ࡱ> ` bjbj :u &F>4rrr)))8"*4V*r++"0+0+0+0+"R+ ^+VrXrXrXrXrXrXr$thawd|rrN0+0+NN|rrr0+0+r0+U+U+UNr0+r0+Vr+UNVr+U+Uznrrp0++ p%v6)OrFoqTr<r`owiTdw4pwrp f+ f7+U?F-f+f+f+|r|rT^f+f+f+rNNNNd!))rrrrrr  Imperfect Information and Transaction Costs for Contraception in the United States and Abroad  Nicole Jones Economics 411: New Institutional Economics May 12, 2005 Table of Contents 1. Introduction ................................................................................................... 1 2. Gary Beckers Model for Fertility Choices .... 3 3. Contraception in Developing Countries . 6 3.1 Imperfect Information, Access, and Cost of Contraceptives 6 3.2 Mexico City Policy: Imperfect Information and Increasing Transaction Costs 9 3.2.1 The effects of the Mexico City Policy in Kenya 12 4. Contraception in the United States 14 4.1 Abstinence-only Education .. 14 4.2 Access to Emergency Contraception .. 17 4.3 Contraceptives and Health Risks . 19 5. Implications for the Becker Model ............................................................................ 21 6. Conclusion . 22  1. Introduction Access to contraception is not universal, nor is information about contraception methods perfect. This is unfortunate for many reasons. First, having access to reliable forms of contraception is a powerful way to advance womens autonomy. It is also important for improving the health of both men and women, particularly protecting them from sexually transmitted infections such as HIV. Improving access to modern contraception allows men and women to make more precise decisions about fertility. When people are capable of controlling their fertility decisions, this typically has positive implications for curbing high rates of population growth. Because of information problems and transaction costs, contraception is not always easy to obtain. While there are many people who do not seek contraception, its availability is necessary for the health of men and women. In many African countries (for example, Sudan, Ethiopia, Chad, Niger, Mali, and Cameroon), less than 10 percent of married women use modern contraception (Seager 2003). One explanation for low contraception use rates is that access to contraception in these countries is poor. There are, however, plenty of social explanations for low use rates of modern contraception for example, social taboos and preference for large families. One example is in areas where preference for sons is very high (Ray 1998). Typically, large families are desired in order to ensure that at least two sons survive past childhood. Also, in cultures where children are depended upon for production, large families make economic sense. This is particularly true if the probability that a child will be an adequate income earner is high (Ray 1998). Even people who desire large families benefit from access to contraceptives because sexually transmitted infections are prevented from spreading (particularly by condom use), and also because the space between childrens births can be controlled. For anyone who wishes to choose the number of pregnancies or children they have, access to contraception is essential. Men and women deserve good information about the effectiveness and safety of contraceptive methods, as well as easy access to contraception. There are undoubtedly problems that face those seeking contraception. When applied to economic models for fertility decisions (particularly Gary Beckers model, to be introduced later), the transaction costs and information asymmetries in the market for contraception significantly alter how fertility decisions are actually made. It is important to recognize this so that government policies can be designed to better address these imperfect information and high transaction cost problems. Appropriate policies would aim to improve the amount of information consumers have about contraceptive methods both in the United States and abroad. Also, policies that increase the cost of moving contraceptives from the United States to the rest of the world, specifically developing nations, could be eliminated. 2. Gary Beckers Model for Fertility Choices One of the most prominent economists to write about the economics of fertility decisions is the University of Chicago economist Gary Becker. As part of the Chicago School of Economic Thought, Becker used economics to write about many non-traditional economic topics for example marriage, divorce, human capital and most important to this paper, fertility decisions. Thomas Malthus argued that fertility was determined primarily by two primitive variables, age at marriage and the frequency of coition during marriage, or in other words, how often couples have sexual intercourse (Becker 1976). As modern contraception methods were developed, there became a need for a more detailed model for fertility decisions. Also, it became more pertinent to create a model for fertility choices that did not assume that all children were born inside of marriage. Unlike Malthus, Beckers model acknowledges that people have sexual intercourse outside of marriage, and thus make fertility decisions outside of marriage. Influenced by Theodore Schultzs work on human capital, Becker developed an economic model for fertility choices. The general framework of Beckers model is as follows: children are