Pregnancy and fertility research come with powerful emotive and political connections beyond medicine alone. Professor Richard Santen, a reproductive endocrinologist and past-president of the Endocrine Society of America shares his decades of experience in research and care for patients reproductive health, and shares his view on how to reshape perspectives on, and provisions of care for, unexpected pregnancies.
Listeners should be aware that this interview discusses pregnancy, family planning and contraception at length, including abortion, though we do not discuss any legal or moral aspects of what, and when, counts as a person.
Read more from Prof Santen at: https://researchfeatures.com/?s=santen
Image Source: Monster Ztudio / Shutterstock
The following transcript is automatically generated.
00:00:07 Will Mountford
Hello I’m Will, welcome to Researchpod.
00:00:09 Will Mountford
The following interview touches on topics that may be near to some listeners hearts.
00:00:13 Will Mountford
As a matter of health, politics and personal affairs, so please be aware that we are about to discuss at length the issues of pregnancy.
00:00:22 Will Mountford
Family planning and contraception.
00:00:24 Will Mountford
This includes discussion of abortion, though, as is repeated in the interview, we are steering clear of the legality and morality of what and when counts as a person.
00:00:34 Will Mountford
These topics come with powerful emotive and political connections well beyond the purely medical realm.
00:00:40 Will Mountford
Fortunately, for the sake of the medical perspective in all of this discussion.
00:00:44 Will Mountford
From talking today with Professor Richard Santen, A reproductive endocrinologist and past president of the Endocrine Society of
00:00:51 Will Mountford
America, from his decades of experience in researching fertility and caring for patients, making decisions for their reproductive health, he puts forwards his proposals here for how to reshape perspectives on and provisions of care for unexpected pregnancies.
00:01:10 Will Mountford
And joining me from the University of Virginia, Richard Santen.
00:01:16 Will Mountford
Hello, thank you so much for.
00:01:17 Will Mountford
Your time today for.
00:01:18 Will Mountford
Myself and for the listeners at home, could you tell us a bit about yourself?
00:01:22 Will Mountford
Some of your academic professional background and what brings us here today?
00:01:26 Prof Richard Santen
So I’m a reproductive endocrinologist.
00:01:29 Prof Richard Santen
I’ve trained to study patients who have problems with estrogen and male hormone.
00:01:37 Prof Richard Santen
Because of this, I’ve studied contraceptives as well.
00:01:40 Prof Richard Santen
I’ve had a rather varied career.
00:01:44 Prof Richard Santen
My first faculty position was at Penn State University.
00:01:48 Prof Richard Santen
In Pennsylvania, I became Chair of medicine at Wayne State University in Detroit, and over the last 20 years have been at the University of of Virginia in Charlottesville, VA my interest recently has been to think a little bit about the long term strategy.
00:02:08 Prof Richard Santen
Of dealing with unwanted pregnancies. Now, how did I come to want to do that? So I was the President of the Endocrine Society, which is an 18,000 Member international organization.
00:02:22 Prof Richard Santen
One of the former vice presidents contacted me and asked me to share with her an opinion piece about abortion.
00:02:31 Prof Richard Santen
That the Endocrine society would then publish.
00:02:36 Prof Richard Santen
I really thought that rather than the issue being the short term concerns about abortion, the real issues are the long term issues of how to deal with unwanted pregnancy.
00:02:50 Prof Richard Santen
So that led me to review a lot of literature about unwanted pregnancy and about.
00:02:57 Prof Richard Santen
After this I was asked.
00:03:00 Prof Richard Santen
By one of Doctor Carolyn Becker, she was the vice president.
00:03:05 Prof Richard Santen
I was asked to give a college course on one session on this topic, so it was quite a labor of love to try to go back even as far as the Roman Empire to see what people thought about abortion, and I framed some views that I think are.
00:03:25 Prof Richard Santen
Reasonably rational and are not really based on the.
00:03:30 Prof Richard Santen
Controversies about the morality of abortion, but more about the practical issues.
00:03:35 Prof Richard Santen
The last part of this is that my first mentor.
00:03:39 Prof Richard Santen
Doctor C Wayne Barden became the chairman of the International Contraception Research Committee internationally, and he developed the contraceptive implant.
00:03:51 Prof Richard Santen
This is the hormonal implant that lasts 10 years and was really a breakthrough for development of contraception.
00:03:59 Prof Richard Santen
In in developing countries.
00:04:02 Prof Richard Santen
So that’s really the background of how I got interested in this topic.
00:04:06 Prof Richard Santen
And have tried to become scholarly in my my assessment of what’s going on at this point.
00:04:17 Will Mountford
Now, to make things contemporary, to put a little bit of time bound perspective on our conversation today, would you say that there is anything that has changed globally nationally, even domestically, about attitudes and management of unwanted pregnancies and hormonal care generally in the last say?
00:04:36 Will Mountford
1015 years compared to any other trends or attitudes that you’ve seen over the course of your career.
00:04:43 Prof Richard Santen
I have to focus more on the United States and it’s quite interesting that back in 2005, Hillary Clinton was.
