says Joan Kaufman, Distinguished Scientist at the Schneider Institutes for Health Policy at Brandeis University. "They can certainly purchase birth control at drug stores, but it is harder for them access services from China's free family planning program."

Temporary means of contraception such as condoms or hormonal contraception are used in low frequency in China. Among married couples, only 1.2% use pills and 8.5% use condoms. For adolescents who are likely to choose non-permanent contraceptive methods, the lack of usage could indicate a lack of knowledge of these methods or simple inaccessibility. According to Euromonitor, however, sales of emergency contraception grew by 8% in 2011 to reach almost RMB1.3 billion, a method that has seen a steady growth within the last decade.
Gaps in education and its effect

You need to upgrade your Flash Player

The inaccessibility of state services parallels a rapid rise in premarital sex rates among China's young people. A 2003 report by the China Family Planning Association showed that in most provinces, 60-70% of respondents engaged in premarital sex.

While abortion and its connection to China's family planning laws have long been a highly contentious issue, the high abortion rate among China's youth is thought to be a direct result of inadequate services and education. In 2009, Chinese health officials reported that 13 million abortions are performed in China annually. Of the total, 62% were among women between 20 and 29 years old, while most were single.

"Many young people don't use contraception at all and that is reflected in high abortion rates for youth," Dr. Kaufman says.

China's health care industry has taken note of the trend. The Beijing Modern Women's Hospital offers a government-subsidized "Safe & Easy A+" discount abortion package at RMB 880 or US$130, seemingly targeting Chinese students and young people.

While there have been increases in sex education, these improvements have been slow and targeted toward abstinence education. Chinese adolescents are hungry for information on sexual health and many turn to anonymous social media websites such as RenRen and Weibo for information on preventing unwanted pregnancy. Mary Stopes International, a UK based non-governmental organization providing sexual and reproductive healthcare services, even created a Chinese online resource called You and Me in order to create open dialogue on sexual health.

"Two decades ago it was so strange for parents and schools that there should be some marriage sex education," Zhang says. "Now we see more and more publications from the [Western] countries saying that we have to give children more information and choice before marriage."

Within the adolescent group, migrant youth in particular are excluded from the current system. Under the current residency registration system, or "hukou" system, an individual may only access state services in their home province or district, leaving most migrants with few options. For many young Chinese seeking work in urban areas, this creates a problem for free contraceptive access and sexual health education.

In a study published in the Journal of Adolescent Health, 63.6% of urban non-migrants reported unprotectedintercourse compared to 83.1% of rural-to-urban migrants in Shanghai. Though lack of access to free contraceptives is high for both groups, urban migrants face significantly higher barriers.
Changes in Family Planning Oversight
One facet of China's family planning measures does seem to be relaxing.

"The vigilance and implementation of the One-Child policy, while it is centrally decided, is less stringent in the rural areas instead of the cities," Dr. Tsui says. "The implementation is not [as] coercive as the Western media makes it out to be."

While urban families with additional children will easily draw unwanted attention, rural areas have seen a easing of enforcement in recent years. Nationwide, individuals who have no siblings, and marry another single child, may have two children under the current policy. Members of China's 55 ethnic minority groups are also exempt from the One-Child policy.

The policy shift is partially fueled by increased abortions for couples unwilling to pay second child fines or participating in selective sex abortions, hoping to conceive a male child. Further, reports of forced abortion for women with multiple children add gravity to the situation.

"When you read their laws, definitely they do talk about issues of quality of care and access to resources," says Sai Sulo, of the Asian-Pacific Research and Resource Centre for Women. "But in terms of what we've observed, we are not exactly sure of how that whole policy is translated."

China has made strides in recent years to creating a more open dialogue and adhering to the prevailing rhetoric of the international health community regarding contraceptive use. The nation still can improve in terms of providing universal state coverage and increasing sexual health education initiatives.