thought of as consumer durables that provide some level of utility to their parents, who have their own relative preference for children. Families must choose the number of children to have, and also the amount of income to spend on them - more expensive children are called higher quality children (1976). This is sometimes referred to as the choice between quantity and quality of children. Becker argues that fertility is determined by income, child costs, knowledge, uncertainty, and tastes (1976). It is assumed that individuals have well-ordered preferences and make rational choices. Becker devotes an entire chapter in A Treatise on the Family to the demand for children (Becker 1981). The price of children and real income are what Becker uses to explain why rural fertility is typically higher than urban fertility (1981). Becker explains fertility decisions by arguing that the demand for children is partially determined by the wage rate of women (1981). As the economic value of a womans time in the workplace increases, having children becomes more expensive. In other words, the wage rate for women is strongly negatively related to the number of children demanded. An assumption that needs to be made in order for Beckers model to work is that people have a high degree of control over their own fertility to begin with, because they have adequate access to contraception. This is clearly not the case for many women, and is perhaps most clear for women in developing countries. Becker writes in societies lacking knowledge of contraception, control over the number of births can be achieved either through abortion or abstinence, the latter taking the form of delayed marriage and reduced frequency of coition during marriage (Becker 1976). The central assertion of this paper is that this assumption is flawed because of high transaction costs and information problems in the market for contraception, many men and women cannot make the controlled fertility decisions Becker assumes. While this is especially true for women in developing nations, women in the United States also face problems in the market for contraception. Beckers models have been critiqued since before they were published. Other economists were uncomfortable with the idea of modeling human behavior and decisions that were stereotypically non-economic. Using microeconomic theory to model how individuals decide whether or not to invest in their education, to get married, and the number of children to have has proven to be useful, particularly to those designing policies aimed at improving the quality of life for people. Beckers models have been critiqued since before they were published. Other economists were uncomfortable with the idea of modeling human behavior and decisions that were stereotypically non-economic. Using microeconomic theory to model how individuals decide whether or not to invest in their education, to get married, and the number of children to have has proven to be useful, particularly to those designing policies aimed at improving the quality of life for people. People have found it difficult to conceptually define and measure the true costs and satisfactions of children to their parents (Willis 1974). When it comes to the importance of contraception availability in making fertility decisions, the idea that it contraceptives could not be available is taken for granted even by critiques of Becker. They acknowledge that the model leaves room for change so that the assumptions of perfect fertility control could be removed in favor of a theory of imperfect fertility control, but do not elaborate any further, aside from saying that Beckers model leaves no room for accidental births (Willis). Shultz (1969) wrote that when the range of birth control methods is limited to traditional methods, that large costs are incurred in achieving a high degree of reliability, as in induced abortion, and that for the individual living in a traditional community, it might be very costly for him to search for more reliable forms of contraception. Some write that Beckers models are too simplistic to apply toward political problems (Rogowski 1999), which of course could be said of many economic models. This paper elaborates on Willis (1974) and Schultzs (1969) comments about Beckers assumption about perfect fertility control by providing modern examples of how imperfect information and transaction costs affect access and use of contraceptives. 3. Contraception in Developing Countries Beckers model for fertility choices assumes that individuals have the tools they need to control their fertility, and that when access to contraceptives is poor or information is imperfect they can simply rely upon abortion and/or refrain from having sexual intercourse. The problem with this assumption is that access to abortion is not always easy, nor is abortion something that every woman is willing to do. Access to contraception is important so that women can avoid pregnancy in the first place. The Mexico City Policy (MCP), a policy that puts restrictions on US foreign aid to family planning non-governmental organizations (NGOs), has increased the difficulty that individuals have in attaining contraceptives. 