The following is a conversation between Mark Edwards, co-founder and CEO of Upstream USA, and Denver Frederick, Host of The Business of Giving on AM 970 The Answer in New York City.
Denver: An unplanned pregnancy can really disrupt a young woman’s life. It can have negative health effects for both her and her baby. It can lead to her dropping out of school, and the college completion rates among young mothers is quite low. But there is an organization that is tackling this problem head-on with remarkable success. It’s Upstream USA, and with us tonight is the co-founder and CEO, Mark Edwards. Good evening, Mark, and welcome to The Business of Giving.
Mark: Thank you. Thanks for having me.
Denver: Before we get into particulars of what you do and how you do it, let’s first discuss the topic of unplanned pregnancy in the US. Give us a sense of the dimensions of this issue.
Mark Edwards, Co-founder and CEO of Upstream USA
Mark: The dimensions are really significant here in the US. In a typical year in the US, nearly half of all pregnancies are actually unplanned pregnancies. This data comes from women themselves describing their own pregnancies. What’s surprising to most people is that a significant percentage of these pregnancies occur to women who are actually using birth control. They know this is not the time they want to have a child, but the method of birth control they’re using fails them. And we see much higher rates among poor and low-income women, in large part because the places that poor and low-income women get their healthcare make it very difficult to get access to the most effective methods of birth control… which are the new IUDs and implants.
Denver: I touched upon this a little bit in the opening. What are the negative impacts, health and otherwise, for both the woman and child that are connected with these unplanned pregnancies?
Mark: When women have pregnancies before they plan them or want them, there are a whole set of downstream effects that are negative. One, health outcomes are poor because, of course, if you aren’t planning to become pregnant, then you may not do all the prenatal care you would otherwise– I see a higher incidences of things like fetal alcohol syndrome. And of course there are a whole set of other downstream outcomes beyond the pregnancies themselves which are negative. Having a child before you plan for it – it’s challenging enough having children when you’re planning. So, the important thing here is we’re really trying to help women achieve their own goals of becoming pregnant only when they want to.
Denver: Picking up on what you said a moment ago, birth control pills are the most popular contraceptive among US women. Condoms are slightly behind. Are they not that effective?
Mark: They aren’t that effective. Those methods of birth control are very effective if you are very good at taking them. But the truth is that many women are not. What the data shows is in a typical year, nearly 10% of pill users become pregnant. And it’s mostly because of compliance issues. What’s exciting is that there are new methods of birth control that are in clinical trials 20 times more effective than the pill. These are the new, long-acting, reversible contraceptive methods. The new IUDs and implants. These are the methods of birth control that Ob/Gyns use themselves for their own birth control. You won’t find an Ob/Gyn who uses the pill because she understands that these are much more effective methods of birth control. Lower doses of hormones– you don’t have to think about it every day. You return to fertility faster with these methods compared to the pill. So, these are just modern methods of birth control.
But the places that particularly poor, low-income women get their healthcare makes it very difficult for them to get access to these methods. The interesting thing is, it’s not because of cost issues. It’s mostly because of a set of administrative and systems barriers in health centers, which means they can’t get those methods in one visit. It will take them three or four visits. Women don’t have time to make three or four visits to the doctor to get birth control.
Denver: That’s for sure. Let’s talk a little bit more about these LARCs, I guess they’re referred to- long-acting reversible contraception. IUD and hormonal patches, how long do they last?
Mark: There are several methods of IUDs. One method is the implant. Among the IUDs, they last anywhere from 5 to 10 years. But again, these are completely reversible; so when you take them out, you can become pregnant right away. The implant NEXPLANON lasts for 3 years. There are hormonal IUDs; there are non-hormonal IUDs. There’s a whole selection there.
Denver: What do they cost compared to, let’s say, a pack of birth control pills?
Mark: For most women in this country, these methods are free. Let’s just start with that. They are free. That’s of course the tragedy here. Most women are actually not even offered these methods. The barriers are not cost barriers. I think in any other form of medicine: imagine a stent that was 20 times more effective than another stent, and then when you went to the doctor… they wouldn’t even offer you that stent. They said, “Well let’s give you this one instead.” That’s what’s happening with birth control. Our goal is to make sure that women can get access to all methods of birth control, and then they can choose which methods are best for them.
Denver: Seems to make a lot of sense.
What are the challenges then at these health centers where these women go? Why are they not offered these options as it stands right now?
Mark: There are a number of challenges. I wish there was just one or two, but there are a number of them. It starts with the fact that, for example, not enough providers are trained to place these methods. Literally, they don’t have the skills to do that. That’s part of the work that we do; it’s to make sure that providers are trained so they can place and remove these methods. In addition, health centers often won’t stock the methods.