# data[].attributes.attachment_link.keywords[]
united states ãƒâ¢ã¢â€šâ¬ã¢â‚¬å" china relations

# data[].attributes.attachment_link.keywords[]
united states of america ãƒâ¢ã¢â€šâ¬ã¢â‚¬å" peopleãƒâ¢ã¢â€šâ¬ã¢â€žâ¢s republic of china relations

# data[].attributes.attachment_link.keywords[]
president jimmy carter diplomatic relations

# data[].attributes.attachment_link.keywords[]
chairman mao zedong president richard nixon

# data[].attributes.attachment_link.description
US-China Today is a student-driven publication of the USC U.S.-China Institute. The magazine focuses on the multidimensional and evolving U.S.-China relationship and on significant trends in contemporary China. The magazine offers coverage of and commentary on a wide range of political, economic, social, and cultural issues.

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In support of religious rights:
-being forced to provide contraception by the government violates religious rights because it "strongly conflicts with it's faith and morality"
-"Pope Paul wrote that birth control leads to a lowering of moral standards, a rise in illegitimate children, the degradation of women and government control over reproduction."
In support of women's reproductive rights
-allowing access to contraception is important for women who cannot normally afford it
-“Nobody is denying religious liberty,” Chaiten said. But, “they aren’t free to dismantle a broad-ranging health care system that exists for the benefit for all American citizens.”

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This patch prevents pregnancy by blocking out sperm with the thickening cervical mucus and also preventing eggs from being released from the ovaries. There is hormones in the patch that are absorbed by the skin of the wearer. It "exposes a woman to more than 60% more estrogen than the birth control pill" and has "a failure rate of less than 1%" when used properly.

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Birth Control Patch: Side Effects, Effectiveness and Costs

What is the Birth Control Patch?

The birth control patch is a thin plastic patch (1 3/4 inch square) placed directly on the skin of the woman. It is a hormonal method of contraception obtained by prescription.

How does the Birth Control Patch Work?

The birth control patch works by hormones that are absorbed from the patch into your system.
The birth control patch prevents pregnancy in one of three ways:

First, it prevents eggs from being released from the ovaries.

Second, it thickens the cervical mucus preventing the sperm from reaching the egg.

Third, it changes the lining of the uterus preventing implantation. Ethical Consideration.

How Do You Use the Birth Control Patch?

The birth control patch is a prescription and must be obtained from your healthcare provider. The patch is worn for one week at a time and it is placed directly on the skin of your buttocks, stomach, upper arm or upper torso.

The patch is replaced once a week on the same day each week for three weeks in a row. The patch is not worn during the fourth week to allow your menstrual flow to occur at this time.

How Effective is the Birth Control Patch?

The birth control patch has a failure rate of less than 1% when it is used correctly and consistently. The patch may not protect you from pregnancy if you are taking antibiotics or medications for fungal infections or seizures. The patch may not prevent pregnancy if you weigh 198 pounds or more.

What are the Side Effects or Health Risks of the Birth Control Patch?
Other side effects may include:
The birth control patch has side effects similar to those experienced by users of oral or other hormonal types of contraception.
The birth control patch should not be used by women who:
Additional side effects may include: yeast infections, contact lens problems, and depression.

Have high blood pressure

Have breast or uterine cancer

Have a history of blood clots

Have uncontrolled diabetes

Have a history of heart attack or stroke

Are allergic to hormones

Have diabetes

Have liver disease

Have unexplained vaginal bleeding.

Contact your healthcare provider immediately if you experience any of the following:
Additional information was released from the FDA in late 2005 to warn patients and health care providers that the patch exposes a woman to more than 60% more estrogen than the birth control pill. This increased level of estrogen can lead to risks such as blood clots, strokes and heart attacks.

Chest pains

Redness, swelling, or pain in your legs

Abnormal or irregular vaginal bleeding

Jaundice (your skin looks yellow)

If you are experiencing pregnancy symptoms

Women who wish to use the birth control patch should seek additional consultation with their physician if they are experiencing any of the following medical concerns:

Depression

Diabetes

High blood pressure

High risk for heart disease

History of blood clotting conditions

History of liver disease

Is the Birth Control Patch Reversible?
There are two fees associated with the use of the birth control patch:
Yes. Ovulation usually returns within three menstrual cycles after discontinuing the patch. Pregnancy is possible when you stop using the birth control patch.