3.1 Imperfect Information, Access, and Cost of Contraceptives Becker was correct in stating that sometimes, particularly in developing nations, information is not perfect about contraceptives effectiveness and that it can affect contraceptive use. The lack of knowledge about contraceptives is an important reason for non-use of contraceptives among women who want to limit their fertility or space their childrens births. For example, a researcher working in Columbia found that women were averse to using progestin-only contraceptives because they delay or eliminate menstruation, and the stopping of expected blood flow is perceived to be signs of an illness (Hardon 1997). In Romania, hormonal contraceptives, specifically the birth control pill, are avoided because they are thought to contribute to cancer and cause weight gain (Global Gag Rule Impact Project 2003). There is no scientific evidence that proves that the pill causes either cancer or weight gain, in fact it is said to reduce certain types of cancer particularly cervical cancer. The direct cost of modern contraception in some countries can be very high, which makes it difficult for women to limit their fertility. As shown in table 1, the cost of one years supply of condoms in certain countries is a very high percentage of annual income. A problem that is uniquely faced by developing nations is low per capita income in terms of purchasing power parity. Having low purchasing power is a hindrance to being able to afford contraception to begin with. In some countries, for example in Russia and Romania, the cost of contraception has traditionally been so high that it was more cost-effective to use abortion as a method of birth control instead of actual pregnancy-preventing contraception (Global Gag Rule Impact Project 2003). This might explain why in the mid-1990s, there were 63 legal abortions for every 100 pregnancies in Russia and in Romania (Seager 2003). While the direct cost of contraceptives remains high in only a small minority of developing countries, it is a significant problem nonetheless. Table 1 Source: Seager Cost of one years supply of condoms (as a proportion of GNP per person). Early 1990s (latest available data).Countries42% - 45%Burma, Burundi30% - 31%Ethiopia, Togo23% - 27%Madagascar, Mali10% - 16%Guinea, Rwanda, Congo, Benin, LaosLess than 1%France, Japan, Singapore, UK, USA Access to contraception for those who need it is not perfect, and this is most evident in developing countries. It has been calculated that unmet need for contraception is highest in Sub-Saharan Africa, where it is estimated that approximately 60 percent of women who need contraception do not have it (Hardon 1997). In developing countries, it is now estimated that 105.2 million married women have an unmet need for contraception. Unmarried women add 8.4 million, and the former Soviet republics add 9.1 million for a total of 122.7 million women who desire contraception and do not have access to it (Ross & Winfrey 2002). Women ages 15-24 account for one-third of this need (Ross & Winfrey). Access to contraception is indeed very poor for many (but not all) women in developing nations. In order for Beckers model to work an individual needs to have access to effective methods of contraceptive, or be willing and able to have an abortion or abstain from sex. As will be shown in the next section, access to abortion services can be complicated for those living in developing nations. 3.2 The Mexico City Policy Imperfect Information and Increasing Transaction Costs Government policy can affect the true cost of contraception, making it more difficult for people to control their fertility. One clear example is the Mexico City Policy (MCP). This policy adds costs to the access for contraception, making it difficult or impossible to obtain. The MCP was put into effect by President Reagan in 1984, rescinded by President Clinton in 1993, and put back into effect by President Bush in 2001 within days of the beginning of his first term. There are three basic components of the Mexico City Policy. (1) The first is a restriction that withholds USAID family planning grants and technical assistance from foreign non-governmental organizations (NGOs) that, using non-U.S. funds, perform or actively promote abortions or conduct research to improve abortion methods (Cincotta & Crane, 2001). Examples of such NGOs include reproductive health organizations, womens groups, private hospitals and clinics, as well as health research centers. Funds are not restricted for such groups who perform or actively promote abortions in cases of rape, incest, or when it is necessary to save the life of the pregnant woman. None of the funding restrictions apply to U.S. grants to foreign governments, only to NGOs (2001). (2) The second component of the MCP is a restriction on recipient NGOs from lobbying (with non-U.S. funds) for liberalization of legalization of abortion, or conducting informative campaigns regarding the benefits of abortion as a method of family planning (2001). Basically, this means that if an NGO receives funding from the U.S. government, it is not allowed to campaign to legalize abortion in its host-country. (3) The last component of the MCP is that in countries where abortion is legal in all situations, health workers in USAID-funded NGOs cannot refer women to an abortion provider (2001). In other words, even if abortion is legal in a country, the health workers are not allowed to counsel women on all legal pregnancy options. Under the MCP, aid-recipient NGOs cannot perform abortions, campaign for the legalization of abortion, or counsel women on the option of abortion. What USAID-receiving NGOs are allowed to do under the MCP:What USAID-receiving NGOs are not allowed to do under the MCP: Use US and non-US funds to actively promote abstinence Lobby, even with non-US funds, for the criminalization of abortion or stricter punishment for women who have abortions. Use US and non-US funds to perform or actively promote abortions Lobby, even with non-US funds, for the legalization or liberalization of abortion Refer women to abortion providers, providing knowledge of all legal pregnancy options.  