By definition, it requires multiple visits. You have to come in; they get ordered. Then you have to come back. Women don’t come back. Health centers don’t know how to bill and code properly. So, when that happens, they don’t feel like they get properly reimbursed. Which means there’s a disincentive to offer these methods. For example, they don’t have a proper workflow, so that women can actually get them. There are a bunch of those kinds of administrative and systems barriers that get in the way. That’s why the work that we do is to remove those barriers.
Denver: Let’s get into the work that you do. I don’t think there’s a better place to start than Delaware. Upstream has spent a lot of time, a lot of energy, and a lot of resources in Delaware. Let me start with this, Mark. Why Delaware?
Mark: We learned early on that Delaware has one of the highest unplanned pregnancy rates in the country.
Denver: No kidding.
Mark: Which surprised lots of people. It is bundled along with a whole set of other states. Those are the ones that you would probably imagine, mostly in the South. But Delaware has a very high rate of unplanned pregnancy. The governor at that time, Gov. Jack Markell, a very entrepreneurial governor, now on our board. We went to him and said, “Look, Delaware has one of the highest rates of unplanned pregnancy. He believed that unplanned pregnancy is associated with a whole set of other downstream costs that the state was in many ways shouldering. We said, “Look, if we can reduce unplanned pregnancy, that’ll have a number of positive outcomes for Delaware.” He got very excited about it. Asked us to develop a statewide plan, and so for the last couple of years, that’s been our work. It’s literally transforming the healthcare system in Delaware so that all women can get access to all methods of birth control, with great counseling, in a single visit.
Our goal is to make sure that a typical primary care visit is not a specialty care visit, but a primary care visit. No matter why you enter into a healthcare system for anything at all, you’ll be asked, “Do you want to become pregnant next year?”
Denver: You mentioned training and technical assistance to these Title X health centers and some of the big hospitals and the private providers, what exactly do you do?
Mark: There are three core things that are important about our work. The first is, we’re trying to bring reproductive healthcare into the center of primary care. If you’re a woman of reproductive age, unplanned pregnancies can be part of your life. So, our goal is to make sure that a typical primary care visit… not a specialty care visit, but a primary care visit, you’re asked for example a very simple question: “Do you want to get pregnant in the next year?” as a standard question. In Delaware today, that is the state of play. No matter why you enter into a healthcare system for anything at all, you’ll be asked, “Do you want to become pregnant next year?”
Reproductive healthcare is often not at the center of primary care.
Denver: That can lead to a conversation, I bet.
Mark: Absolutely. What happens is if the answer is, “Yes, I do.” Then fantastic. Let’s make sure you have a nice healthy baby and do the preconception care. But if the answer is “No” in that visit, you should be able to leave with any method of birth control that you want. It’s very important. I can’t tell you how often we’ll talk to women who were in a health center for some other reason, unrelated reason in January; it could be for diabetes, depression, whatever she’s there for, and then back in June with a high-risk, unplanned pregnancy.
You tell yourself, she was right in that health center, why didn’t we talk about it? And the reason is that reproductive healthcare is often not at the center of primary care. So, that has really changed dramatically. That’s the first thing you do. The second thing of course is that, when women say no, I don’t want to become pregnant. They should be able to leave that visit, not come back, but leave that visit with any method of birth control, including one of these long-acting, reversible methods. So, you can imagine that requires a whole set of training, technical assistance, systems work to make sure that even though she came in for diabetes, she wants to leave with a method of birth control. That work at the health center itself– of putting those workflows in place, billing and coding, stocking the methods, proper counseling… that’s at the core of the work.
Finally, the third major part of our work is we run large-scale consumer marketing campaigns so that women know about this. They know they can get these methods– Education campaigns.
The goal is that women really should be able to choose whatever method works for them with great counseling.
Denver: When LARCs are made available to women, what percentage of them choose that method?
Mark: We’re just learning this now, but what we know is that many more women choose these methods, and we also know they’re much happier with these methods than with birth control pills. There’s lots of data about that. We’re already seeing in Delaware, even though we’ve only been working there for three years, significantly more women choosing these methods. They’re happier with these methods. We also have very good data that show that women are actually in charge of making their own choices about birth control. This is really important to us. The goal is that women really should be able to choose whatever method works for them with great counseling. We have good evidence that shows upwards of 99% of women are saying, “I was in charge of choosing my method of birth control. This is really a decision that I made, by me.”
People often think that unplanned pregnancy is all about teens. It’s not.
Denver: You’ve been in Delaware, as you say, for a few years. What has been the impact? What are the results?
