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Free contraception may prevent abortions
Researchers say the IUD, a form of contraception that can last up to 10 years, is more effective than short-term options.
October 4th, 2012
07:51 PM ET

Free contraception may prevent abortions

Contraception includes condoms and birth control pills, but there are other, longer-term methods that are effective and reversible: Intrauterine devices and implants.

A new study in the journal Obstetrics & Gynecology set out to see what would happen if these methods were given out at no cost. The study incorporated more than 9,000 girls and women at risk for unintended pregnancy.

Researchers found that teen births within the group of women who were part of this program was 6.3 per 1,000, which is much lower than the national rate of 34.1 per 1,000.

“We already spend $11 – 12 billion on unintended pregnancies in the U.S., and I bet that money could go very far to provide contraception for many women in the U.S.,” said Dr. Jeffrey Peipert, lead study author and researcher at Washington University in St. Louis School of Medicine.

Peipert and colleagues also found that the percentage of abortions that were repeat abortions was lower in this group of participants than in the St. Louis region in general, and the national average, during 2008 to 2010. The study intervention appeared to prevent one abortion for every 79 to 137 women who participated.

In previous research, Peipert and colleagues showed that these longer-term methods are as much as 20 times more effective than the birth control pill, the hormone patch and the hormonal vaginal ring. The long-acting options do not require the user to remember to take medications or change out a device, failings which can lead to unwanted pregnancies.

There are many barriers to the widespread use of long-acting reversible contraceptives in the United States, he said. One is the cost. One IUD costs a little over $700, not including the insertion fee, Peipert said, but it is very cost-effective given how long these devices last compared to other methods. The implant lasts three years, while the copper IUD lasts 10 years.

These longer-term options should be covered under insurance plans under the Affordable Care Act, although it remains controversial whether religious-based insurance carriers must provide contraception, Peipert said.

Another challenge is that clinicians are wary to give them to very young women, although they have been shown to be safe. Patients are also less aware that these methods exist.

Participants in the program were between 14 and 45 years old, did not want to get pregnant for at least 12 months, and planned to engage in sexual activity with a male partner within the next six months. About 5,000 participants received a free reversible contraceptive method for three years, while the rest got it for two years. Researchers used a variety of methods to enroll people in the study; 16% of the participants had been recruited at abortion facilities.

“Increasing access to the most effective contraceptive methods by removing cost and access as barriers has greatly increased the number of adolescents and women in the St. Louis region using the most effective methods of birth control,” the study said.

There are limitations, however. This study was limited to a very specific demographic area, so it’s hard to say how it would apply on a broader scale. Also, the study authors did not directly measure unintended pregnancies, but used measures of teen pregnancy and repeat abortions as a proxy.

The funding for the study came from the Susan Thompson Buffett Foundation. One of the study authors, Dr. Tessa Madden, is on the Speaker’s Bureau for Bayer Pharmaceuticals; there were no other conflicts of interest reported. The Washington University Human Research Protection Office gave approval before recruitment.


soundoff (72 Responses)
  1. Jim, San Antonio

    Here we see the biggest problem with healthcare. Costing $700, I bet that IUDs cost practically nothing to make. Probably could be sold for a significant profit at $25.

    October 4, 2012 at 21:48 | Report abuse | Reply
    • Tara

      Yeah, but when your device works for ten years, you're going dry up your market really fast.

      I agree with you though, the markup shouldn't include the LACK of purchases in the future.

      October 4, 2012 at 22:10 | Report abuse |
    • Nyltiak

      I don't know what that figure refers to, actually. I paid out of pocket for my IUD a couple of years ago, and it was less than $400, including the insertion procedure (and then my insurance reimbursed me anyway, even though they originally said they wouldn't). The hormonal IUD is a bit more expensive (needing to be imbued with hormones, and all), but $700 still seems awfully high if they're not including insertion costs.

      October 4, 2012 at 22:13 | Report abuse |
    • Alex

      $700 does sound like a lot, but think of it another way. The IUD is good for 10 years, that works to $70 per year or less than $6 per month. What other reliable birth control can be had so cheaply.