00:04:53 Prof Richard Santen
Quoted in the New York Times saying that if we use contraception more effectively and more widely, that abortions would become relatively rare, and that was the thinking at that time when.
00:05:07 Prof Richard Santen
The Constitution of the United States said that abortion was a a right for women up to about the the second trimester.
00:05:16 Prof Richard Santen
But in the last few months since the DOB decision and Roe V versus Wade was counteracted by the Supreme Court, the focus now has been exclusively.
00:05:29 Prof Richard Santen
The issue of abortion, the morality of abortion, which states should approve it, and so on, so the the discussion in the United States has been totally away from the whole issue of contraception.
00:05:41 Prof Richard Santen
Now if we go back several years, I think there have been so many different advances in the the whole area of contraception.
00:05:50 Prof Richard Santen
That this this has become or has been a a major topic and one of the most recent ones, of course, is the.
00:05:57 Prof Richard Santen
Ability to have contraceptive pills for men, which still is a major discussion in the in the literature.
00:06:05 Prof Richard Santen
But of course every time an article is written, it says that we’re 10 years away from having a contraception pill for men, and each ten years the same the same system.
00:06:16 Prof Richard Santen
So I would say that.
00:06:18 Prof Richard Santen
That over the last 10 or 15 years, there’s been a lot of discussion about contraception, but this has really been superseded now by the the focus on the the whole issue of abortion.
00:06:32 Will Mountford
And to kind of briefly put that in a global context, what does the prevalence of unintended pregnancy in the US globally?
00:06:41 Will Mountford
And then we get into some of the access to contraception and how that differs on a national basis as well.
00:06:46 Prof Richard Santen
So let’s talk a little bit about that.
00:06:48 Prof Richard Santen
So first of all, what is, how do you define an under attended pregnancy?
00:06:53 Prof Richard Santen
And this is either that you really don’t want a pregnancy at.
00:06:56 Prof Richard Santen
Small or the pregnancy is too early and you would like to plan your family later, so that’s what we’re talking about globally in the last period of time that we have data from 2015 to 2019, there were 120 million unintended pregnancies.
00:07:18 Prof Richard Santen
That really surprised me. That’s a huge number, and it turns out that if you compare high income countries and low income countries, there’s quite a big difference. So let’s talk about the overall incidence of unintended pregnancies. It’s 64 women out of 1000.
00:07:38 Prof Richard Santen
Ages 15 to 49.
00:07:40 Prof Richard Santen
But if you talk about low income countries, that’s 95 per thousand. And if you took a talk about.
00:07:48 Prof Richard Santen
High income countries it’s 30 per thousand and this really says a lot about socioeconomic factors, financial factors and healthcare factors.
00:07:58 Prof Richard Santen
Now it turns out that of those 121,000,000 unintended pregnancies, about 50% were ended by induced.
00:08:08 Prof Richard Santen
Abortion and the number or the percentage of induced abortion has gone up over the last 30 years.
00:08:16 Prof Richard Santen
From 51% of unintended pregnancies to 61%. So it really focuses on the fact that the application of contraception to reduce unintended pregnancies has not really kept up with the level of science that’s been there.
00:08:35 Prof Richard Santen
I think that influential.
00:08:38 Prof Richard Santen
Individuals who have expertise in this field probably need to work assiduously, trying to write scientific articles that go over the science of this and apply the science to the practical applications ultimately, of of contraception often.
00:08:59 Prof Richard Santen
Gets the attention of the media when some of this information is is written in influential journals.
00:09:07 Prof Richard Santen
So I’m kind of looking ahead to trying to put together some of these concepts, all of which are exceedingly complicated in ways that would frame this on a on a scientific basis.
00:09:20 Prof Richard Santen
It’s quite interesting when we look at the COVID-19 educational rollout in the United States, that doctor, Anthony Fauci always talks about.
00:09:29 Prof Richard Santen
Let’s follow the science.
00:09:31 Prof Richard Santen
That’s what he says in every talk that he gives.
00:09:33 Prof Richard Santen
He’s had a lot of pushback by the politicians saying that he has an attitude.
00:09:38 Prof Richard Santen
But when you, you look at all of this over time.
00:09:42 Prof Richard Santen
We have done a an amazing job in developing vaccines for COVID and people have.
00:09:48 Prof Richard Santen
Taking it up and so on.
00:09:49 Prof Richard Santen
So people really have followed the science.
00:09:51 Prof Richard Santen
So I think this is something that is a strategy that one needs to focus a little bit more on the overall aspect of contraception and not the individual risks and benefits of the individual components of it.
00:10:07 Prof Richard Santen
Everyone is worried about using hormones for menopause and they say.
00:10:11 Prof Richard Santen
There’s a 30% increased.
00:10:14 Prof Richard Santen
Risk of breast cancer. If you take hormones, what that is is relative risk. So it means that if there’s a very small risk of breast cancer in the population, a 30% increase is a very small number of patients. If you fly round trip from New York to Paris.
00:10:34 Prof Richard Santen
About a one in 10 million chance that you’ll crash if you fly on five round trips. There’s a 5 in 10 million chance. That’s a 500% increase in risk. That’s relative risk, the absolute risk.