Mark: It’s very exciting. It’s really been just about three, three-and-a-half years. We’ve seen a number of results, both at the health center level; literally, a higher percentage of women are choosing these more effective methods. What we’re also seeing though is a higher percentage of women overall on birth control because now this question, “Do you want to become pregnant in the next year?” is a standard screening question. More women are just on more birth control of all kinds. That has a huge impact on reducing unplanned pregnancy.
One thing I should say that’s important is that people often think that unplanned pregnancy is all about teens. It’s not. Teen pregnancy represents about 15% of overall unplanned pregnancy. The bulk of unplanned pregnancy is actually single women in their 20s. That’s where you really see it. Teen pregnancy is important. I think we’re making good progress in this country about teen pregnancy, even though of course the rates are still higher than any place else. We’ve made good progress.
Mark Edwards and Denver Frederick inside the studio
Denver: There was a great campaign by MTV a few years ago around that.
Mark: Yes. Again, those numbers are still higher than they should be. The bulk of unplanned pregnancy is actually single women in their 20s. We’re beginning to see those rates come down already. Just recently, a group out of Washington, Child Trends, released a report showing that among women in Delaware on Title X…. Title X represents some of the most vulnerable women in Delaware. We’ve already seen in just two years a drop of 15% in unplanned pregnancy in Delaware, which is really very exciting.
Denver: Congratulations. That is truly significant.
Another early success story was in Colorado. Tell us what happened there.
Mark: Of course, we’re not involved with the Colorado project, but it was very inspirational for us, and it was one of the reasons that we started Upstream. Colorado demonstrated by that making these methods available to women throughout the state, they were able to reduce the teen pregnancy by close to 50% over about eight or nine years. Better birth outcomes, significantly reduced cost to the state. A real important demonstration project.
Denver: One that you are involved in is right here in New York City, and that’s a partnership that you have with an organization called Door. Tell us about that intervention and the results that it has yielded.
Mark: The Door is a fabulous partner of ours. They are a multi-service site for adolescents here in the city downtown. They have a whole set of programs for adolescents ranging everything from healthcare to classes to job training… the whole bit. But unfortunately, in their health center there, they were not set up to be able to offer the most effective methods of birth control. They are basically offering pills. Predictably, I think they had relatively higher rates of unplanned pregnancy as they do throughout the country.
We were able to work closely with the medical director there and their whole medical team so that now, patients at The Door can really get all the methods of birth control, including these long-acting reversible methods. We’ve seen the numbers of women choosing these methods go up significantly. What’s exciting is that even though our formal partnership really has ended with The Door– it’s sort of a one-time intervention– we’ve seen they’ve continued to be able to offer these methods on an ongoing basis. So, the cumulative impact of this has really been quite significant.
Denver: There’s a lack of evidence around so many programs. You’re one that really does have hard data and results. The next question would be: government support for these kinds of programs which has to happen at the state level… are they providing the necessary funding to be able to scale these programs?
Mark: What’s unusual about the work that we are doing is that we’re operating in a policy environment. It’s actually pretty positive. Most states in this country have policies that mean that insured women in the state, whether insured privately or insured with Medicaid, can get these methods for free. That’s just standard care here in the US. The challenge is that the actual practice though in health centers is not that way. In practice it means, you can get the pill right now, but it may take you three or four visits to get one of the more effective methods; and women don’t have time to make those visits.
Denver: They don’t come back.
Mark: Exactly. Our goal, we’re not an advocacy organization. We’re not trying to change laws. We’re operating in places where the laws and the policy environment is actually really supportive. It’s really about changing healthcare practice to make the spirit of those laws available. But you’re right. The work we do, of course, is training and technical assistance. That work is not really supported by government. They often will pay for the actual birth control themselves as part of your insurance. But they’re not paying for this critical training work to make sure that actually, it’s made available. That’s the place where we really need support.
Denver: You got some of it from an organization called Blue Meridian Partners. They have invested a significant amount, $60 million, in the work that you do, and that’s an incredible testimonial, Mark, for a young organization like yours to breed that level of confidence. Tell us about that partnership and what it’ll mean for the organization and for the women that you serve.
Mark: Upstream feels incredibly fortunate to have a partnership with Blue Meridian Partners. They are a funder collaborative that has raised about $1 billion to make large-scale, 10- to 15-year investments in a small number of nonprofits that they think can really make a big difference in expanding opportunity for young adults. They’ve made a significant investment to Upstream to really help us scale. And on the back of that, we are really in the process of raising additional resources to bring the work we’ve done in Delaware to three other states in this first chapter of work.