How Much Does the Birth Control Patch Cost?

1. The office visit

2. The supply of birth control patches

Office visits to obtain a prescription for birth control patches range from $50 to $200. A monthly supply of birth control patches costs approximately $30-$35.

What About the Birth Control Patch and Sexually Transmitted Infections (STIs)?

The birth control patch should NOT be considered as a means for protection against the transmission of sexually transmitted infections.

Frequently Asked Questions About the Birth Control Patch:

When does the patch begin to work?

The patch begins to work immediately, but a second form of birth control should be used during the first seven days of the first month the patch is used.

What day should I start using the patch?

Your "change patch day" is determined during the first month you start. It may either be the first day after your period ends or the Sunday following the start of your period.

Should I wear it in the same place?

When you change your patch each week, it should be worn in a different approved location. This keeps your skin from getting dry or irritated.

Can I use it while I am breastfeeding?

If you have recently been pregnant or if you are breastfeeding, it is best to consult your physician for the best time to start using the patch.

What do I do if the patch comes off?

If the patch comes off, it is best to replace it with another patch right away. If you do this within 24 hours, no back up method should be necessary.

Can I wear the patch in the water?

The patch may be worn during exercise, swimming or bathing.

What if I don't like where I put it?

The patch should not be moved once it has been applied until the week has been completed.

Can I make it smaller?

The patch should not be trimmed or altered in any way, and additional adhesives including tape should not be used to keep the patch in place.

What are the Pros and Cons of the Birth Control Patch?

The Pros of the Birth Control Patch include:

Highly effective when used correctly

You do not have to remember to take a pill each day

You do not have to go to the doctor's office for a shot each month

Does not inhibit sexual spontaneity

Minimal side effects

It is reversible

The Cons of the Birth Control Patch include:

Does not protect against sexually transmitted diseases.

Requires a prescription

Requires weekly application

Increased exposure to estrogen, which can cause other health complications

# data[].attributes.attachment_link.title
Birth Control Patch: Side Effects, Effectiveness and Costs

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The birth control patch is a thin plastic patch (1 3/4 inch square) placed directly on the skin of the woman. It is a hormonal method of contraception obtained by prescription. The birth control patch works by hormones that are absorbed from the patch into your system.

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The Birth Control Pill:
- 1960 Carl Djerassi created the first pill and was approved by the FDA for contraceptive use
Condoms:
- Invented by Charles Goodyear in 1839
- Patented in 1844
- 1855 first rubber condom produced
- late 1850's condoms began mass produced by companies

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Antiquity: Ancient Egyptian women use a combination of cotton, dates, honey and acacia as a suppository, and it turns out fermented acacia really does have a spermicidal effect. The Bible and the Koran both refer to coitus interruptus (the withdrawal method).

1914-1921 Activist Margaret Sanger coins the term "birth control," opens first birth control clinic in Brownsville, Brooklyn, and starts the American Birth Control League, the precursor to Planned Parenthood.

1934 Endocrinologist Gregory Pincus creates a test tube rabbit - and is vilified as a Frankenstein.

1951 Sanger and Pincus meet at a dinner party in New York; she persuades him to work on a birth control pill.

1951 Meanwhile, Carl Djerassi, a chemist in Mexico City, creates a pill by synthesizing hormones from Mexican yams. On a chemical level, the pill has been invented, but Djerassi isn't equipped to test, produce or distribute it.

1952 The race is on. Pincus tests progesterone in rats and finds it works. He meets gynecologist John Rock, who has already begun testing chemical contraception in women. Frank Colton, chief chemist at the pharmaceutical company Searle, also independently develops synthetic progesterone.