For non-governmental organizations who have signed the MCP in order to receive funding from USAID, information is incomplete many family planning organizations are not sure what they can and cannot say or do. In the early instatement of the MCP, there were large information problems about what was allowed under the restrictions. As a result, many NGOs acted overly cautious because they were not properly informed about what they could do while maintaining eligibility for USAID funding. In the USAID-funded Blane-Friedman report of 1990, it was found that several organizations were cutting back research on statistics on abortion trends because they thought that it was not allowed under the MCP (Blane & Friedman 1990). People were motivated by a fear of losing funding and thus engaged in actions not mandated by the MCP. Such actions negatively impacted the access women had to non-abortion related health services. This may have been more of problem during the first instatement of the MCP than it is today. To further exemplify this, the Blane-Friedman study (1990) found that some organizations chose to err on the side of caution and decided not to help women who were undergoing complications due to unsafe abortions. In several clinics in Bangladesh, it was found that if a woman were to come in suffering from a septic abortion, that staff would not be permitted to accompany her to the hospital treatment, even if done on the staff members own time (1990). It was also found that basic health equipment was not purchased for fear of being accused of performing abortions. This was the case in Pakistan when one organization had planned to purchase a D&C (dilation and curettage) kit for gynecological purposes, but the idea was dropped because the clinic was afraid that it would cause some people to think that the clinic performed abortions (1990). In a more recent study on the effects of the MCP, it was found that non-abortion health services were being reduced as a consequence of the MCP. An African family planning organization said that due to the MCP, some clinics have closed and hence are denying young women post-abortion care, family planning advice, and provision of modern methods of family planning. Similarly, women have been denied the all-important referral services for abortion (Reece-Evans 2003). As USAID funding for family planning organizations outside of the US falls, for whatever reason, so does the availability of contraception and basic health services. The GGR has led to the termination of all US contraceptive supply shipments to leading family planning organizations in 29 countries (Crane & Dusenberry 2004). In the absence of contraception, women are likely to face more unwanted pregnancies and more unsafe abortions, even though it is difficult to quantify. The distance between some people and the nearest supplier of contraception has greatly increased due to the Mexico City Policy, as will be shown in a case study on Kenya. 3.2.1 The effects of the Mexico City Policy in Kenya In Kenya, abortion is illegal unless it is required to save a womans life. Kenya also faces very high maternal mortality rates: 1,000 or more mothers die in every 100,000 live births (Seager 2003). Women in Kenya have an average of 4.4 children, and nearly half give birth before age 20 (Global Gag Rule Impact Project 2003). According to a Nairobi newspaper, the number of unsafe abortions are said to have increased to approximately 800 a day since the MCP was re-introduced in 2001 (Off Our Backs 2004). It is estimated that one-third of maternal deaths can be attributed to unsafe abortion, and nearly half of all births are reported to be unwanted or unplanned (Global Gag Rule Impact Project 2003). Kenyas per capita purchasing power is $1,035 USD (World Bank 2001). Because of the Mexico City Policy, two of the most prominent family planning providers in Kenya have closed clinics, scaled back services, cut nearly one-third of their staff, and raised prices. These two family planning providers are the Family Planning Association of Kenya (FPAK) and Marie Stopes International Kenya (MSI Kenya). Because of this, the restrictions placed on funding NGOs had a large impact on Kenya, particularly in rural areas. Understaffing clinics and scaling back will cause client fees to go up and might increase the number of women who do not use contraception. According to the Global Gag Rule Impact Project of 2003, Kenyan womens success in using contraception to plan their families can be largely attributed to community-based