00:10:50 Prof Richard Santen
Is only four in 10 million.
00:10:54 Prof Richard Santen
So as we talk about the risks and benefits of contraception, the newspaper likes to talk about relative risk.
00:11:02 Prof Richard Santen
Even recently, talking about progesterone only contraceptives and premenopausal women, there is an increased risk to about 30.
00:11:11 Prof Richard Santen
Percent, but the absolute risk is minuscule when one really talks about the actual numbers affected.
00:11:18 Will Mountford
Yeah, going from 1%, it’s not up to 30. It’s going from one to one point.
00:11:23 Prof Richard Santen
That’s correct, but it depends on what the underlying risk is.
00:11:26 Prof Richard Santen
So if it’s, if the underlying risk is exceedingly small, any increased relative risk is almost meaningless.
00:11:38 Will Mountford
And when we talk about contraceptive techniques that are available, are we strictly talking about hormonal interventions, things like the pill or the implant here?
00:11:47 Will Mountford
Are we including barrier methods?
00:11:49 Prof Richard Santen
So really, when you think about it, this is really a complicated topic because there are so many different methods of contraception now.
00:11:58 Prof Richard Santen
And of course, we all know about the birth control pill, which was developed in the in the 60s.
00:12:05 Prof Richard Santen
And that’s hormonal contraception.
00:12:07 Prof Richard Santen
The implant is a another way of of hormonal contraception, which involves putting a silastic rod under the skin.
00:12:16 Prof Richard Santen
Probably the more recent development is the morning after pill.
00:12:20 Prof Richard Santen
This doesn’t cause abortion.
00:12:22 Prof Richard Santen
It basically causes prevention of.
00:12:25 Prof Richard Santen
Of pregnancy and there are several different methods.
00:12:30 Prof Richard Santen
Or morning after pills, but they can be taken for up to a couple or even three days after intercourse to prevent pregnancy.
00:12:39 Prof Richard Santen
It’s interesting that the copper intrauterine device, which works for a long period of time and is quite safe if that’s put in right after.
00:12:50 Prof Richard Santen
Intercourse. That’s also a.
00:12:52 Prof Richard Santen
Method for both morning after but also long term.
00:12:56 Prof Richard Santen
One of the other recent developments is to use intrauterine devices that have the hormone progesterone included.
00:13:03 Prof Richard Santen
These last up to about five years and are quite effective and without a lot of side effects.
00:13:09 Prof Richard Santen
So we’ve talked about hormonal contraception.
00:13:12 Prof Richard Santen
We talk about copper and some devices like that surgical contraception, of course.
00:13:20 Prof Richard Santen
Where we tie the tubes in a woman or we tie the tubes in a man or another method, we usually call it vasectomy.
00:13:28 Will Mountford
Reversible or non reversible?
00:13:30 Prof Richard Santen
They’re both non reversible.
00:13:32 Prof Richard Santen
One of the things that’s interesting about tying the tubes in men is something called scalpel free tubal ligation.
00:13:41 Prof Richard Santen
What they do is they basically just stick a needle around the the tubes and the scrotum insert, something that dilates that and then they can tie off the tubes and prevent.
00:13:52 Prof Richard Santen
Very simply, it takes about 5 minutes and then finally we have barrier contraception.
00:13:58 Prof Richard Santen
And of course, mainly this would be a diaphragm in a woman or a condom in a male.
00:14:03 Prof Richard Santen
And I think when we talk about that, this is something that requires some planning prior to the time of intercourse, and it’s not so helpful for most people.
00:14:13 Prof Richard Santen
But it’s very important in countries that have.
00:14:16 Prof Richard Santen
Of a high incidence of sexually transmitted diseases.
00:14:21 Prof Richard Santen
Then, finally, there’s something that many people would call Catholic roulette or Russian roulette, and this is the family planning method to avoid intercourse at the time of major possibility of of.
00:14:36 Prof Richard Santen
Of pregnancy and there been some developments there too, because.
00:14:40 Prof Richard Santen
Now we have a method of testing the urine to determine just when ovulation occurs. So I think you can you can understand from from what I’ve said that number one, this is pretty complicated #2 there’s been a huge advance in science in the last 30 years, primarily for hormonal contraception.
00:15:01 Prof Richard Santen
But also for the inner uterine devices and the and the copper containing devices, and of course, one of the problems with this is that it’s so complicated that many general physicians or even gynecologists.
00:15:18 Prof Richard Santen
Don’t have a complete understanding of all of the different techniques that are available.
00:15:24 Will Mountford
Well, to come back to something that you mentioned in terms of the long term versus short term solutions that.
00:15:30 Will Mountford
The implant could be a long term solution that the implanted ID could be a short term solution for morning after and kind of family planning.
00:15:40 Will Mountford
I’ve got it written down here that it’s not an exact quote that the most manageable pregnancy.
00:15:44 Will Mountford
Is the one that you don’t have in the 1st place and that seems to be the ongoing thrust of the literature that you’re citing and what you’re trying to communicate.
00:15:53 Will Mountford
Here is that that having kind of the best foot forward before conception is even on the table is.