1953 If Sanger is the activist behind the pill and Pincus the scientist, Katherine McCormick - biologist, women's rights activist and heiress to a great fortune - is the money. She writes Pincus a check for $40,000 to conduct research.

1954 Rock and Pincus conduct the first human trials on 50 women in Massachusetts. It works.

1956 Large scale clinical trials are conducted in Puerto Rico, where there were no anti-birth control laws on the books. The pill is deemed 100 percent effective, but some serious side effects are ignored.

1957 The FDA approves the pill, but only for severe menstrual disorders, not as a contraceptive. An unusually large number of women report severe menstrual disorders.

1960 The pill is approved for contraceptive use.

1962 It's an instant hit. After two years, 1.2 million Americans women are on the pill; after three years, the number almost doubles, to 2.3 million.

1964 But the pill is still controversial: It remains illegal in eight states. The Pope convenes the Commission on Population, the Family and Natality; many within the Catholic Church are in favor.

1965 Five years after the FDA approval, 6.5 million American women are on pill, making it the most popular form of birth control in the U.S.

1967 The controversy over the pill takes on a new dimension when African-American activists charge that Planned Parenthood, by providing the pill in poor, minority neighborhoods, is committing genocide.

1968 Pope Paul VI ultimately declares his opposition to the pill in the Humanae Vitae encyclical.

1969 Barbara Seaman publishes The Doctor's Case Against the Pill, which exposes side effects including the risk of blood clots, heart attack, stroke, depression, weight gain and loss of libido.

1970 Senate hearings on the safety of the pill are disrupted by women demanding a voice on the issue.

1979 Sales of the pill drop by 24 percent in four years due to publicity about health risks.

1988 The original high-dose pill is taken off the market; an FDA study shows the heath benefits of newer pills, including a decreased risk of ovarian cancer, iron deficiency anemia and pelvic inflammatory disease.

1997 Not just a contraceptive any more - the FDA approves Ortho Pharmaceutical's Tri-Cyclen pill as treatment for acne.

2000 The Equal Employment Opportunity Commission rules that prescription contraception must be covered by health insurance offered by employers.

2003 The FDA approves Seasonale, a pill that gives women only four periods a year.

2007 What could be next? Lybrel makes the annoying period a thing of the past for those willing to try it.

2010 Fifty years after the FDA approval, problems remain: there are currently 1,100 lawsuits pending against Bayer Healthcare Corporation regarding blood clots, heart attacks and strokes allegedly caused by the popular pills Yaz, Yazmin and the generic Ocella.

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A brief history of the birth control pill

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Antiquity: Ancient Egyptian women use a combination of cotton, dates, honey and acacia as a suppository, and it turns out fermented acacia really does have a spermicidal effect. The Bible and the Koran both refer to coitus interruptus (the withdrawal method).

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The current controversy surrounding birth control is whether religious institutions must abide by the Affordable Care Act and provide access to birth control for all women. The religious groups that provide health insurance object to providing birth control for religious reasons.

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Lyle Denniston Independent Contractor Reporter

Posted Wed, July 15th, 2015 12:04 am
Commentary
Amid widening claims that religious liberty in America is under siege, the Supreme Court over the past year and and a half has reacted eight times to one of the most intense and emotionally charged conflicts within that broader controversy. Only once has the Justices' reaction to that particular conflict led to a full-scale decision, and yet all of its actions, taken together, do stand for something.

This is the controversy over the contraceptive, or birth-control, mandate in the Affordable Care Act - a high-stakes legal feud that has been unfolding in scores of lawsuits across the country. It has been running for five years, and so is further along than the just-beginning conflict over the impact on religious belief of the Court's same-sex marriage ruling last month.

The opposite sides in the birth-control dispute for years have been talking past each other about what the Supreme Court has done about that so far, and what it means, and both sides continue to try to persuade the Court to see the controversy their way.

There is a lot involved, but let's try to make it simple.