      October 5, 2012 at 00:29 | Report abuse |
    • Guest

      Currently; 50% of IUD users have them removed after only 1 year, Alex. Plus the effectiveness is less for anyone under 25. The hazard ratio is 5.9% for younger users. That greatly reduces the 99% this article quotes. When used properly; condoms have a 98% effectiveness, protect against HPV & HIV, & do not have the risk of hormone induced cancer, infection, or the uterine perforation which occurs in 1 out of 100 IUD users.

      October 5, 2012 at 01:30 | Report abuse |
    • phlip02

      The effectiveness is not lessened in patients under 25. Your uterus is not significantly different between ages 15-25 and 25-35. The key phrase in your post is "when properly used", we can all agree that sexually active teenagers are probably not properly using anything. – A practicing MD

      October 5, 2012 at 08:59 | Report abuse |
    • phlip02

      And there is no increased risk of cancer. Many studies have shown this. But if you are worried, just get a copper IUD. And if you want to compare risks, please include the risks involved with pregnancy. I would much rather have a perforated uterus than a postpartum cardiomyopathy (Mortality is 50%!!)

      October 5, 2012 at 09:03 | Report abuse |
    • Leo

      $700 doesn't just cover the cost of the device itself. Implanting one is a medical procedure. It requires a doctor, probably an attending nurse, and the other staff at the clinic. There are overhead costs. I'm glad that in YOUR world, doctors and nurses don't deserve to get paid.

      October 6, 2012 at 12:24 | Report abuse |
  2. merecat

    fewer abortions since the fetus (baby) has already been scraped off the uterine lining.. ie just another abortion without the abortion procedure

    October 4, 2012 at 21:54 | Report abuse | Reply
    • burnz

      It's not a fetus at that point. It's about 8 cells.

      October 4, 2012 at 22:04 | Report abuse |
    • Tara

      No, no. Go educate yourself on how contraceptives work, and don't just google "how are contraceptives the same as abortion."

      October 4, 2012 at 22:07 | Report abuse |
    • Nyltiak

      Um, IUDs work by PREVENTING fertilization and implantation, thus there is no abortion. If you're going to speak, at least be informed before you spout of something that is demonstrably false.

      October 4, 2012 at 22:08 | Report abuse |
    • luddite1817

      Merecat..... that smell is your own urine!!! Before you shoot off your mouth, how about you learn about the topic first. IUD's work by preventing the egg from implanting into the uterine wall... So gestation never starts... Hence no pregnancy...

      October 4, 2012 at 23:20 | Report abuse |
    • AA

      And just to add, it makes one's uterine environment hostile to sperm thus in the vast majority of cases preventing fertilization!

      October 4, 2012 at 23:28 | Report abuse |
    • Evolved One

      OH, go roll up a fattie from your bible pages already! Idiot.

      October 5, 2012 at 00:00 | Report abuse |
    • Guest

      Conception must still be occurring because a pregnancy results in 1 out of 100 users. I actually know a pair of identical twins who were born with the IUD imbedded in their placenta.

      October 5, 2012 at 00:50 | Report abuse |
    • Guest

      Conception & implantation are two different things. Conception is the fusion of gametes to form a new organism(look it up). Implantation occurs at the end of the first week of embryonic development, when the blastocyst normally begins to attach itself to the uterine wall & form the placenta. The blastocyst can grow outside the uterus as a ectopic or extrauterine pregnancy, so clearly a pregnancy has begun regardless of whether the blastocyst has reached the uterus yet.

      October 5, 2012 at 01:16 | Report abuse |
    • Doc

      No. You are completely wrong. IUD thickens uterine secretions preventing fertilization. Please get your facts right before you speak.

      October 5, 2012 at 13:23 | Report abuse |
    • Women's health Nurse

      The IUD scrapes NOTHING. It does not move, it is not intended to move, IF it does then the woman has a problem. The IUD emits COPPER IONS which act as a potent spermicide, their heads explode, and can prevent implantation.

      They 100% do not scrape anything, however, they stand still.

      October 5, 2012 at 16:10 | Report abuse |
  3. Guest

    Only $700 per person? What kind of bargain is that? Protection from pregnancy without protection from STDs is short sighted policy that will cost all of us when the use of retro viral drugs soars for treatment of HIV.

    October 4, 2012 at 21:57 | Report abuse | Reply
    • j wang

      Dear Guest:

      The issue here is preventing unwanted pregnancy. Once an IUD is "installed", the person has to make choices about safer sex, which is completely under the discretion of the involved parties who may not be able to behave safely. With the IUD, at least they will not produce more of the ever increasing number of special needs kids flooding and subsequently bankrupting the schools and other social service agencies.

