Long term strategies for unintended pregnancies


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 

Preventing pregnancy. 

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 

Long term. 

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 

That doesn’t. 

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 

It’s about. 

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 

On it. 

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 

At once. 

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 

Most advanced. 

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 

And then. 

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 

Friendly government. 


Leave a Reply

Your email address will not be published.

Researchpod Let's Talk

Share This

Copy Link to Clipboard