The Supreme Court has attempted to fashion something that it thinks of as a compromise, giving something to each side. That, in fact, is the very heart of what the Court did last year in its one fully considered ruling in this series - the decision in Burwell v. Hobby Lobby Stores. But the depth of disagreement was newly apparent as the government and the owners of the Hobby Lobby chain of arts-and-crafts stores resumed fighting in lower courts over how to carry out the Justices' decision, and the government keeps rewriting the rules with scant chance of closing the gap between the two sides.

Here is what the Court thought the compromise should be:

For the government, the Court appeared to assure that the ACA mandate providing free access to birth-control drugs and techniques would reach millions of women of child-bearing age, no matter for whom they work or where they go to school or where they get served by a charity. For religious institutions - non-profits operating colleges, hospitals, and charities, as well as for-profit businesses whose owners are religiously devout - the Court appeared to assure that they do not have to obey the mandate themselves, if they have religious objections to it - as hundreds and maybe thousands of them do.

What is starkly apparent, after the Supreme Court's eight actions and a string of rulings by lower federal courts, is that there is very little reason to expect the two sides to find common ground on how this controversy should come out in the end. So far, four new appeals have been filed at the Supreme Court, in pursuit of that outcome, and more are definitely on the way. It seems quite likely that the Court will take up the issue again at its next Term.

The government in implementing the ACA has been determined, sometimes stubbornly so, to make sure that female employees and students have access to birth control, free of charge, even if their employers or college administrators totally object, for religious reasons, and part of that determination comes from the confidence of officials in Washington that such coverage can be arranged without intruding on anyone's faith. Just ask for an exemption, the government promises, and it shall be given. How, it has wondered, can officials know that a religious group objects if they don't say so?

But the religious groups that are providers of health insurance for their employees or students insist, sometimes stubbornly so, that there is simply no way that such plans can be rearranged to provide birth-control access without violating the sponsors' religious beliefs. Even, they say, when the government takes over their plans, and dictates what they will cover, there is still no break from the sin of facilitating the use of the prohibited methods. The only way they can protect their faith, they say, is to do nothing at all in response to the mandate, and thus face millions of dollars in fines, or else to shut down their health plans altogether - so everyone loses. And, they add, even closing their plans would violate their faith principle that they should take care of their own.

Although it is often quite apparent that each side is deeply suspicious of the other side's motives, it goes too far to assume that the government is hostile to faith and, similarly, it goes too far to assume that the religious groups are trying to regiment the private lives of their employees and students. The government notes that it has revised its official rules several times, each time broadening the available religious exemption; so, it asks, why not take advantage of that? And the religious groups note that they would have no objection if the government itself were the provider of contraceptives; so, they ask, why not just leave us out of it?

These so-far unbridgeable differences, of course, began to emerge soon after Congress passed the Affordable Care Act in 2010, and grew more intense when the government began issuing specific rules to put the Act into effect. The ACA does not refer to birth control directly, but does require existing group health plans to provide "essential coverage," which includes "preventive services" for women, free of charge. Congress told the government to decide how to work that out.

In general, the resulting rules have meant that women must have access, without paying anything, to all of the contraceptives that have the approval of the federal Food and Drug Administration. Because many religious individuals and institutions, especially those affiliated with the Roman Catholic faith, believe that at least some forms of birth control destroy human life, which they regard as sinful, the ACA mandate and the government rules have been challenged in more than a hundred lawsuits. About half were filed by non-profit entities which hold that religious view, and the remainder by for-profit companies whose owners object for the same reason.

The government rules gave the non-profits a way to claim an exemption, but not the for-profit businesses. It was in one of the for-profit firms' cases, the Hobby Lobby case, that the Supreme Court ruled last year that the for-profit firms, too, had to be allowed to claim an exemption. That decision also spoke more broadly about the interaction of the problem of religious objection and the goal of assured access to birth control.

