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March 6th, 2017 Senator Patricia Spearman Chair, Health and Human Services Committee Nevada Senate Re: S.B. 233 Chair Spearman and members of the committee: I am here today in support of SB 233. I am an ObGyn and practice in Carson City, NV. Over my 27 years here, I have delivered thousands of Nevadans and have spent my life working to protect women and their families. It’s my strong belief that an ounce of prevention is worth a pound of cure. By supporting this bill you will be joining with me to protect and care for Nevada’s women and their families. This bill includes provisions that remove barriers for women to obtain preventative services, prenatal care, assistance with smoking cessation, checks for sexually transmitted diseases, vaccinations and contraception. In each of these situations science clearly shows that the cost of screening/ prevention is far less than the cost of treating the consequences of failure. The clearest example is with unintended pregnancy. Births resulting from unintended or closely spaced pregnancies are associated with adverse maternal and child health outcomes, such as delayed prenatal care, premature birth, and negative physical and mental health effects for children. In 2010 52% of all pregnancies in Nevada were unintended and the majority were teen pregnancies. We can all agree that that number is too high. Over the past 5 years we have seen a steady drop in both unplanned pregnancy and in teen pregnancy. Those of us in healthcare firmly believe that much of this is due to removing the barriers to effective, reliable and affordable contraception. Poor and low income women are much more likely to be effected by unintended pregnancy. Women with a family income below the federal poverty level are 5 times more likely to have an unintended pregnancy. These women are much more sensitive to barriers for services that allow them to prevent pregnancy. Most unintended pregnancies are in the one third of women not using EXHIBIT N Senate Committee on Health And Human Services Date: 3-6-2017 Total pages: 4 Exhibit begins with: N1 thru N4 contraception. These pregnancies are expensive. In Nevada in 2010, 102.9 million dollars of public money was spent on unintended pregnancy. Most women spend several decades during their reproductive years trying to prevent pregnancy. I have submitted a list of contraceptive choices. Some types of birth control are within the couple’s control, for example condoms, diaphragms, rhythm method, withdrawal, oral contraception, rings and patches. These have the highest failure rates since use may not be consistent for many reasons. Birth control pills are especially susceptible to error in use caused by lack of availability. For this reason this bill mandates that this contraception should be dispensed with up to one year of supplies. This may be a surprise to you, (and it has certainly surprised many of my patients over the years), but missing the very first pill in the package places women at the highest risk of unplanned pregnancy. For years the answering service has been putting calls through on weekends from desperate women who find themselves without their next package of pills. This is the most common reason for accidental pregnancy in birth control pills users and is very easily addressed. Passing access to 12 packages of birth control pills with one visit will solve this problem. The second, and more effective class of contraceptives, are called LARCs, (Long Acting Reversible Contraceptives). They include IUDs, implants and shots. They have very low failure rates and user error is less common. Some people have expressed concern that IUDs cause abortion. The progesterone IUDs work in the same way that the shot and the implants work; they prevent the sperm from getting through the cervix. The copper IUD creates a sterile inflammation, copper is toxic to sperm, causing the sperm to be engulfed upon entering the uterus. The third type is permanent sterilization. Vasectomy and tubal ligation are both popular methods of pregnancy prevention. They are the most effective and their use should be encouraged for couples that have decided their families are complete. Since vasectomy is a minor surgery, performed in the office setting it is especially important that we remove barriers to this option. Access to the morning after pill as an emergency resource is also important. I prescribe this to my patients that use barrier methods for contraception. Plan B is over the counter; however there is a more effective drug called Ella that requires a prescription. It’s much more effective for women who are overweight and unfortunately this includes much of our population. Both drugs work by delaying ovulation. Neither of them will cause abortion. N2 There are many reasons why couples choose one contraceptive method over another. Sometimes it is personal chose and other times there are reasons why certain methods can’t be used safely. An example is migraines with aura. Women with this diagnosis have an increased risk of stroke if they use birth control pills, rings or patches. This is why it’s important for couples to be able to obtain without barrier every method approved by the FDA. Thank you for taking the time to give serious consideration to these concerns. Your vote for this bill is a vote to protect the health and welfare of women in Nevada. The benefit to our society and our budget is tremendous. Sincerely, Sandra Koch, M.D. Carson Medical Group Carson City, Nevada [email protected] PDF on contraception http://www.reproductiveaccess.org/wpcontent/uploads/2014/06/contra_choices.pdf N3 N4