distribution efforts by both FPAK and MSI Kenya, which were supported by USAID for yearshealth providers expressed concern that without consistent, well-staffed community-based programs, recent gains in maternal and child health may slip. The MCP has caused five family planning clinics to shut down completely, two of which are MSI Kenya clinics and three FPAK clinics. In some cases, these clinics were the only source of health care for both men and women (2003). Community outreach programs by the remaining family planning clinics have been shut down, which is incredibly problematic because of those living in very rural areas who might not live near a clinic to begin with. The Mexico City Policy increases transaction costs in the market for contraception. By affecting the number of family planning clinics operating, people must travel farther to gain access to birth control. It also has created imperfect information problems that have led to a decrease in access to contraception. Not only is abortion illegal in Kenya, it is also illegal in the rest of Africa as well (with the exception of South Africa) and all of South America (except for Guyana). Abortion is illegal in Mexico and most of Central America (with the exception of Belize) too. In these continents, some countries do allow abortion, but only if it is to save the life or preserve the health of a woman or if the fetus is impaired (Seager 2003). The legal status of abortion does not fully reflect the reality of abortion availability, because in countries where it is legal that does not necessarily mean it is available to all who want it. Access to contraception is poor in many parts of developing nations, but access to abortion is very poor as well. Beckers model relies on the assumption that people can control their fertility using contraception, and that if not they can rely upon abortion. Clearly, this is not a very modern assumption as many people do not have access to abortion or contraception in the first place. 4. Contraception in the United States Even though there are significant information and transaction cost problems hurting access to contraception in developing nations, the United States is certainly not immune to such issues. Beckers model assumes that when individuals choose the number of children they have, they do based on their income, preferences, the cost of raising a child, and uncertainty in the future. Before Beckers model can be used, however, there are fundamental factors influencing fertility decisions: good information and access to contraception and abortion. Without these tools, people will have a more difficult time choosing the number of children they have. In the United States, three examples of information and transaction cost problems include: abstinence-only education where sex education is incomplete, non-universal access to emergency contraception, and inaccurate perceptions of health risks associated with certain contraceptives. 4.1 Abstinence-Only Education In the United States, adolescents in public schools receive abstinence-only sex education. While a discussion of abstinence is important and necessary, it is only one part of a discussion about safe sex. Abstinence-only education encourages students to wait until marriage to have sex or participate in sexual activity in lieu of providing a complete range of information about contraceptives and safe sex. In 1981, congress passed the chastity law which funded education programs to promote self-discipline and other prudent approaches, which until twelve years later contained curriculum with direct references to religion. (Planned Parenthood 2005). In fiscal year 2005, the United States has devoted about $170 million to abstinence-only education (United States House of Representatives Committee on Government Reform 2004). While public funds do not go toward the promotion of safe sex, they do go to religious institutions for anti-sexuality education. For example, the Catholic diocese in Montana received $14,000 from the states Department of Health for abstinence classes (Planned Parenthood 2005). In the United States, less than half of public schools offer information on how to obtain birth control and only a third include discussion of abortion and sexual orientation in their curricula (Planned Parenthood). Clearly, public schools in the United States have become the source of information problems about contraception and safe sex for teenagers. A disturbing part about abstinence-only education is that there are cases of where textbooks are chosen or edited so that students are not provided a full range of information about safe sex. In North Carolina, the school board ordered that three chapters be cut out of ninth-grade health textbook because the material did not comply with state law mandating abstinence-only education (Quillen 1997, Heins 2001). The chapter covered AIDS and other STDS, marriage and partnering, and contraception. In Virginia, school board members refused to approve a high school science textbook unless an illustration of a vagina was covered or cut out (Associated Press 2000). If sexual health is to be promoted and unwanted pregnancies are to be avoided, students need a full range of health information about sex. Teachers are not allowed to practice freedom of speech under abstinence-only