In fact, all of the seven other actions by the Court, none of which was a final decision, have involved non-profit institutions. Here is what the Court has done in those seven: two were orders by individual Justices temporarily delaying the contraceptive mandate until the Court could act further after new legal papers were filed; two were orders of the full Court telling lower courts to reconsider prior rulings; and three were orders by the full Court directing the kind of compromise that appeared to lay behind the Hobby Lobby ruling.

Each of those actions has been proclaimed by lawyers for the non-profits as victories, even if only temporary ones, because each had the effect of interrupting a lower court decision enforcing the government rules on the mandate.

The most significant of those actions were the three that told each side what it must do under the mandate, in response to religious objections by non-profits operating health plans. In cases involving an order of nuns in Colorado (Little Sisters of the Poor), a religious college in Illinois (Wheaton College), and a group of Roman Catholic institutions in Pennsylvania (the Zubik case), the Court blocked the government from compelling the objecting institution itself to obey the mandate, as long as that institution notified the government - even by a brief, informal letter - of its objection.

That duty to notify the government appeared to be, or was said explicitly to be, a condition of blocking any duty by the institution itself to provide the ACA contraceptives. In effect, the orders said: No notice of an objection, no protection. But each order also seemed to be saying that, with the objecting institutions' notices in hand, the government was free to arrange for that institution's employees or students to have access, without cost, to "the full range of FDA approved contraceptives."

Just last week, three government departments in Washington - Health and Human Services, Labor, and Treasury - issued final rules to carry out the ACA contraceptive mandate. Some were partial rewrites of earlier rules for non-profits, some were new rules for for-profit institutions owned by religious individuals. Saying explicitly that the rules were enforcing what the Court had directed in the Wheaton College case (non-profits), and what the Court had set the stage for in the Hobby Lobby decision (for-profits), the departments ordered these binding rules into effect as of Tuesday, July 14.

Almost no observer of this legal saga expects those regulations to be the end of the matter. The main reason for that skepticism is that the rules do keep the religious institutions in the mix: they have to do something to get the protection they want. The health plans that will, from then on, provide the birth control and methods will remain their own, the institutions note, and the government will simply be "hijacking" them in a way that keeps the institution as sponsor and, besides, violates the legal arrangements for operating such a plan. This, then, keeps in place, the institutions argue, the burden that the ACA rules impose upon their religious beliefs.

That is basically a legal as well as a theological and moral argument, and, in its legal form, is a claim under the federal Religious Freedom Restoration Act that the institutions' lawyers have been using in the court cases. They had remarkable success in the federal trial courts - the district courts - where they won more than eighty percent of the time. But, when the cases have reached the federal appeals court level in the wake of the Supreme Court's Hobby Lobby ruling, the institutions' objections have been turned aside each time, so far. Five courts of appeals, not all by unanimous votes, have decided that the notice the institutions give the government does not "trigger" access to birth control; it is the ACA that does so. That has been the result so far in the Third, Fifth, Seventh, D.C. Circuits - and just on Tuesday, the Tenth Circuit. Other cases are apparently nearing the release of rulings in other federal appeals courts.

The Hobby Lobby case had gone through the lower federal courts in the first round, went to the Supreme Court, was decided there, and then returned to the district court level. The Supreme Court's ruling did not wind things up, because the Justices' rulings are usually not self-enforcing. What happened back in the district court illustrates well why the entire controversy over ACA contraceptives continues to run on.

Lawyers for the arts-and-crafts company asked U.S. District Judge Joe Heaton of Oklahoma City to put the Justices' ruling in the company's favor in effect by issuing a simple order to block enforcement of the mandate in the ACA itself as well as the government regulations, and not just as they applied to Hobby Lobby. The government countered that the judge should only bar enforcement of the law and the existing regulations as applied to Hobby Lobby.

The company wanted to avoid being drawn into future legal wrangling over any new regulations that the government might issue under the mandate and seek to apply to Hobby Lobby, and the government wanted to avoid having that future option foreclosed as to Hobby Lobby. Judge Heaton sided with the government, saying that Hobby Lobby had won in the Supreme Court on the ACA rules as they existed at the time. Moreover, the judge said, he was concerned about prematurely ruling on potential future changes in the legal obligations under ACA. He thus confined his order to the regulations as they existed.