      October 4, 2012 at 22:52 | Report abuse |
    • Guest

      What about the risk of loss of fertility from a perforated uterus in 1 out of 100 users? Plus 50% of IUD users opt to have them removed within a year. All that risk, & no protection from STDs. That seems like a very high price to pay in more ways than one!

      October 5, 2012 at 00:45 | Report abuse |
    • phlip02

      Condoms are still available. This is not an all or nothing scenario. Ideally people will use both condoms and another form of contraception. But either one is better than none.

      October 5, 2012 at 09:05 | Report abuse |
  4. ManTex

    No worries. The right wing religious right GOTP will never permit funding for something like this. They prefer to see unintended births live in poverty under bridges or stay in the US long enough to qualify for dream act treatment after collecting welfare benefits for 18 years

    October 4, 2012 at 22:32 | Report abuse | Reply
  5. Semantics

    Yes, IUDs work by preventing both fertilization AND implantation, just like the pill, Plan B, the patch, the ring, etc. Not trying to start a fight here, but it's worth clarifying that many people (pro-life, obviously) equate direct, intentional interference with the implantation process (i.e., after conception has occurred) with abortion. There are just as many people who don't. - a licensed OBGYN

    October 4, 2012 at 22:35 | Report abuse | Reply
    • Evolved One

      Trying to educate these fools is a tiresome exercise.

      October 5, 2012 at 00:01 | Report abuse |
    • Guest

      OK; let's talk comparative ten risk versus benefit assessment. What is the risk to the patient with a condom other than pregnancy? Can it cause uterine perforation? What about permanently elevating the risk of a hormonally driven cancer by 60%.
      You DO remember that oath about doing no harm to the patient, right?

      October 5, 2012 at 00:36 | Report abuse |
    • Guest

      One of my keystrokes did not register. The word is supposed to be "teen", not ten.

      October 5, 2012 at 00:38 | Report abuse |
    • phlip02

      The risk is a higher teen pregnancy rate. Condoms have a higher error rate (especially in the inexperienced hands of a teenager). Furthermore condoms are already available, and will continue to be available, so there is no need to make a this or that argument. Ideally teens will use both, but using at least one is preferable to none.

      October 5, 2012 at 08:51 | Report abuse |
  6. Candecker

    they should pay the women to tie the tubes...instead of having 20 abortions in the lifetime... much cheaper

    October 4, 2012 at 22:41 | Report abuse | Reply
    • Evolved One

      Maybe more men should get vasectomies or wear condoms.....less invasive.....but oh my goodness, heaven forbid a man take responsibility for what comes out of his johnson.

      October 5, 2012 at 00:03 | Report abuse |
    • Cherries

      Why can't men get nutered?? It's cheaper with less risks and complications.

      October 5, 2012 at 00:03 | Report abuse |
  7. MashaSobaka

    Of course contraceptives prevent abortions. DUH. Ready access to contraceptives also lowers the cost of healthcare. You think "birth control" is expensive? Try footing the bill for the pregnancy and the birth.

    October 4, 2012 at 22:43 | Report abuse | Reply
    • Guest

      Try footing the bill for the cancers caused by hormones, & the lawsuits for the 1 in a 100 kids with perforated uteri.

      October 5, 2012 at 00:23 | Report abuse |
    • phlip02

      There is no increased risk of cancer in pre-menopausal women taking oral contraceptive pills ("the pill"). There have been many very large studies that have shown this. We have more data on the safety and effectiveness of oral contraceptive pills than just about any other medications.

      October 5, 2012 at 08:56 | Report abuse |
  8. Candecker

    filthy world... best contraception is...keep your legs closed

    October 4, 2012 at 22:44 | Report abuse | Reply
    • Shane

      It is, I agree, but you know what. It isn't reaslitic.

      In the perfect would, there would be no unintended pregnancies, no rape, no "oops" moments. But we are in the real world, and you need real world solutions for real world problems.

      October 4, 2012 at 23:13 | Report abuse |
    • jean

      Not a bad idea for women, but I think many men would have a problem with it. Why don't we just instruct all males to take cold showers instead?