You can imagine, the scale of work is significant. So, in a typical year in the US, about 1.5 million unplanned children born. So, if you think about the math, these are big dollars, and states around the country without exception spend hundreds of millions of dollars just on healthcare-related costs for unplanned pregnancies. We’re really trying to tackle a problem which is really quite significant. So as extraordinary as that level of support is, we actually have to raise more money to be able to do this at scale.
…our entire goal is really to try and create an environment where women can decide for themselves when and if they become pregnant.
Denver: Give us a story or two in terms of the impact that this has on the women that you serve. I just can’t even imagine how the trajectory of their lives has changed. What have you seen, having done this work now for four or five years?
Mark: One of the most extraordinary, inspirational stories I heard was from an Ob/Gyn in Denver who told me about a patient that she had… actually a 40-year-old mother of two, married, high-powered lawyer. And this patient told her Ob/Gyn that when she was 16, for some reason her pediatrician was able to get access to one of these long-acting reversible contraceptive methods. This patient says that it really made all the difference for her because she had nine female cousins in Denver, none of whom had access to effective birth control, all of whom got pregnant and had children before the age of 18; all of whom ended up on welfare. She went on to become a very successful lawyer and really credits access to effective birth control as being her ticket to be able to achieve the goals that she had for herself.
We see stories like this on a daily basis. Having a child before you plan for it or want it is a very challenging situation. So, our entire goal is really to try and create an environment where women can decide for themselves when and if they become pregnant.
Denver: I can’t think of a better way to alter this intergenerational cycle of poverty because this is particularly in low-income communities. Right?
Mark: It is concentrated in low-income communities, though if you understand the fact that nearly half of all pregnancies in the US are unplanned, this actually happens across the spectrum. It can have obviously some more challenging outcomes for low-income women. The whole conversation about opportunity in this country starts when kids are born. You say, this child is here. What do we do now to make sure this child can achieve its full potential? Our view is that helping women achieve their own goals of becoming pregnant only when they want to really is at the center of the opportunity conversation. We need to include that in this dialogue.
…we need to shift dialogue about opportunity in this country, so that we understand that pregnancy planning and prevention should be at the center of this.
Denver: Let me close with this Mark, and let’s get back to scaling. Blue Meridian has been a wind at your back; $60 million, hopefully, a million and a half women, four states, but you’ve got to do a lot more than that to make this available to all women across the country.
What are the challenges? And what are the things that need to happen to make these choices accessible to all women?
Mark: I think first and foremost, we need to shift dialogue about opportunity in this country so that we understand that pregnancy planning and prevention should be at the center of this. I’m not talking about abortion here. I’m talking about making sure that women get access to effective birth control so they can decide when and if they become pregnant.
Denver: That’s a big distinction too. I’m sure a lot of people conflate the two.
Mark: They do. We’re really talking about… of course, most abortions happen because people have unplanned pregnancies. So, if you can actually help women prevent those, it’s a critical distinction. Second is, I think we need to ensure that all women have access to the full range of birth control methods. In many states, insured women have the access, but many uninsured women do not.
So, it’s really important I think. It makes so much sense from a cost perspective as well. Of course helping women prevent pregnancies that they don’t want is really much more cost-effective than dealing with the issue once we have an unplanned child. So, that’s an important distinction as well.
Finally, I think what’s really important to remember is this is simply best-in-class healthcare. These methods of birth control are considered by the CDC, by the American College of Ob/Gyns, most recently by the American Academy of Pediatrics as being best-in-class healthcare, best-in-class birth control for all women, all adolescents. This is just simply modern birth control. There is no reason….This should be more politicized. These are really methods that women prefer when they get access to them, and it has a huge impact.
Denver: No reason is absolutely right. There are a lot of problems in this country. We can’t solve many of them, but this is one that we can, with the right will.
Mark Edwards, the Chief Executive Officer of Upstream USA, I want to thank you so much for being here this evening. If listeners should be interested in learning more about the organization, tell us a little bit about your website and the kind of information that you have there.
Mark: We’re upstream.org, and there you’ll find case studies about the work we’re doing, the kinds of training and technical assistance we’re doing, a lot of information about our work in Delaware, and of course, information about how to donate as well.
Denver: Absolutely. Thanks, Mark. It was great pleasure to have you on the show.
Mark: Thanks so much for having me.
Denver: I’ll be back with more of The Business of Giving right after this.
Mark Edwards and Denver Frederick
The Business of Giving can be heard every Sunday evening between 6:00 p.m. and 7:00 p.m. Eastern on AM 970 The Answer in New York and on iHeartRadio. You can follow us @bizofgive on Twitter, @bizofgive on Instagram and at http://www.facebook.com/BusinessOfGiving