That was last November. At the time, the government had not yet issued new rules that would require for-profit companies with religious objections to birth control to notify the government of their views as a condition for their exemption from the mandate. The three government departments filled that gap last week, so Hobby Lobby now faces the prospect that federal officials will now move to arrange for the retail chain's female employees to have access to birth control, at no cost. In issuing the new rules, the government agencies said they would reach all companies that had sued the government over ACA contraceptives.

The focus of the overall controversy now shifts back to the appeals courts that have yet to decide, and to the Supreme Court, where the new appeals have started arriving.

Recommended Citation: Lyle Denniston, The ACA birth-control controversy, made simple, SCOTUSblog (Jul. 15, 2015, 12:04 AM), http://www.scotusblog.com/2015/07/the-aca-birth-control-controversy-made-simple/

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The ACA birth-control controversy, made simple - SCOTUSblog

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Commentary Amid widening claims that religious liberty in America is under siege, the Supreme Court over the past year and and a half has reacted eight times to one of the most intense and emotionally charged conflicts within that broader controversy. Only once has the Justices' reaction to that

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Shortly before the menstrual cycle, the levels of the hormones Progesterone (P) and estrogen (E) increase in the body to prepare for pregnancy. If the egg is not fertilized, levels of these hormones drop and levels of Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH) spike, which causes menstruation (bleeding). The birth control pill contains P and H hormones, which suppress the FSH and LH hormones. In other words, birth control is "tricking the body into thinking it's pregnant" so that the person taking the pill will not get pregnant.

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March 15, 2008

Almost 50 years ago the combined oral contraceptive pill was approved by the Food and Drug Administration (FDA) for use in preventing pregnancy, ushering in a new era of hormonally-based birth control. Now, in addition to the original "Pill" women can chose from an overwhelming variety of oral contraceptives, from different hormone combinations and doses to different Pill schedules that result in skipping or stopping menstruation entirely. Most of us have heard that the Pill contains hormones that suppress ovulation, but how does this really work? And with the recent marketing of Lybrel - a Pill designed to stop menstrual cycling entirely - we might wonder how far we can reasonably take this hormonal control. Simply put, how does the mechanism of oral contraceptives guide us in their use, and what (if any) are the repercussions of eliminating menstruation?

The story of how the Pill was engineered to suppress ovulation is one of the first examples of researchers using naturally occurring hormones to re-direct normal human biology. As far back as the 1920s, scientists had determined that transplanting ovaries from pregnant rabbits into other fertile rabbits prevented pregnancy, and by the mid-1940s it was known that the hormone Progesterone was responsible for this effect. Researchers then wondered: What is the role of Progesterone and other hormones in regulating normal reproductive biology, and could this knowledge be safely used to suppress ovulation in humans?

How does the Pill work?

Before pills could be formulated to modify human ovulation, researchers needed to figure out how the menstrual cycle usually works. The normal cycle consists of several distinct phases that average approximately 28 days in total; each phase corresponding to physical changes that occur to "build up" and "break down" the uterus in preparation for pregnancy, with ovulation occurring at the midpoint of the cycle. These phases are associated with dramatic changes in the levels of certain hormones that follow carefully scripted roles in promoting ovulation and subsequently (in the absence of fertilization) menstruation.

The shedding of uterine lining leading to the observed bleeding is the Menstrual Phase. As bleeding ends, Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH) show small peaks above their normal low levels, leading to thickening of the uterine lining and maturing of oocyte(egg)-containing follicles in the ovary. Meanwhile, the estrogen, Estradiol (E), is steadily rising to a peak a few days before ovulation, after which point FSH and LH spike once more, triggering the release of a mature oocyte. Levels of Progesterone (P) and E rise for the next two weeks, preparing the uterine lining for implantation of an embryo. If no implantation occurs, both hormone levels drop sharply, triggering menstruation. If fertilization and implantation do occur, levels of P and E remain high throughout pregnancy, suppressing the spikes of FSH and LH that drive ovulation.