00:16:00 Will Mountford
Ideally, the right way to be managing family planning and medical planning and legal and moral planning to just start off from that kind of position is that equally a professional position that you can start off with family planning well ahead of.
00:16:18 Will Mountford
Actually getting to planning a family.
00:16:20 Prof Richard Santen
So it’s it’s quite interesting that Mrs.
00:16:23 Prof Richard Santen
Sanger, back in the early days, uh, was talking about birth control as a way of.
00:16:30 Prof Richard Santen
00:16:32 Prof Richard Santen
Because it was safer to do that than the complications of a pregnancy, and this LED basically to the Planned Parenthood clinics and the Planned Parenthood clinics really were originally designed for contraception.
00:16:45 Prof Richard Santen
But of course later you have a major focus on on abortion.
00:16:49 Prof Richard Santen
So if you, if you look into the literature.
00:16:52 Prof Richard Santen
This whole idea that we now have the ability to control the whole reproductive process and pregnancy has been an advancement of science.
00:17:02 Prof Richard Santen
And it really is a better way to deal with the whole issue of unintended pregnancies, and particularly the contraceptive techniques are really safer in fact, than pregnancy.
00:17:15 Prof Richard Santen
And of course, this depends really on what country you live in.
00:17:19 Prof Richard Santen
So if you tend to be an individual in a country.
00:17:22 Prof Richard Santen
It’s very low income and they’re very poor resources.
00:17:26 Prof Richard Santen
The maternal mortality rate is quite high in areas that are very high income and and high.
00:17:34 Prof Richard Santen
The mortality is quite a lot less.
00:17:37 Prof Richard Santen
So I think one can look at the issue of contraception as as something that actually could help in countries that have a very high pregnancy mortality rate.
00:17:47 Prof Richard Santen
It could help with that also.
00:17:48 Will Mountford
And in terms of making that clear or available to people working in medicine, from that, you know, family planning clinic, a fertility clinic or the community setting.
00:18:01 Will Mountford
Is control of fertility and control of conception.
00:18:06 Will Mountford
As valid or as professionalized.
00:18:09 Will Mountford
The field as post fertility research, or the attempts to conceive, is the planning against as well prepared as the planning.
00:18:18 Will Mountford
For a family.
00:18:19 Prof Richard Santen
You know when you think about it, a family that is dealing with infertility, where you have in vitro fertilization and you have a number of techniques that can allow you to become pregnant, that’s going to have much more visibility.
00:18:33 Prof Richard Santen
To individuals, because it’s very personal, then the concept of preventing unwanted pregnancies or or reducing population and so on, so that the the the science on in vitro fertilization has has really been much more to the forefront.
00:18:49 Prof Richard Santen
But I think this needs to change.
00:18:50 Prof Richard Santen
You know, when you think about what the way that.
00:18:53 Prof Richard Santen
The world moves short term solutions always have.
00:18:58 Prof Richard Santen
More emphasis than long term solutions and for unwanted pregnancies. Abortion is really a an effective short term solution, but when you get up to 10,000 feet and think about it, contraception is is really something. That’s a long term solution and it’s complicated and it requires a strategy.
00:19:18 Prof Richard Santen
All of its own and I believe having looked at the what’s been published recently in the media and reviewing the literature, I think this whole issue of.
00:19:30 Prof Richard Santen
Contraception is a long term strategy, has really been neglected recently.
00:19:36 Prof Richard Santen
And I think that we just need to think of all of the aspects of this that could make long term contraception more appealable to individuals, more effective and something that that becomes a an important goal.
00:19:52 Prof Richard Santen
00:19:53 Will Mountford
And I believe that leads to the speech that you also give on the six key steps for building a better system.
00:20:00 Will Mountford
If we could work through some of what those are and you know where the action currently is in terms of the US healthcare system, the US legal political landscape and what needs to change to move that.
00:20:13 Will Mountford
Towards something that has compassion and justice at its heart.
00:20:17 Prof Richard Santen
When we look at this, I think that we have to look at the principles rather than what’s really happening in the US and elsewhere in the US these issues have been so.
00:20:28 Prof Richard Santen
Seal that one could think this is even a swamp.
00:20:31 Prof Richard Santen
So we need.
00:20:31 Prof Richard Santen
We need to go above that and think of what is possible and what are some of the six, six steps that would be needed if we’re going to be successful on this.
00:20:41 Prof Richard Santen
So the first one is the change attitudes and one attitude that needs to be changed is that.
00:20:48 Prof Richard Santen
We need to convince people that unwanted pregnancies are really not OK.
00:20:53 Prof Richard Santen
This is something that’s a failure, and women and men should know that they have the responsibility to prevent unwanted pregnancies.
00:21:04 Prof Richard Santen
So the attitude should be not.
00:21:07 Prof Richard Santen
Women have the ability to control their bodies and to have the choice to terminate a pregnancy, but the attitude should be that unwanted pregnancies are not alright and as a couple or as women, we should really use the techniques that are available to reduce the number of unwanted pregnancies.
00:21:26 Prof Richard Santen
The other issue about.
