The high rate of unplanned pregnancy presents enormous challenges for women, families and society. Through Upstream USA, Mark and his colleagues are changing the culture of reproductive healthcare in the U.S. and pioneering a new model for ensuring all women receive same-day access to the full range of modern contraceptive methods.
The New Idea
Mark has worked for more than two decades on interrupting intergenerational poverty. He got his start working with organizations focused on early education and homelessness and started working at the national level when he founded Opportunity Nation, a bi-partisan coalition of more than 300 antipoverty organizations. Through conversations with one of these organizations, the National Campaign to Prevent Teen and Unplanned Pregnancy, he learned about a startling, but well-documented statistic: over half of all pregnancies in the U.S. are accidental and unplanned. Of the 6.6 million pregnancies in the U.S. each year, 3.4 million are unplanned. The downstream impact on mothers, fathers, and children is significant and can reverberate for generations. Mark circled back to many of the Opportunity Nation organizations – nonprofits, community colleges, youth development organizations – and virtually all of them confirmed that unplanned pregnancy was a significant issue with the populations they served. National surveys of poor and low-income women from the Centers for Disease Control and Prevention showed that 65% of their pregnancies were unplanned. But what was even less understood what that so many of these women were using a contraceptive method when they became pregnant – but the method they were using wasn’t working for them, which led to an unplanned pregnancy. And all this was taking place despite new, rigorous research showing that there were new methods of contraception that women actually preferred, but were rarely offered: the new IUDs and implants. These methods are twenty times more effective than other methods, as safe as any other method of contraception, and were held up by the CDC, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics as the best methods of contraception for all women. Mark believed that if we could change healthcare so that women could get access to these new methods of contraception, it would give them more control over their lives. And by helping women achieve their own goals and become pregnant only when they want to could be a powerful way to support women, men, and children, and help break the cycle of intergenerational poverty in America. So Mark co-founded Upstream USA, a non-profit organization that is changing the U.S. healthcare system so that all women can receive the highest quality services and conveniently access the full range of modern contraceptive methods, particularly the most effective ones, IUDs and implants. Upstream USA is showing that this transformation of women’s healthcare is possible in the U.S. They’ve already changed the practices of twelve health centers around the country that serve 37,000 women of reproductive age per year, and their ambition is to do much more. The difference in patient experiences in a pre- and post-Upstream health center is night and day. But this isn’t just about better customer service training. Upstream USA trains clinicians on how to place and remove these new methods; they train the billing and coding staff about how to get reimbursed for them; they ensure that these methods are stocked so that they can be offered the same day they are desired; they teach counseling skills so that patients can make an informed choice. Upstream USA is working with nurses, doctors, receptionists, CEOs, translators, and others in healthcare to make contraceptive counseling and care a centerpiece of women’s health and by doing so, ensure that women can achieve their own goals and have children only when they want them and plan for them.
Mark Edwards insists that “breaking the cycle of intergenerational poverty is among the most important challenges facing the United States, yet we are not making progress as fast as anyone would like.” Despite anecdotal stories of resilience and beating the odds (in his own family and in popular American culture), there is less social mobility than Americans think.
According to economists at the Brookings Institution, National Review, and elsewhere, the U.S. now lags behind Canada and many western European nations in economic mobility, with children of African American and Hispanic parents faring the worse. By the time children are teenagers, their economic prospects are increasingly fixed. Mark Edwards, a co-founder of Upstream USA asks, “What has happened to the American Dream? Why haven’t we made more progress? And what are the biggest levers we have to rapidly increase educational attainment and economic opportunity?”
Mark believes that accidental pregnancy – a pregnancy that isn’t planned – is at the center of these issues. According to the Guttmacher Institute, more than half of all pregnancies in the United States are accidental or unplanned, and among low-income women, 65% of all pregnancies are accidents. Of the 6.6 million pregnancies in the US last year, 3.4 million were unplanned. Unplanned pregnancy is associated with a wide range of adverse maternal and child health outcomes, including delayed prenatal care, premature birth, and poor physical and mental health.
Though unplanned pregnancy is clearly a health issue, Mark adds that “at its core it is an opportunity issue.” According to the Gates Foundation and others, unplanned pregnancy is a leading reason young women drop out of high school and community college. The US military also reports very high rates of unplanned pregnancy. Mark says “people always think we’re focusing on teen pregnancy, but the vast majority of unplanned pregnancy occurs to single women in their twenties.” These accidental pregnancies can derail the trajectories of women and men, and present particular challenges for children.