      October 4, 2012 at 23:22 | Report abuse |
    • Evolved One

      Your suggestions are misogynistic and unrealistic.

      October 5, 2012 at 00:05 | Report abuse |
  9. just sayin'

    Decreasing the number of unwanted pregnancies will decrease the number of abortions. This isn't what the GOP wants becuz it is a handy wedge issue. Anyone who is REALLY against abortions would support the idea of education and birth control.

    October 4, 2012 at 23:06 | Report abuse | Reply
    • Guest

      Please, go back to school for Biology. The egg has already been fertilized, & the IUD prevents it's growth in the uterus. Therefore, this IS an extremely early form of artificially induced abortion.
      I DO support education & birth control that prevents both STDs & fertilization. Condoms are a healthier,cheaper method that will not perforate the young woman's uterus. What we need is better education in using condoms properly.

      October 5, 2012 at 00:19 | Report abuse |
    • phlip02

      Biology, eh? I would suggest Anatomy, Physiology and Pharmacology. Most IUDs work by thickening the cervical mucus, thereby preventing the sperm from entering the uterus. But hey, why bother looking this stuff up?

      October 5, 2012 at 09:11 | Report abuse |
    • Charles

      Guest is right. The IUD operates a fail safe to pregnancy that is nothing more than an early form of abortion, a coerced expulsion of a human life from the nurturing womb of its mother.

      http://www.fda.gov/ForConsumers/ByAudience/ForWomen/FreePublications/ucm313215.htm

      Copper IUD – "may prevent the egg from attaching (implanting) in the womb (uterus)"

      http://www.webmd.com/sex/birth-control/intrauterine-device-iud-for-birth-control

      Hormonal IUD – "It also keeps the lining of the uterus (endometrium) from growing very thick.1 This makes the lining a poor place for a fertilized egg to implant and grow."

      October 7, 2012 at 03:00 | Report abuse |
  10. ArchieDeBunker

    IUD's are some of the most dangerous devices ever invented. I don't know the specific type of IUD my daughter-in-law was using, but a few months after she started it she became severly depressed and anxious – for no apparent reason – no history of anxiety, depression or other mental illness whatever. Her anxiety became so bad that she was able to function at only a level about 10% of normal – couldn't eat, couldn't sleep, couldn't drive, couldn't care for her children, etc., etc., etc. After evaluation by all kinds of mental-health experts and attempting many, many different therapies including traditional psychiatry, antidepressents, anti-anxiety meds, acupuncture, and yoga, she met another woman who had been through the same hell and had finally had the IUD removed – after which she gradually recovered. Google searches of various types turned up other case histories of the same thing. My daughter-in-law made no progress toward recovery until she had the IUD removed. Today she is back living a normal life again, but she lost almost a full year of her life to the IUD. If I were a woman I would not even consider using one of those – FAR too dangerous!

    October 4, 2012 at 23:07 | Report abuse | Reply
    • Shane

      You're looking at a rare instance of a reaction, when weighed against saving billions of dollars, and stopping thousands of unwanted children being born every year to people who are shamed into not getting an abortion but have no means to take care of those children.

      There is always risk for any medication, including the UID, but it is a rare side effect that your sister in law had, and there still could have potentially been other causes than the UID.

      October 4, 2012 at 23:15 | Report abuse |
    • Guest

      The risk of perforation of the uterus is 1 in 100, Shane. That is definitely not a "rare Instance". The IUD failure rate is higher under age 25.These are kids with a future of getting married & raising a family of their own someday. IUDs & hormones are both risky for teens. These methods can permanently alter their lives in ways a condom will not.

      October 4, 2012 at 23:57 | Report abuse |
    • consumer

      Agree!! Stay away from it!!! Removed it after around 1 year. Depression, axiety, mood swings!!! Not mention a cyst on my ovary (pain!!!) and IUD imbeded in my uterine wall... Has anyone noticed the age of the participants – 14!!! those are kids that should not worry about birth control! Education and parenting needed..........

      October 5, 2012 at 01:20 | Report abuse |
  11. ems

    Wow. You folks need to read up! IUD's dont prevent conception. They induce abortion after the fetus has already been conceived. "I knew you before I formed you in your mothers womb"

    October 4, 2012 at 23:13 | Report abuse | Reply
    • Guest

      Plus, pregnancies that do not abort with the IUD are at high risk of complications, & will require extremely careful monitoring. I personally know a pair of identical twins who survived having their mother's IUD embedded in their placenta.