00:21:27 Prof Richard Santen
Education is that we now have 9 billion people in the world.
00:21:32 Prof Richard Santen
India has gone up to 1.4 billion and we really need to think about long term control of population and one way to do this is to prevent unwanted pregnancies, and this is part.
00:21:45 Prof Richard Santen
Of the overall education to change attitudes, now the next area has been pretty controversial.
00:21:52 Prof Richard Santen
And that is that that individuals need to understand.
00:21:57 Prof Richard Santen
About reproduction and about pregnancy and the issues about pregnancy, if they’re going to deal with this issue.
00:22:04 Prof Richard Santen
In the United States, many of the political attitudes have been we really shouldn’t touch this in high school or even earlier.
00:22:13 Prof Richard Santen
But it’s quite interesting that in the Netherlands, sex education is starting in primary school.
00:22:19 Prof Richard Santen
It’s not happening in the US.
00:22:21 Prof Richard Santen
But I think that we really need to have effective educational programs in high school in the United States and elsewhere.
00:22:30 Prof Richard Santen
And this really is to let.
00:22:33 Prof Richard Santen
People know what is available.
00:22:35 Prof Richard Santen
What are the concepts under underlying family planning and so on.
00:22:40 Prof Richard Santen
And this would require a commitment really of of governments in the educational system to have these programs put in place.
00:22:48 Prof Richard Santen
Those are the 1st 2 attitudes and education.
00:22:51 Prof Richard Santen
The Third Point is governmental action.
00:22:54 Prof Richard Santen
So what can governments do to help with the problem?
00:22:58 Prof Richard Santen
Well, it’s interesting.
00:22:59 Prof Richard Santen
the United States has actually taken some action in this recently.
00:23:03 Prof Richard Santen
And that’s to make the morning after pill available.
00:23:07 Prof Richard Santen
There are some colleges in the United States now that have free morning after pills available for the college students.
00:23:14 Prof Richard Santen
So they don’t need a prescription.
00:23:15 Prof Richard Santen
There’s no moral issues involved in this.
00:23:18 Prof Richard Santen
They they can do this, and governments can actually make the morning after pill available with.
00:23:24 Prof Richard Santen
Without prescriptions can subsidize it so that it’s at lower cost and make it generally.
00:23:29 Prof Richard Santen
Available, the government can also subsidize clinics that can provide this level of education.
00:23:38 Prof Richard Santen
What I would see is that rather than having a a family planning clinic, we would have clinics that are really designed for contraception.
00:23:48 Prof Richard Santen
Now, that doesn’t seem reasonable to a lot of people.
00:23:51 Prof Richard Santen
But I’m an expert at this and it’s very hard for me to keep up with all of the various aspects of the risks and benefits of hormonal contraception or the other forms of contraception.
00:24:03 Prof Richard Santen
I’ve gotta look up things, and so have.
00:24:06 Prof Richard Santen
Specialized clinics that deal with contraception, the individuals in those clinics would be able to know everything there is to know about the scientific aspects, and this is something that hasn’t really been, uh, hasn’t really been talked about.
00:24:21 Prof Richard Santen
The next thing is targeted strategies.
00:24:24 Prof Richard Santen
We can talk about contraception.
00:24:25 Prof Richard Santen
In the US, but what about Bangladesh?
00:24:28 Prof Richard Santen
What about Kenya and countries that are underdeveloped, or or developing and the issue there I think is that the forms of contraception?
00:24:40 Prof Richard Santen
Will be very different in those in those areas. I go back to my mentor, Wayne Barden, who developed the contraceptive implant, and his whole perspective was that in underdeveloped countries, a woman’s not gonna go to the doctor periodically to get a birth control pill and have it followed.
00:25:01 Prof Richard Santen
Or the side effects and so on.
00:25:02 Prof Richard Santen
If one could put in a relatively inexpensive implant into the arm and it lasts 10 years, you have a way that is.
00:25:13 Prof Richard Santen
Inexpensive and practical to reduce the chances of fertility in those in those individuals, and that’s beginning to take off now.
00:25:22 Prof Richard Santen
Globally, this concept and these implants really are associated with very few side effects and complications.
00:25:29 Prof Richard Santen
So it’s something that really, really has worked.
00:25:32 Prof Richard Santen
The other targeted strategy.
00:25:34 Prof Richard Santen
Which I really liked in concept was that at one time I met the urologist who was the doctor for Chao and Lai in China, and he developed a form of tubal ligation.
00:25:49 Prof Richard Santen
In men that they could basically do in the subway station, it was a very interesting approach and he began to popularize that.
00:25:57 Prof Richard Santen
But his whole idea was that if you had a quick.
00:26:01 Prof Richard Santen
Inexpensive way of causing sterilization or prevention of pregnancy in men.
00:26:08 Prof Richard Santen
This would be an appropriate way.
00:26:10 Prof Richard Santen
Now his technique never caught on but the non scalpel ligations certainly did and I think he was a pioneer visionary thinking about how all this could happen.
00:26:22 Prof Richard Santen
Well, then you have individuals who have very strict religious convictions and don’t want to use hormonal contraception, the methods.
