The New Old Age Blog: On the Way to Hospice, Surprising Hurdles

I’ve often wondered why more families don’t call hospice when a loved one has a terminal disease — and why people who do call wait so long, often until death is just days away.

Even though more than 40 percent of American deaths now involve hospice care, many families still are trying to shoulder the burden on their own rather than turning to a proven source of help and knowledge. I’ve surmised that the reason is families’ or patients’ unwillingness to acknowledge the prospect of death, or physicians’ inability to say the h-word and refer dying patients to hospice care.

But maybe there’s another reason. A study in the journal Health Affairs recently pointed out that hospices themselves may be turning away patients because of certain restrictive enrollment policies. It’s possible, too, that physicians who know of these policies aren’t referring patients whom the doctors fear wouldn’t qualify.

Surprisingly, this randomized national survey of almost 600 hospice programs represents the first broad inquiry into enrollment practices, though it’s been nearly 30 years since hospice became a Medicare benefit.

Nearly 80 percent of hospice programs, the study found, reported having at least one policy that could restrict access. “It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a geriatrics and palliative care researcher at the Mount Sinai School of Medicine.

What kind of barriers are we talking about? More than 60 percent of hospices won’t accept a patient on chemotherapy, and more than half won’t take someone relying on intravenous nutrition. Many won’t enroll patients receiving palliative radiation or blood transfusions; a few say no to tube feeding.

This made more sense a couple of decades ago, when Medicare developed the regulations requiring patients to forgo curative treatments when they entered hospice. Hospice patients must have a terminal disease, likely to cause death within six months, so such treatments were presumed futile.

But medicine evolves. Now, Dr. Aldridge Carlson pointed out, the distinction between curative and palliative treatments has grown blurry. “It’s increasingly an artificial dichotomy,” she said. “That’s not the reality for most patients today with end-stage disease.”

Chemotherapy, for instance, is often used to shrink tumors that cause pain; radiation can prevent nausea and vomiting for patients with bowel obstructions. Though neither will cure a terminal cancer, as palliative treatments they can improve quality of life. Blood transfusions can help anemic cancer patients feel better, too, at least for a while.

Why, then, would hospices not accept dying people using these treatments? First, these are expensive to provide. The national average Medicare reimbursement for hospice care is just $140 a day, the study notes, and it’s not adjusted to reflect the cost of more complicated regimens. Besides, hospices worry about running afoul of Medicare regulations and being denied even that inadequate reimbursement.

This probably explains why the researchers found that smaller hospices were more likely than large ones to say no to patients receiving such treatments. “If you’re a small hospice caring for someone with many medical issues and the reimbursement doesn’t even cover the care – and then Medicare comes to take it back – that’s a big hit,” Dr. Aldridge Carlson said. Larger organizations with more patients and bigger budgets can better absorb the costs.

One bright note, though, is that almost 30 percent of the hospices studied offer some kind of open access enrollment without insisting on those prohibitions. Much more common in nonprofit hospices (a pity, because the real growth is in for-profit ones), open access usually means enrolling people who don’t yet meet the Medicare criteria, then converting them to Medicare patients as they become eligible.

At Gilchrist Hospice Care in Baltimore, for instance, patients still using chemotherapy, radiation, transfusions and several other treatments can enter what it calls “expanded care,” sometimes also known as “concurrent care.” (At Gilchrist, however, such patients still must meet the six-month hospice eligibility requirement.)

“If you say, ‘You can’t get blood transfusions any more,’ people say, ‘Why would I go with your program?’” said Regina Bodnar, Gilchrist’s clinical director. The hospice’s concurrent program “is not so either/or.”

People who enter hospice care with palliative treatments usually decide to forgo them anyway when they become less effective or more burdensome, Ms. Bodnar said, but “this allows people to make the transition over time.” As the largest hospice program in Maryland, a nonprofit with generous donors, Gilchrist can afford this more flexible, but expensive, approach.

Could it be the future of hospice? That would require Medicare to make some changes in eligibility and reimbursement practices — a shift that might bolster Medicare’s solvency, too.

“Hospice saves money because it keeps people out of the hospital,” Dr. Aldridge Carlson said. Even more expensive outpatient treatments, like palliative radiation, are less costly than days spent in intensive care. Adjusting policies to allow more patients into hospice might bring costs down.

But as important, it could make the call to hospice a slightly less terrifying prospect and provide more families with the help they need at the end of life. “We need to take down the barriers to hospice care,” Ms. Bodnar said, “and this is one way to do it.”

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Used to Hardship, Latvia Accepts Austerity, and Its Pain Eases

RIGA, Latvia — When a credit-fueled economic boom turned to bust in this tiny Baltic nation in 2008, Didzis Krumins, who ran a small architectural company, fired his staff one by one and then shut down the business. He watched in dismay as Latvia’s misery deepened under a harsh austerity drive that scythed wages, jobs and state financing for schools and hospitals.