      October 5, 2012 at 00:04 | Report abuse |
    • Evolved One

      We do not need to read propaganda from the rabid, righteous rightwingnut misogynistic set.

      October 5, 2012 at 00:07 | Report abuse |
    • Educated One

      All leading embryology textbooks claim human life begins at conception.

      October 7, 2012 at 02:45 | Report abuse |
  12. Guest

    The current medical facts on the risks of IUD usage; 1 out of every 1,000 users suffers a perforated uterus from the IUD, & 50% of IUD users opt to have them removed after only 1 year.
    According to the Oxford journal;For every 100 users there will be 2 pregnancies in developed countries, & there are 10 for every 100 in China where they rely almost exclusively upon the IUD. The failure rate is much higher than 1% for those under 25. For that group the hazard rate is 5.9% which is comparable with barrier methods.
    The more fertile the group, the higher the pregnancy rate. Also, any resulting pregnancy from IUD failure will be a high risk pregnancy requiring extremely close monitoring. For example; I actually know a woman whose doctor found the IUD embedded in the placenta upon the birth of her twins.
    This is too risky for teens, & does not guard against STDs.

    October 4, 2012 at 23:43 | Report abuse | Reply
  13. NEW ORLEANS

    Mandating Norplant after "Sustainable Two" kids (both environmentally & economically sustainable) w/ any and all "aid" -from US food shipped from crisis depleted Farm Belt to "meet the world's food demands", to Welfare in US
    WOULD END POVERTY IN LESS THAN 2 GENERATIONS, AND BE HEALING TO CRISIS OVERPOPULATED PLANET.

    Anyone intent on selfishly, racist-ly (self-promoting) overbreeding is Free to Decline the Aid, just as We, The Tax Payers **SHOULD BE ALLOWED** TO DECLINE PAYING FOR IT.......but instead we get yet another diversion piece........

    October 4, 2012 at 23:48 | Report abuse | Reply
  14. Cherries

    WELL DUH!!! If there is no conception, obiously an embryo isn't going to form, there nothing to abort. The abortion issue become null in void. Birth control is the greatest thing to happen since pockets on shirts.

    October 5, 2012 at 00:02 | Report abuse | Reply
  15. Rage

    700$?? Says who? Mine was like 350. Then again, I got it at Planned Parenthood, so maybe they were discounting it for me or something, I don't recall.
    Random person: *GASP* You mean they do things other than ABORTIONS?
    lol.

    Also, this headline read to me like saying the sky is blue.

    October 5, 2012 at 01:01 | Report abuse | Reply
  16. mmi16

    I am always amazed that by and large, those that are against abortion are also against contraception to prevent the pregnancy in the first place.

    Ignorant Hypocrites!

    October 5, 2012 at 01:41 | Report abuse | Reply
  17. Janet

    Forget the cost. I want to know where I can get funding for a study for which I already know the outcome. For example, excluding meth users, I bet I can demonstrate that free dental care results in fewer toothless people. I'd do it on the cheap too; a few hundred thousand ought to be more than enough. Seriously, early childhood abuse may lead to behavioral problems in the future; free contraceptives reduces the abortion rate. Good grief!

    October 5, 2012 at 10:30 | Report abuse | Reply
  18. Sy2502

    If the bigoted religious right really was as concerned for them poor murdered babies as they claim, they would shell out the money for contraception, to prevent all them terrible murders. But when the time comes to put their money where their mouth is, the hypocrisy really comes out. They don't really care about them poor babies, they just want to impose their bible on women. It's desire for power that really moves them, not compassion.

    October 5, 2012 at 13:31 | Report abuse | Reply
  19. dt

    I'm about as liberal as they come, but for the life of me I can't understand why I have to pay for other peoples contraception at all. If you want to use birth control, go buy it. If you can't afford it, too bad. If you can't stop yourself from indulging, then the results are on you. A baby is not a disease, its a personal choice.

    I want a Ferrari but you don't see me complaining to my car insurance to pay for it...

    October 5, 2012 at 14:16 | Report abuse | Reply
    • I call BS

      Fine. Then don't whine and moan when girls and women choose to terminate a pregnancy. That's a personal choice, too, and none of your business.