In the US, the contraceptive method of choice is the oral contraceptive pill which is only fully effective when a woman is extremely consistent about taking it, and many women are not. A 2014 New York Times article stated that, on average, a woman’s chances of becoming pregnant over 10 years is 61% if she uses the pill as her method of contraception. This, researchers point out, is one of the reasons why rates of unplanned pregnancy in the U.S. have not improved in the last 20 years, and have actually gotten worse for poor and low-income women.
There are new methods of contraception – the new IUDs and implants – that are 20 times more effective than the pill, as safe as any method of birth control, endorsed by the major medical governing bodies in the field as best in class, and that research shows women prefer if they are fully educated about them and can get them the same day they seek birth control. But even at health centers that do offer these effective methods, Mark learned, the process of getting an IUD or implant was prohibitively (and unnecessarily) complicated for the patient, usually requiring multiple visits. Though all contraceptive options are technically free under the Affordable Care Act, too often women aren’t told about them, clinicians aren’t trained to place them, and the health center thinks they lose money when doing the procedures. These barriers often translate into women only being offered methods of contraception like the pill, patch or ring that have far greater, real world failure rates than these new methods. “We’re leaving one of the most important decisions we make – when, under what circumstances, and with whom we have children – to chance, and it’s the system’s fault,” Mark says.
After looking at the range of barriers, Mark and his co-founder saw the big opportunity as changing the “supply side” of the equation by ensuring that women could get same-day access to all methods of contraception in one healthcare visit.
A few years ago, a group at Washington University started publishing findings from their large research study showing that when nearly 10,000 women were offered the full range of all FDA approved contraceptive methods with same-day availability, 75% of them chose the more effective methods, IUDs and implants. This study demonstrated impressive health outcomes, including a 75% reduction in teen pregnancy and abortion. And recently the Colorado Department of Public Health and Environment announced the results from their own experiment modeled after Wash U’s. In that case the birthrate among teenagers across the state plunged by 48 percent while their rate of abortions fell by 48 percent as well. When Mark Edwards first heard about the Wash U. study he called the lead researchers to ask if they also measured some of the things he cared most about – wages, educational attainment, job security – among those women who chose to use these more effective methods of contraception. But they didn’t; the researchers just measured health outcomes. Mark believes this is one of the main issues Upstream USA combats: people don’t make the connection between pregnancy planning and economic opportunity, and that’s a huge mistake. “The irony is that we know this about the developing world. Helping women achieve their own goals and become pregnant only when they want to increases educational attainment and improves outcomes for their children. Yet here in the US, where unplanned pregnancy rates are higher than in most developed countries, we’re not taking our own advice.” Mark is quick to point out the long and ugly history in the US of reproductive coercion. There are well-documented cases in the not-too-distant past of judges who have offered lighter jail sentences to women who choose to become sterilized, for example. Because of this, Upstream USA is deeply committed to ensuring patient choice: the goal is to create a healthcare environment where women can make a real choice among the full range of methods. “What gets measured gets managed,” Mark says, and so one of their core values is to measure patient voluntarism after a health center has been trained. All women of reproductive age are asked confidentially, “Who chose your contraceptive method today: you, you with your provider, or did your provider choose it for you?” Mark is careful to point out that their success is not to be measured in numbers of IUDs or implants inserted. Their primary metric of success is increasing the national percentage of women who get same day access to the full range of contraceptive methods, no matter which method they ultimately choose. “Equal access, informed decision-making, and total choice are our goals. Upstream USA is tackling the systemic barriers in health centers so that women can make a true, informed choice about the best methods of contraception for themselves. Mark believes that reducing unplanned pregnancy is one of the fastest, most easily achievable, most highly leveraged, most evidence-based and least expensive ways to break the cycle of intergenerational poverty. Women themselves want to plan their pregnancies, and the evidence out of Washington University and Colorado show that this is achievable. Upstream USA delivers a comprehensive, multi-visit, on-site training and technical assistance curriculum that addresses all these issues. They start with the premise that women will have the best experience in a health center when everyone working there is aligned to make these methods available. They train clinicians, management, front desk and support staff. The training begins long before the on-site visit with an intensive baseline assessment to better understand the particular needs of the individual health center. Before training clinicians on insertion and support staff to provide better counseling, they address billing and coding roadblocks. Some health centers are worried