But instead of taking to the streets to protest the cuts, Mr. Krumins, whose newborn child, in the meantime, needed major surgery, bought a tractor and began hauling wood to heating plants that needed fuel. Then, as Latvia’s economy began to pull out of its nose-dive, he returned to architecture and today employs 15 people — five more than he had before. “We have a different mentality here,” he said.

Latvia, feted by fans of austerity as the country-that-can and an example for countries like Greece that can’t, has provided a rare boost to champions of the proposition that pain pays.

Hardship has long been common here — and still is. But in just four years, the country has gone from the European Union’s worst economic disaster zone to a model of what the International Monetary Fund hails as the healing properties of deep budget cuts. Latvia’s economy, after shriveling by more than 20 percent from its peak, grew by about 5 percent last year, making it the best performer in the 27-nation European Union. Its budget deficit is down sharply and exports are soaring.

“We are here to celebrate your achievements,” Christine Lagarde, the chief of the International Monetary Fund, told a conference in Riga, the capital, this past summer. The fund, which along with the European Union financed a bailout of 7.5 billion euros for the country at the end of 2008, is “proud to have been part of Latvia’s success story,” she said.

When Latvia’s economy first crumbled, it wrestled with many of the same problems faced since by other troubled European nations: a growing hole in government finances, a banking crisis, falling competitiveness and big debts — though most of these were private rather than public as in Greece.

Now its abrupt turn for the better has put a spotlight on a ticklish question for those who look to orthodox economics for a solution to Europe’s wider economic woes: Instead of obeying any universal laws of economic gravity, do different people respond differently to the same forces?

Latvian businessmen applaud the government’s approach but doubt it would work elsewhere.

“Economics is not a science. Most of it is in people’s heads,” said Normunds Bergs, chief executive of SAF Tehnika, a manufacturer that cut management salaries by 30 percent. “Science says that water starts to boil at 100 degrees Celsius; there is no such predictability in economics.”

In Greece and Spain, cuts in salaries, jobs and state services have pushed tempers beyond the boiling point, with angry citizens staging frequent protests and strikes. Britain, Portugal, Italy and also Latvia’s neighbor Lithuania, meanwhile, have bubbled with discontent over austerity.

But in Latvia, where the government laid off a third of its civil servants, slashed wages for the rest and sharply reduced support for hospitals, people mostly accepted the bitter medicine. Prime Minister Valdis Dombrovskis, who presided over the austerity, was re-elected, not thrown out of office, as many of his counterparts elsewhere have been.

The cuts calmed fears on financial markets that the country was about to go bankrupt, and this meant that the government and private companies could again get the loans they needed to stay afloat. At the same time, private businesses followed the government in slashing wages, which made the country’s labor force more competitive by reducing the prices of its goods. As exports grew, companies began to rehire workers.

Economic gains have still left 30.9 percent of Latvia’s population “severely materially deprived,” according to 2011 data released in December by Eurostat, the European Union’s statistics agency, second only to Bulgaria. Unemployment has fallen from more than 20 percent in early 2010, but was still 14.2 percent in the third quarter of 2012, according to Eurostat, and closer to 17 percent if “discouraged workers” are included. This is far below the more than 25 percent jobless rate in Greece and Spain but a serious problem nonetheless.

This article has been revised to reflect the following correction:

Correction: January 2, 2013

An earlier version of this article misstated the amount of a bailout given to Latvia in 2008. It was 7.5 billion euros, not $7.5 billion.

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Gadgetwise Blog: Paper For The Paperless Revolution

It may appear that apps like Evernote are intended to cut down on your use of paper. After all, they let you jot notes, store webpages and contact information, while making all of that data electronically searchable on computers, phones and tablets.

But you wouldn’t recognize them as part of the paperless revolution from the posh notebooks that are being manufactured specifically with such apps in mind.

For one, there is the Evernote Smart Notebook by Moleskine. Ranging in price from $25 to $30, depending on size, these 192- or 240-page books are ruled with subtle dotted lines. The lines are supposed to help Evernote’s “page camera” straighten your notes or drawings. My test notes, when photographed, didn’t seem any straighter than those made on regular paper.

The Moleskines also come with sets of stickers that Evernote recognizes and uses to categorize your notes. For instance, put an airplane sticker on notes about travel, and you can find them under the app’s travel tags. You can also change the headings that go with each sticker to anything you’d like.

The Smart Notebooks entitle users to three months of Evernote’s premium service, which is normally $5 a month.

Evernote isn’t the only digital organizer that recommends a paper product as an accessory. Springpad, a service similar to Evernote, had a promotion in October with Whitelines notepads. Whitelines pads are especially camera friendly because they have a slightly gray background ruled with white lines that are supposed to disappear when scanned. Whitelines has its own app, Whitelines Link, for capturing notes and drawings, but users have not rated the app very highly. You may be better just using the notepaper with Springpad.