      October 6, 2012 at 14:14 | Report abuse |
  20. Tombstone

    Well, DUH. That's what they're for, why the fuss?

    October 5, 2012 at 15:34 | Report abuse | Reply
  21. srsrsr

    IUD did not worked for me a year after getting it got pregnant, so did husbands mom:)

    October 5, 2012 at 15:53 | Report abuse | Reply
  22. jb

    I had an IUD for the full 10 years, from ages 28 to 38. It was Mirena. Best birth control ever. The only issue I had was that my periods stopped, I had no complaints about that side effect. I had it removed last year and everything was back to normal after that. I don't need the birth control anymore, hubby is "fixed", but thinking about getting another one to make the periods go away.

    October 5, 2012 at 18:57 | Report abuse | Reply
  23. sissy

    While married,I had a copper 7 IUD placed, after our firstborn's c-section delivery. It worked for 2 yrs. I had a tubal ligation after the birth of our second child.Years later I had a 5 1/2 hr. hysterectomy for fibroid tumors, severe endrometriosis & a large ovarian cyst.I wonder if the IUD caused any of those issues.

    October 7, 2012 at 14:43 | Report abuse | Reply
    • Annalisa

      "I wonder if" is not the same as saying it caused something. You don't even have enough to show correlation, let alone causation. Using the logic which has led you to your conclusion, I can construct a new scenario using the same pattern: "I parked my car under a tree everyday for five years. Then one day, the tree fell on the place where I used to park my car. I wonder if the fact that I had once parked a car there is why the tree fell in that exact spot..." Does that sound like logic to you? Yeah, me neither.

      October 11, 2012 at 04:05 | Report abuse |
  24. laurapaxton

    This makes no sense. Birth control is already either cheap or free wherever you go and abortions aren't dropping. In fact, we have far more abortions now than before the pill.

    October 7, 2012 at 19:13 | Report abuse | Reply
    • Annalisa

      Your statement is full of gaping holes. 1: Birth control is not cheap or free everywhere. I have no idea what you are talking about. I am a grown woman with a college education and three children of my own. I did not ever have insurance which covered birth control until this year. Prior to that time, I worked for a Catholic hospital, paid $400 a month in health insurance premiums, and did not have birth control covered by my insurance. I looked into getting an IUD with my tax return, since I would have to pay out of pocket (and yes, my OB-GYN quoted me $700 plus the cost of an office visit).

      Second problem with your argument: Birth control pills pre-date the Roe v. Wade decision. Prior to Roe v. Wade, abortions were not recorded nor reported. OF COURSE there are more abortions REPORTED now; it used to be illegal. To be sure, though, they were performed prior to their legalization. However, they were performed unsafely and in dangerous conditions. I recently read an account of an Ohio coroner who said he used to see 10 women a month, on average, dead from complications of an attempted abortion. After Roe v. Wade, that stopped overnight. Abortions have been happening for a long time, but they used to kill women, and now they don't. If you think that birth control doesn't lower the number of women seeking abortions, you're completely ignorant of all logic.

      October 11, 2012 at 04:11 | Report abuse |
  25. The Contraceptive CHOICE Project

    Thank you for featuring our research! Find out more information on out website: http://www.choiceproject.wustl.edu and on Facebook: http://www.facebook.com/choiceproject. We also have a new video to accompany the results: http://youtu.be/cd46pXtMHOo

    October 8, 2012 at 09:51 | Report abuse | Reply
  26. DKF in Florida

    Really? We needed a study to determine something so completely obvious?

    October 8, 2012 at 21:06 | Report abuse | Reply
  27. Guest

    I've had my IUD since I was 16. I am 22 now. Never got pregnant. No complications or pain. It was well worth it. Thanks Planned Parenthood, and my mom, for educating me and giving me options!

    October 8, 2012 at 22:53 | Report abuse | Reply
  28. Boo

    Well DUH!

    October 9, 2012 at 14:39 | Report abuse | Reply
  29. The Contraceptive CHOICE Project

    Thank you for featuring our research! For more information, please visit http://www.choiceproject.wustl.edu and join us on Facebook: http://www.facebook.com/choiceproject We also have a new video to accompany the results from the article: http://youtu.be/cd46pXtMHOo

    October 18, 2012 at 10:12 | Report abuse | Reply

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