00:26:32 Prof Richard Santen
For natural family planning, my take on that is that.
00:26:37 Prof Richard Santen
They’re probably effective in allowing a family not to have four or five 6-7 or eight.
00:26:44 Prof Richard Santen
Children, but not very effective in in preventing individual pregnancies.
00:26:49 Prof Richard Santen
There’s an interesting story here that Henry Berger, who was asked by the World Health Organization to evaluate the scientific aspects of family planning, came up with this same concept.
00:27:01 Prof Richard Santen
And after he and his family had had five.
00:27:05 Prof Richard Santen
Children using the family planning method, they decided maybe they would try something else, so I thought that was an interesting insight into the issue.
00:27:14 Prof Richard Santen
So those are are are some of the the long term strategies that need to be applied.
00:27:21 Prof Richard Santen
Ultimately, I haven’t gone over.
00:27:23 Prof Richard Santen
6 But I’ve gone over most of the critical ones and I and I think that when one looks at that one size, does not fit all.
00:27:31 Prof Richard Santen
We have many different ways to do this and the reasons to use one versus another are complicated but realistic and should be understood and ultimately applied.
00:27:46 Will Mountford
The first case that you made was in terms of attitudes towards pregnancy.
00:27:51 Will Mountford
The idea of.
00:27:52 Will Mountford
Shame and stigma around sex and pregnancy, especially unwanted pregnancies, are nothing new.
00:27:59 Will Mountford
And I wonder if there were maybe any ways to focus on, you know, building the success stories of.
00:28:06 Will Mountford
Deferred Parenthood, rather than necessarily using it as a.
00:28:11 Will Mountford
A road to peak people with.
00:28:12 Prof Richard Santen
Yeah, this is a difficult question.
00:28:14 Prof Richard Santen
I think that the major focus on.
00:28:16 Prof Richard Santen
In this issue, has really been to try to reduce world population and, for instance countries like Kenya where 30 years ago the average number of children in the family was six or seven.
00:28:31 Prof Richard Santen
It’s now down to two or three and and this has really been accomplished primarily by education.
00:28:37 Prof Richard Santen
The other approach, of course, is the one taken by China, which was very, very constrictive, that you could only have one child and obviously that’s not something that we we want to encourage.
00:28:50 Prof Richard Santen
So I think that.
00:28:51 Prof Richard Santen
For two reasons. One, the overall issue of family reducing population, but the other one, which is really important, is that families that really can’t afford to effectively take care of 3456 and seven children by using contraception to limit family size.
00:29:12 Prof Richard Santen
The two children that you do have, one has.
00:29:16 Prof Richard Santen
Much more resources to provide appropriate education, appropriate nutrition, appropriate clothing and upbringing, and so on.
00:29:26 Prof Richard Santen
So all all of these issues focus on the on the need ultimately to reduce family size.
00:29:33 Prof Richard Santen
00:29:34 Prof Richard Santen
If I if I can go on that.
00:29:36 Prof Richard Santen
Doesn’t really address the issue of induced abortion, where you’re reducing family size and and contraception, and I think this is an issue that we need to to grapple with, but it’s not a new issue I found out in my reading that Saronis, who was the preeminent gynecologist in Rome.
00:29:56 Prof Richard Santen
In 110 AD, basically said it’s much better to prevent a pregnancy to abort. I was amazed at that because it was exactly the thinking of today.
00:30:07 Prof Richard Santen
And of course, Hillary Clinton said the same thing, that if we effectively use contraception, we aren’t going to have to be concerned to such an extent about abortion because it will be rare.
00:30:19 Prof Richard Santen
So this again, is is, I think.
00:30:22 Prof Richard Santen
The educational thinking that we need to emphasize at this point and really hasn’t.
00:30:28 Will Mountford
Well, there’s two points on education that I think are worth bringing up and ones on the domestic scene for you and ones on a more global.
00:30:34 Will Mountford
People that start off.
00:30:35 Will Mountford
With in the US at the moment there has been in the last 5-10 years and intensified backlash against sex education.
00:30:43 Will Mountford
What there is compared to like you raised in the Dutch example of getting it in primary education, I know that when I was growing up we had sex classes in I think.
00:30:53 Will Mountford
It was year 4.
00:30:53 Will Mountford
00:30:54 Will Mountford
9 or 10 they just went through the anatomical diagram of ovaries, ovum, cervix, like, basically flipchart.
00:31:01 Will Mountford
This is like the mechanics of where that all fits together.
00:31:04 Will Mountford
But with this backlash against the sex Ed as kind of the one arm of A to put it in politely a culture war that is being raised against liberal ideas and anti LGBTQ campaign.
00:31:17 Will Mountford
Is that something that challenges the idea of a national rollout of these kind of education programs?
00:31:24 Will Mountford
Or is it something that would require a more targeted approach to?
00:31:28 Will Mountford
And you know, at home based interventions or self led provisions, if schools are made unable to provide the kind of education at that age.
00:31:36 Prof Richard Santen
You’ve asked me a question that it’s impossible to answer, but let me give you my take.