To make it all a bit more confusing, Whitelines is also allied with Evernote. When you save your notes in Whitelines Link, a button gives you the option of saving them to Evernote or Dropbox.

The Whitelines notebooks come in a variety of sizes and layouts ranging from a 48-page pocket-size notebook for $4 to an 80-page 8-by-12-inch hardbound book for $35. There is also a $12 shipping charge, because the books are coming from Sweden.

There are also the unallied Dot Grid notebooks from Creative’s Outfitter. Their pages are a field of light gray dots that can be used as a guide like graph paper. A two-pack of 64-page 4-by-6-inch notebooks costs $7 and a 200-page 6-by-8-inch hard cover notebook sells for $17.50.

Of course, no special notebook is required to use any of these apps. A $1.50 spiral-bound from an office supply store will do just fine. You can always preserve your hipster cachet by writing with a fountain pen.

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Scant Proof Is Found to Back Up Claims by Energy Drinks

Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.

Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.

The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.

“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.

Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.

Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.

As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.

Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.

“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”

A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.

In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.

Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.

Consider the case of taurine, an additive used in most energy products.

On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.

But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.

Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.

Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.

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Scant Proof Is Found to Back Up Claims by Energy Drinks

Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.

Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.

The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.

“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.

Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.

Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.

As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.

Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.

“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”

A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.

In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.

Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.

Consider the case of taurine, an additive used in most energy products.

On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.

But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.

Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.

Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.

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Global Markets Rise on Fiscal Deal

HONG KONG — Stock markets in the Asia-Pacific region began the year with gains Wednesday, as investors took some relief from the last-minute fiscal deal reached in Washington but wrestled with the lingering uncertainties about many other aspects of the U.S. budget.

Two important markets, Japan and China, remained closed for holidays Wednesday, but elsewhere in the region, markets gained modestly during the morning and climbed further after a crucial vote in Washington passed a compromise deal that staved off income tax increases for most Americans.

The Hang Seng index in Hong Kong had the biggest increase, closing up 2.9 percent at its highest level since June 2011. In South Korea, the Kospi rose 1.7 percent, while the benchmark indexes in Singapore, Australia and Taiwan climbed more than 1 percent.

European markets also headed solidly higher, with the DAX in Germany, the CAC-40 in France and the FTSE 100 up about 2 percent in the late morning.

With the Chinese economy having regained momentum in recent months, Asian economic prospects are relatively positive, and growth in most of the region’s developing economies is expected to outpace expansion in the beleaguered West and in Japan.

Purchasing managers’ index reports from Taiwan, South Korea and India, which gauge the health of the manufacturing sectors in those countries, underlined the improving picture Wednesday, with readings that climbed in December. The reading for Indonesia slipped but still indicated expansion.

But in Europe, similar surveys showed that euro zone factories had ended 2012 in poor shape, with both production and new orders declining in December. Spanish manufacturing shrank for the 20th consecutive month, with the decline and the pace of job cuts accelerating.

Analysts have long cautioned that the economic and budget travails of the United States and Europe were likely to overshadow global market sentiment and could cast a pall over Asia this year, especially in highly trade-dependent countries like Taiwan and South Korea and small, open economies like Singapore and Hong Kong.

The deal reached in Washington on Tuesday averted looming income tax increases for most Americans. Combined with significant spending cuts, these would have dealt a major blow to an economy that has been growing anemically since the global financial crisis.

Market relief, however, was likely to be short-lived, analysts said, as other important issues have not been tackled. In particular, decisions on spending cuts of $110 billion were delayed for two months, and politicians have not come up with a long-term solution that would allow the U.S. government to get past the borrowing limit known as the debt ceiling, which was reached at the end of the year.

The scaled-down deal “addressed the fiscal cliff but did nothing to address longer-term fiscal health of the nation,” Aneta Markowska, an analyst at Société Générale in New York, wrote in a research note sent before the final vote in the House of Representatives on Tuesday night in Washington. “This puts the U.S. rating at risk for a downgrade.”

Broader tax overhauls also remain on the table for 2013, while the negotiations about the debt ceiling are likely to involve more potentially unsettling brinkmanship in Washington.

The U.S. fiscal problems, noted Tom Kenny, an analyst at Australia & New Zealand Banking in Australia, “are far from over.” U.S. politicians, he added, will face intense negotiations over the next two months about raising the debt ceiling. These “are likely to prove more harrowing than those just completed.”

For financial markets, the last-minute, partial deal reached Tuesday is thus likely to have brought only a temporary reprieve, analysts said.