about their ability to stock the devices, so they iron out those issues, too. As the teams of trainers get to know each facility, they identify areas for improved efficiency. This early work sets the stage for the on-site experience that consists of two, intensive five-hour days of training. While on site, Upstream trainers focus on those elements of the training that require interaction: role-playing counseling sessions, insertion training, and hands-on skills. Mark and the Upstream USA team are currently focused on perfecting their model and proving its impact, and they are experimenting with e-learning modules and web-based teaching that they and others could rely on to reduce the on-site training time. After the on-site work, they follow up with mentoring to ensure that the skills taught have been embedded in the experience. And particularly in the primary healthcare setting where asking about a woman’s pregnancy intention is not the norm, they work to change the electronic health records so that all women of reproductive age are asked if they want to become pregnant in the next year as a standard part of their screening. If they don’t desire to become pregnant, they are offered great counseling about the full range of contraceptive methods, and if they do, they are provided with great preconception care. Over the last year, Upstream USA has developed its training curriculum, completed twelve trainings in a wide variety of health centers in Texas, Arizona, Ohio, New York and Massachusetts that serve a total of 37,000 women per year; received early impact data from their first trainings that indicate a 700% year-over-year increase in IUD and implant rates compared to a similar period before the training; and hired independent program evaluators to measure the impact of their trainings going forward. In addition, they are launching a statewide initiative in Delaware (the state with the highest rates of unplanned pregnancy in the nation) to reduce unplanned pregnancy by training all the major public and private healthcare systems in the state and informing women about their options. But this is more than a change-management process. At its core, Mark points out that what is required is a deeper reframing of the roles of healthcare workers. Armed with data from this project that will show significant reductions in unplanned pregnancy, abortion, teen pregnancy, and pregnancy related costs paid for by Medicaid, he hopes to inspire other states to do the same. Mark envisions reaching a tipping point in the next ten years when the majority of women in the US are offered these methods the same day they want them, resulting in significant decreases in unplanned pregnancy. Over time, they hope to tackle another challenge: to get more people who are working to increase economic opportunity in the US to incorporate pregnancy planning into the suite of things we can do to ensure that everyone achieves their full potential. By sharing the compelling data that Upstream USA is having with policy makers and funders, Mark is hopeful that more attention and support will flow in this direction. “The central question over the next decades is how we can restart the American Dream,” Mark says, “and helping women achieve their own goals and become pregnant only when they want to should be at the center of that conversation. This is not about blaming poor women. This is all about helping women achieve their own goals. Candidly, this is what I would want for my own daughters.” He envisions a day when every child born is a planned for and wanted child.
Mark’s personal passion comes from the fact that he is deeply aware that he has had extraordinary opportunities in his life, and that he has benefited from the American Dream. As he tells it, “my father grew up in a single parent family, struggled through college, joined the Army, and then sent all three of his children to Harvard. That story doesn’t happen with as much frequency today.”
Mark started his first company with a friend while in college, a leading communications firm serving educational institutions. Throughout this time Mark was also highly involved in local anti-poverty work, mainly focused on helping launch a high-quality preschool program serving homeless children in Boston that has grown to include 3 centers with 120 staff and a total annual budget of $10m. Over time Mark grew frustrated with the tired framing in poverty alleviation work of ‘us’ versus ‘them’ and, in 2009, he convened leaders from the Brookings Institution, the Center for American Progress, and the Heritage Foundation around a new framework: creating an ‘opportunity society.’ The bi-partisan campaign he started, called Opportunity Nation, grew to include 300 organizations and played a role in helping shape and pass the reauthorization of the Workforce Innovation and Opportunity Act, the Federal workforce development bill that had been delayed for years. Today the organization is renowned for its “Opportunity Index”, an online tool that ranks America’s 3,000 counties with an A-F score based on measures of economic, educational and civic factors that foster opportunity.
From this perch, Mark was able to get to know 300 anti-poverty “theories of change”. Then, as he puts it, “in the middle of this work, I was asked to join the board of the National Campaign to Prevent Teen and Unplanned Pregnancy, which I joined from a traditional women’s reproductive rights perspective. I had one of those “aha!” moments in a board meeting when I suddenly understood the powerful impact that unplanned pregnancy plays in the things I cared about: economic opportunity and educational attainment. These issues are all intertwined, but it struck me that if we could help women achieve their own goals and have children only when they want and plan for them, it could help increase educational attainment and expand opportunity.”