00:31:41 Prof Richard Santen
00:31:41 Will Mountford
I think I might ask you 7 questions there.
00:31:43 Will Mountford
I do apologise.
00:31:44 Prof Richard Santen
No, no, no, no.
00:31:45 Prof Richard Santen
My take on it is that people have a wide range of opinions and a a wide range of upbringings and religious convictions, and that when we look about what has happened in the world over a long period of time, if one looks at the science.
00:32:03 Prof Richard Santen
And one looks at the principles behind this that in time these opinions can change.
00:32:09 Prof Richard Santen
Now in the United States, it’s quite interesting that of course we talk about the red States and the blue states, the Republicans and the Democrats.
00:32:18 Prof Richard Santen
But the red states are very much against sex education in schools, the blue states.
00:32:24 Prof Richard Santen
Have really welcomed it so it says that even in our country things are done are done differently.
00:32:29 Prof Richard Santen
So how do we get around this?
00:32:31 Prof Richard Santen
I I think.
00:32:32 Prof Richard Santen
In the individuals that are interested in this need to provide the science they need to speak about this and write about this using the principles and trying to get around the the individual biases.
00:32:46 Prof Richard Santen
But this is a challenge and it’s going to take quite a while, I think, but it is evolving in the US.
00:32:52 Prof Richard Santen
Clearly has evolved in the Netherlands and I think more so in the European Union than in the in the US.
00:32:59 Will Mountford
And then the next question I had to address kind of the education and especially the global education points that you’ve raised is when discussing.
00:33:08 Will Mountford
And the idea of there being efforts towards global population control and you know, managing a global population upwards of 9 billion so far, a lot of the interventions and educational policies that you’ve raised have been frankly over there.
00:33:22 Will Mountford
They have been reducing the population for these booming populations in Bangladesh, Kenya.
00:33:28 Will Mountford
Of Southeast Asia and North Saharan Africa, and with those booming populations and that increasing birth rate.
00:33:35 Will Mountford
I think it’s worth taking the time to unpick that.
00:33:37 Will Mountford
If there is an increased birth rate, is that due to an also increased child mortality rate or if there is improved healthcare provisions so that there are more children being born who are then living longer?
00:33:50 Will Mountford
Are we just waiting to see the generational effect of?
00:33:53 Will Mountford
I’m not terrified that all my children are going to die at the age of three, so I won’t have.
00:33:57 Will Mountford
Seven or eight children, so then that overall population boom will tail off, maybe in 20-30 years. Is that worth, you know, considering or address?
00:34:07 Prof Richard Santen
So all of those issues are clearly important issues, but I think what we’ve lost sight of is that the birth rate per country is proportional, inversely proportional to income.
00:34:20 Prof Richard Santen
So high income countries have low birth rates.
00:34:23 Prof Richard Santen
Italy, I think the lowest probably in the world, whereas low income countries.
00:34:28 Prof Richard Santen
Have high birth rates and I think then probably an important issue is this whole idea of trying to increase the overall level of income in in various.
00:34:40 Prof Richard Santen
Countries and with this a direct effect, I think will probably be to reduce birth rate.
00:34:46 Prof Richard Santen
But your concept of having more children because of mortality, high mortality, that that was a concept that was highly prevalent in developed countries before the era of antibiotics and and and public health and so on.
00:35:01 Prof Richard Santen
But those concepts have still been highly prevalent in countries like Bangladesh or India or or countries that are undeveloped.
00:35:09 Prof Richard Santen
So I think that that when I talk about a multi pronged approach.
00:35:14 Prof Richard Santen
And strategy, we really get into an area which is complex and requires multiple strategies, not just one.
00:35:22 Will Mountford
And then to raise the points made of government action and targeting strategies, are there any ways to resolve the idea of doing big, broad, sweeping, national, even international efforts like you say on either raising overall economic stability and income or educational campaigns?
00:35:42 Will Mountford
Or if there is, I don’t.
00:35:44 Will Mountford
That, you know the technology of 10 years in the future of having a safe, reliable contraceptive pill for men comes through to make that as widely available as possible on an international level, is there, I suppose, a tension?
00:35:57 Will Mountford
Or is there any way of getting action on huge sweeping changes?
00:36:04 Will Mountford
Or is the focus better spent on those?
00:36:07 Will Mountford
Targeted strategies is a way of doing both at the same time is a provision to do both at the same time.
00:36:12 Will Mountford
The political will or the funding to make that all?
00:36:14 Will Mountford
00:36:15 Prof Richard Santen
So really, you’re you’re raising the question of priorities.
00:36:19 Prof Richard Santen
Which of these areas are are the most important now?
00:36:22 Prof Richard Santen
I’m a practicing physician.
00:36:23 Prof Richard Santen
I take care of very complicated patients that have endocrine problems, and I recognize that my colleagues who are not endocrinologists throw up their hands about some of the things that I’m.
00:36:36 Prof Richard Santen
An expert at and.
00:36:37 Prof Richard Santen
So I think one of the highest priorities probably would be government sponsored.
00:36:43 Prof Richard Santen
Contraceptive clinics, particularly in low income countries, so that you would have a cadre of highly trained healthcare providers that knew all of the aspects of of contraception.