programs. A seventh-grade health teacher in Missouri was suspended when a parent complained about the teacher discussing inappropriate sexual activities in class when the teacher had simply answered a students question about oral sex, and in Florida, a teacher was suspended after showing a video called Condom Man and his K-Y Commandos, which is about preventing AIDS (Planned Parenthood 2005). A teacher should not risk suspension for providing medically accurate health information. Information about the effectiveness of contraceptives is distorted in many abstinence-only education programs. The information that is provided under abstinence-only programs is not complete, is often misleading and has also been found to be medically incorrect. For example, the effectiveness of condoms and other contraceptives in preventing pregnancy and sexually transmitted infections is grossly underestimated (Alan Guttmacher Institute 2004). Some curriculum shows that HIV can be transmitted through tears and sweat, that twenty four chromosomes from the mother and twenty four from the father join to make a fetus, that tubal and cervical pregnancies are increased after abortions, and that research confirms that 14 percent of women who use condoms scrupulously for birth control become pregnant within one year (United States House of Representatives Committee on Government Reform 2004). Without accurate medical information, students will have less of an opportunity to avoid unplanned pregnancies and sexually transmitted infections than they could with complete information about contraceptives and safe sex. When health information about contraceptives is omitted, skewed, or taken out of context it becomes more difficult for students to make informed decisions about contraception. 4.2 Access to Emergency Contraception In the US (as well as in Canada), there is a large debate about whether or not a prescription should be required for emergency contraception. Emergency contraception is legal in the Untied States, Canada, and Europe but is illegal in Australia, most of Africa, the Middle East, parts of Central America and South America, and India. In the United States, there can be significant transaction costs associated with buying emergency contraception, as it is not always readily available. Some argue that because you need a prescription for birth control pills and other hormonal contraception methods, that you should need a prescription for emergency birth control. This element of time is problematic when the effectiveness of emergency birth control depends upon taking it as early as possible, and requiring a prescription could prohibit the use of emergency contraception in sufficient time. Opponents of emergency contraception argue that eliminating the requirement for a prescription will promote risky unprotected sex and that the drug will be used incorrectly if available over the counter; however, a recent study published by the American Medical Association revealed that there is no evidence to support these ideas (Heavey 2005). Plan-B, the most prescribed form of emergency contraception in the United States, is available without a prescription from pharmacists in six states Alaska, California, Hawaii, Maine, New Mexico, and Washington. Plan-B is sold over the counter in more than 30 countries (Heavey 2005). While requiring a prescription could be considered a transaction cost associated with emergency birth control (particularly if it is needed on a weekend when doctors offices are usually closed), a more noteworthy transaction cost is the searching costs associated with finding a pharmacy to fill an emergency birth control prescription. Pharmacists within the United States are legally allowed to deny filling a prescription for emergency contraception and birth control pills. For example, Arkansas, Mississippi, Georgia, and South Dakota currently have laws allowing pharmacists to deny filling a woman her prescription for contraceptives. Many states are considering implementing the same types of laws, but recently the governor of Illinois issued a temporary order requiring pharmacists to fill every prescription, saying we are not going to allow people to make political statements at the expense of the access to health care that women deserve (Tapper & Miller 2005). One could argue that a pharmacist has a right to refuse to act in a way that would be against his own personal set of moral and ethical values. Many Catholic hospitals do not offer emergency contraception to patients, which is also currently within their legal rights. The issue then becomes a fine line between honoring an individuals ethical and/or religious values and promoting the health and reproductive choices of women. In order for women to have more control over their fertility, better access to emergency contraception in the United States is required. When searching costs become so high that emergency contraception is not obtained until the 72-hour window has passed, a woman may become faced with an unwanted pregnancy. For some, abortion would be a last-choice option to limit the number of children they have but for others faced with unwanted pregnancy, abortion is not an option and is too emotionally costly to endure. It is therefore imperative that barriers to obtaining emergency contraception be lowered. 