Because of the intricate feedback loops controlling the menstrual cycle, artificially altering one or two hormones can affect the entire cycle. This fundamental knowledge has been used both to suppress the cycle, with the goal of contraception, as well as to stimulate ovulation with the hopes of promoting fertility. Two ideal targets for hormonal contraception would be the hormones FSH and LH, which play dual roles in the normal menstrual cycle, first re-starting the cycle after menstrual bleeding and then triggering ovulation at the mid-point of the cycle. Because FSH and LH are required to trigger ovulation, artificially blocking these two hormones would therefore robustly suppress ovulation. Why then are the hormones P and E commonly used in the Pill instead? It is generally easier to add something to a biological system than to remove something, and since P and E suppress the release of FSH and LH these are logical choices for halting the sequence of events that lead to ovulation. Because both P and E are at high levels throughout pregnancy, some people describe taking the Pill as "tricking the body into thinking it's pregnant". While not entirely accurate, this statement does have some truth to it.

How well does the Pill regimen mimic the normal menstrual cycle?

The standard combined oral contraceptive consists of both hormones P and E, taken daily for three weeks, followed by a week of no pills (or placebo pills) that trigger what's known as "breakthrough bleeding", induced by the drop in hormones. Although the outward appearance is the same (menstrual bleeding in week 1 of a 28 day cycle) the constant high levels of P and E for a woman taking the Pill actually abolish the normal hormonal cycling that underlies ovulation. The Pill therefore replaces the normal menstrual cycle with an artificial cycle (3 weeks of "mimicking pregnancy", followed by 1 week with breakthrough bleeding). Historically, women have been pregnant or nursing much of their adult lives and thereby suppressing ovulation naturally, suggesting that halting menstruation is not inherently harmful. Yet, many women still wonder if it is safe to eliminate menstruation using oral contraceptives.

Actually, women have been using the Pill in this off-label manner under medical supervision since the time it debuted - skipping the week of placebo pills in order to postpone their periods during a vacation or special event, for example. Continuous menstrual suppression via the Pill has also been used to treat endometriosis, debilitating menstrual pains and other menstruation-related ailments. However, it is only recently that certain formulations of the Pill began to be marketed for the specific purpose of eliminating periods. The first widely available Pill of this nature was Seasonale, FDA approved in 2003. Each packet of Seasonale contains 84 Pills and 7 placebos, resulting in 4 periods per year. In 2007, the Pill, Lybrel, was introduced, eliminating the placebos entirely with the goal of suppressing menstruation as long as the Pill is taken. So, although at first glance it may seem unusual to provide an oral contraceptive regimen that eliminates periods, the use of Seasonale, Lybrel and other similar formulations is a logical progression from the original concepts behind the Pill. These new formulations contain the same types and amounts of hormones as the standard Pills, so should be comparable in terms of side effects (both immediate and potentially long-term). However, the lack of menstruation does mean that a woman who becomes pregnant on this regimen may not realize it as soon as she otherwise would. How popular this newly-advertised birth control regimen will be (given that it removes the visible monthly proof of its efficacy) remains to be seen.
-Amanda Nottke, Harvard Medical School

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Taming the Cycle: How Does the Pill Work? - Science in the News

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Almost 50 years ago the combined oral contraceptive pill was approved by the Food and Drug Administration (FDA) for use in preventing pregnancy, ushering in a new era of hormonally-based birth control. Now, in addition to the original "Pill" women can chose from an overwhelming variety of oral contraceptives, from different hormone combinations and doses to different Pill schedules that result in skipping or stopping menstruation entirely.

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- Def: the prevention of conception or impregnation by any various drugs, techniques, or devices; birth control

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Contraception definition, the deliberate prevention of conception or impregnation by any of various drugs, techniques, or devices; birth control. See more.