00:36:55 Prof Richard Santen
And then any family that’s considering pregnancy would have a place to go.
00:37:02 Prof Richard Santen
Where they could understand and be be taught all of the the options that were available to them.
00:37:08 Prof Richard Santen
Now that would require government action.
00:37:11 Prof Richard Santen
It would require the decision that these are important and I would put that really highest.
00:37:18 Prof Richard Santen
On my level of prior.
00:37:20 Prof Richard Santen
Already and that would be something that could be done.
00:37:24 Prof Richard Santen
Fairly sweepingly with government support.
00:37:27 Will Mountford
Do you think there is any likelihood of that coming around on the the US domestic scene or if there have been?
00:37:34 Will Mountford
You know the.
00:37:34 Will Mountford
00:37:37 Will Mountford
Well, the most liberal attitudes towards sex education like you see in Europe, do you think they might be the first to do that?
00:37:42 Prof Richard Santen
My sense is in the US, we’ve got to resolve the issue.
00:37:47 Prof Richard Santen
About induced abortion before we can start focusing on this, I’m going to change the subject just a little bit, but one of the other things that I wanted to say and that is I I tried to look historically of what was thought about induced abortion.
00:38:04 Prof Richard Santen
And what I came up with is that we will never resolve what the morality is of induced abortion.
00:38:11 Prof Richard Santen
Why did I think this?
00:38:12 Prof Richard Santen
Well, I thought this because over the centuries in Rome, for instance, in 110 AD or.
00:38:20 Prof Richard Santen
00:38:21 Prof Richard Santen
400 years later, even the Catholic Church said that there were unformed fetuses.
00:38:27 Prof Richard Santen
And what they meant by that was a fetus that was living but was not a human being and that it would be not.
00:38:36 Prof Richard Santen
Sinful or immoral to deal with termination of a unformed fetus that was not yet a human.
00:38:43 Prof Richard Santen
So then I began to look and try to figure out.
00:38:47 Prof Richard Santen
Currently what it what is the thinking about that?
00:38:50 Prof Richard Santen
Well, the Catholic Church says that it’s conception at the time of conception.
00:38:54 Prof Richard Santen
Others say it’s the time that there’s a heartbeat.
00:38:57 Prof Richard Santen
Others say that it’s the time of quickening, and some of the religion say it’s the time that the the baby comes out of the womb, our Supreme Court said that you can’t.
00:39:08 Prof Richard Santen
Really, this was Roe versus versus Wade.
00:39:11 Prof Richard Santen
You really can’t tell and it’s a spectrum such that it’s much more likely that you have a fetus that’s a human being in the third trimester.
00:39:21 Prof Richard Santen
Then in the in the first trimester.
00:39:23 Prof Richard Santen
So right now in the US there’s all the debate about this.
00:39:27 Prof Richard Santen
And when you look at the history.
00:39:29 Prof Richard Santen
And how this has been looked at over the years, I don’t think it will ever be resolved and I don’t think so because there’s there’s no way really to scientifically or objectively.
00:39:40 Prof Richard Santen
Knowing when a fetus ultimately develops human characteristics in such a sense that induced abortion would would be immoral.
00:39:50 Prof Richard Santen
And that’s I think that’s why also in my reading about this and thinking about it recently, I’ve really made my emphasis much more on prevention than on the controversial.
00:40:01 Prof Richard Santen
Moral aspects, and I think most of what I’ve shared with you and my thoughts are not based on morality, but are really based on practical scientific issues.
00:40:17 Prof Richard Santen
We have to prioritize and that’s always the most difficult thing to do.
00:40:21 Prof Richard Santen
I believe that starting with educating healthcare providers about these issues is is probably a place to start.
00:40:29 Prof Richard Santen
The providers then can begin.
00:40:32 Prof Richard Santen
Educating their highly influential patients to begin to act, to convince politicians about this, those of us who have taken care of patients over a long period of time know that if you’ve established a rapport.
00:40:48 Prof Richard Santen
Mutual trust with the patient.
00:40:50 Prof Richard Santen
You can really influence someone to take action, and I’ve seen that in my own my own career and that’s why I’m thinking, starting with physician education would be a good start then educating.
00:41:03 Prof Richard Santen
The general public about this is important and always this is the thought leaders primary.
00:41:09 Prof Richard Santen
Really that we want to influence this again might be done through the physicians only in that way will the politicians ultimately take action, because they generally take action when they there’s a consensus or a groundswell of attitudes among their constituents to to move forward.
00:41:28 Prof Richard Santen
So again, a very complicated.
00:41:30 Prof Richard Santen
Issue I’m a little bit biased because I’m a physician and I take care of patients.
00:41:35 Prof Richard Santen
I have over a long period of time and I know about the the rapport that one can establish, and this is a a scientific issue because of all of the complexities of of the issues of contraception.
00:41:46 Prof Richard Santen
So I see this starting really on a on a medical front, secondarily with patients who are opinion leaders.
00:41:53 Prof Richard Santen
And then thirdly, politicians and.
00:41:55 Prof Richard Santen