4.3 Contraceptives and Health Risks When a consumer is not fully informed about the true health risks of their choice of contraception, or when the health risks are simply unknown, it can create problems for those attempting to control the number of pregnancies or kids they have. Imperfect information about contraceptive health risks affects the type of contraceptives people choose, for better or worse. Fertility decisions, specifically decisions about how to control fertility, are affected by the quality of information about the health risks associated with different contraceptives. An extreme example is that of the Dalkon Shield, a popular method of contraception (first introduced to the US market in 1970) that was once very risky, but has now tarnished the reputation of all intrauterine devices (IUDs). Today, IUDs have the lowest failure rate of any reversible form of birth control and are very safe. Furthermore, IUD users claim to be the most satisfied with their choice of contraception - 98 percent of IUD users report satisfaction with their method, while 92 percent of pill users and 87 percent of condom users say they are satisfied with their contraception (Health Square). One of many Intrauterine Devices (IUDs) on the market at the time, the Dalkon Shield was driven off the market in 1975 after a series of 12 deaths from miscarriage-related infections (Health Square). Even though it was one over-sized version of IUDs that contributed to these deaths, the market for all IUDs plummeted. Even as plastic IUDs were replaced by IUDs containing copper, the popularity of IUDs remained so low that most disappeared from the market by 1988 (Health Square). Claims were made that IUDs contributed to pelvic inflammatory disease; however, when compared with women who had never been sexually active, those using IUDs actually had a lower risk for pelvic inflammatory disease (Health Square). The problem is that there is now bad information about the safety of IUDs. The reputation of IUDs has been tarnished because of the Dalkon Shield despite being the most effective form of birth control on the market. Consumers are relying on outdated information about IUDs, and therefore making less informed decisions about which contraceptives they choose to control their fertility. Another example of a method of contraceptive where there is an unknown level of risk is Depo-Provera. In November 2004, the FDA announced that Depo-Provera, an established injectable hormonal form of contraception manufactured by Pfizer, is only suitable for use if the consumer is extremely unsatisfied with other methods. It added a black box warning to the drug, the strongest warning the FDA issues on drugs of any kind. The new label warns consumers that prolonged use of the drug may result in a loss of bone density, increasing the risk of osteoporosis (Smith 2004). FDA officials say that the loss of bone density associated with Depo-Provera may not be completely reversible after discontinuing the drug (Smith), but recent studies show that it may be (Davis 2005). Depo-Provera is a very a popular form of contraception in the US, and the FDAs warning highlights the possible health risks associated with hormonal contraception methods. Such a warning acts as a way for consumers to receive better information about their contraceptive choices. In the United States, there are unknown levels of risk with certain contraceptives, or at least inaccurate perceptions of such risks. While medically the risk of a contraceptive may be known, the public may not realize that a certain contraceptive is less risky than believed, or is in fact riskier than they previously thought. This information problem affects the type of contraceptives people choose in order to make fertility decisions. 5. Implications for the Becker Model Clearly, the market for contraception is not perfect. Beckers model for fertility decisions rests on the idea that in the absence of contraception, people can control their fertility through abortion or abstinence but worldwide access to abortion is also imperfect. Furthermore, abstinence as a method of fertility control is only perfect for a limited amount of time (as eventually, most people will have sex). Also, not everyone would choose abortion when faced with an unplanned pregnancy hence the importance of keeping contraception accessible. There are significant information problems surrounding contraception both in developing nations and the United States. Access to contraception is also imperfect, again both in developing nations and the United States. This basically invalidates the assumption Becker made about everyone being able to control their fertility, so that they can make fertility decisions strictly based on income, child costs, and tastes and preferences for children. VI. Conclusion When critiquing birth control availability in developing nations, it is important to recognize that the United States also faces similar difficulties. In an ideal world, men and women would be able to limit the number of unwanted pregnancies they are faced with. Contraceptive would be accessible to all who desired it (especially emergency contraception), information would be clear and unbiased about sexual reproduction, and abortion would be easily accessible for those who need it. Reducing the information asymmetries about contraceptives both in the Untied States and abroad would likely increase contraceptive use rates, and therefore lower the occurrence of unwanted pregnancies. Appropriate domestic and foreign policy for the United States would attempt to reduce the information asymmetries surrounding contraceptives, to prevent laws that would make it more difficult for contraceptives to be available overseas, and to make access to abortion easier abroad. References Alan Guttmacher Institute (2004). New report finds federally funded abstinence-only programs offer false, misleading information. December 3, 2004. [Online]. < http://www.guttmacher.org/media/inthenews/2004/12/03/index.html>. Accessed May 11, 2005. Associated Press (2000). Lynchburg school board will censor illustration in anatomy textbook. September 6, 2000. Becker, G. (1981). A treatise on the family. Cambridge: Harvard University Press. Becker, G. (1976). The economic approach to human behavior. 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A thesis presented to the faculty of Western Washington University in partial fulfillment of the requirement for the degree Master of Arts. Rogowski, R. (1999). Gary Becker: an appreciation, some modest proposals, and a disciplinary self-critique. Competition and cooperation: Conversations with Nobelists about economics and political science (1999): 158-69. Retrieved from EconLit database. Ross, J. & Winfrey, W. (2002). Unmet need for contraception in the developing world and the former soviet union: an updated estimate. International Family Planning Perspectives, vol.28, issue 3, pp.138-143. Seager, J. (2003). The penguin atlas of women in the world. New York: Penguin Books. Schultz, T. (1969). An economic model for family planning and fertility. Journal of Political Economy, v.77. March/April, pp.153-180. The Economics of the Family. 1996. Edited by Nancy Folbre. Vermont: Edward Elgar Publishing Company. Smith, M. (2004). New warning for Depo-Provera users. WebMD Health. [Online]. Accessed March 28, 2005. . Tapper, J. and Miller, A. (2005). Pharmacies take up morning-after pill debate. April 5, 2005. [Online]. Accessed April 23, 2005. . United States House of Representatives Committee on Government Reform (2004). The content of federally funded abstinence only education programs. December 2004. [Online]. http://www.democrats.reform.house.gov/Documents/20041201102153- 50247.pdf Willis, R. (1974). Economic theory of fertility behavior. Economics of the Family: Marriage, Children, & Human Capital. Edited by T. Schultz. Chicago: University of Chicago Press.  Modern contraception encompasses hormonal birth control methods such as the pill or IUD, condoms, sterilization, etc. Traditional contraception methods include withdrawal, herbal remedies, planned abstinence, and the rhythm method.  For comparison purposes, in the United States the percentage of married women who use modern contraception is between 51 and 75 percent. In China, Germany, and Switzerland, over 75 percent of married women use contraception.  This can be compared to 26 legal abortions per 100 pregnancies in the US, or 11 legal abortions per 100 pregnancies in the Netherlands.  For comparison purposes, in the United States between 10 to 99 mothers die in every 100,000 live births. Medical causes of maternal mortality include hypertensive disorders, anemia, severe bleeding, and infections (Seager).  2003 dollars.  Morocco, Algeria, Burkina Faso, Ghana, Guinea, Sierra Leone, Liberia, Ethiopia, Eritrea, Cameroon, Equatorial Guinea, Namibia, Botswana, Zimbabwe, and Mozambique in Africa. Ecuador, Peru, Bolivia, Argentina, and Uruguay in South America. Also, Costa Rica allows abortion only to save the womans life.  Emergency contraception reduces the chance of pregnancy after intercourse has occurred, but does not terminate a pregnancy. It can be used for up to 72 hours after intercourse and is especially useful for women who have been raped or have experienced contraceptive failure. Plan-B, for example, contains higher doses of progestin than that in regular birth control pills which women are supposed to take in the form of two tablets 12 hours apart. Some types of regular birth control pills for example Levlen which contains the levonorgestrel type of progestin found in Plan B can be used as emergency contraception if taken with specific instructions. Emergency contraception prevents the implantation of a fertilized egg as opposed to RU-486, an abortion pill that dislodges the egg after implantation. There is a window of up to 24 hours before an egg is fertilized, and days more before it attaches to the uterus.  Arizona, California, Indiana, Rhode Island, Tennessee, Texas, Vermont, West Virginia, and Wisconsin.  At the time, 2.8 million women used the Dalkon Shield.  Only two IUDs remain on the market in the US today the Para-Gard and the Progestasert.  Depo-Provera is also used as a treatment for endometriosis. 10% of American women ages 15-19 use Depo-Provera (Davis 2005). The popularity of Depo-Provera can in part be credited to the fact that it is easy to hide from others (i.e. parents) and is simple to use correctly - one injection is given every three months to administer the drug.     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