“Call it breathing room, call it kicking the can down the road, call it whatever you like — come mid-February, when the decision on the legal U.S. debt limit will be needed, the fight starts afresh,” analysts at DBS in Singapore wrote in a research note. “Two more months of shenanigans and waffling/seasick markets? It certainly looks that way.”

David Jolly contributed reporting from Paris.

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Residents Flee Bangui, Capital of Central African Republic

Sia Kambou/Agence France-Presse — Getty Images

Soldiers from Republic of Congo arrived at Central African Republic's capital Bangui Monday. A regional force is bolstering the country's troops.

JOHANNESBURG — As efforts to broker a deal to stop a rebel advance failed, residents of the capital of the Central African Republic were packing up their belongings and fleeing into the country’s vast hinterlands, fearing a major battle between government troops and guerrilla fighters.

Rebels rejected an offer from the country’s president, François Bozizé. It was brokered by the African Union and proposed forming a government of national unity. But the rebels balked, saying that previous agreements with the president had been made and quickly broken.

“Bozizé speaks, but does not keep his word,” said a rebel spokesman, Juma Narkoyo. “That is why we have taken up arms to make our voices heard.”

The rebel coalition, known as Seleka, is made up of several groups of fighters opposed to the government of Mr. Bozizé, who came to power after a brief civil war in 2003 and has had a tenuous grip on the presidency ever since, winning two elections but facing a constant threat of rebellions aimed at toppling him.

The Seleka rebels say that Mr. Bozizé has not lived up to the terms of a peace agreement signed in 2007. Mr. Narkoyo said the rebels had no plans to seize the capital, Bangui, but in the past they have advanced despite claims that they would stay put.

Government officials, meanwhile, said that the rebels were not actually from the Central African Republic, but were instead foreign provocateurs bent on destabilizing one of the most fragile nations in Africa in order to exploit its mineral wealth.

“They are Chadians, Sudanese and Nigerians,” said Louis Oguéré Ngaïkouma, secretary general of Mr. Bozizé’s political party. “It is a conspiracy against the people of the Central African Republic and its president to steal our riches.”

Suspicion of one’s neighbors is no idle thing in this part of Africa, where local wars often become wider conflagrations. The Democratic Republic of Congo, which lies to the south of the Central African Republic, has been caught up in one of the deadliest conflicts of the last half-century as Rwandan, Ugandan and Congolese troops fought over the country’s bounty of diamonds, coltan and tin.

War in Sudan, which lies north of the Central African Republic, has also spilled over into its neighbors, especially Chad, which also borders the Central African Republic.

Hugues Kossi, a college student in Bangui, said he feared all-out war in his city.

“I am afraid of combat and stray bullets,” he said. But he said he was also tired of the poverty and misrule of Mr. Bozizé’s government.

“It is bad governance that has led us to this situation,” Mr. Kossi said.

The United States has closed its embassy in Bangui and evacuated its staff members. The French government has said it will not help Mr. Bozizé fight the rebels, but that it has deployed an extra contingent of soldiers from a neighboring country to help protect French citizens.

Christian Panika contributed reporting from Bangui, Central African Republic.

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Gadgetwise Blog: Q&A: How to Cut a LinkedIn Connection

I accepted a LinkedIn invitation from someone who looked like a good professional contact, but has just been spamming me with messages. How do I get rid of this person?

Although the LinkedIn social-networking site skews more toward people looking to make business connections, it can still suffer from the same annoyances that plague Facebook, Twitter, and other services. If you need to dump someone you have connected with on the site, start by logging into your LinkedIn account on the Web.

At the top of your profile page, click the Contacts link. On the right side of the Contacts page, click Remove Connections. When your list of LinkedIn contacts appears, turn on the checkbox next to the name or names of the people you wish to remove. Click the Remove Connection button. Your newly severed connection is not notified that you have parted ways.

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Hispanic Pregnancies Fall in U.S. as Women Choose Smaller Families

ORLANDO, Fla. — Hispanic women in the United States, who have generally had the highest fertility rates in the country, are choosing to have fewer children. Both immigrant and native-born Latinas had steeper birthrate declines from 2007 to 2010 than other groups, including non-Hispanic whites, blacks and Asians, a drop some demographers and sociologists attribute to changes in the views of many Hispanic women about motherhood.

As a result, in 2011, the American birthrate hit a record low, with 63 births per 1,000 women ages 15 to 44, led by the decline in births to immigrant women. The national birthrate is now about half what it was during the baby boom years, when it peaked in 1957 at 122.7 births per 1,000 women of childbearing age.

The decline in birthrates was steepest among Mexican-American women and women who immigrated from Mexico, at 25.7 percent. This has reversed a trend in which immigrant mothers accounted for a rising share of births in the United States, according to a recent report by the Pew Research Center. In 2010, birthrates among all Hispanics reached their lowest level in 20 years, the center found.

The sudden drop-off, which coincided with the onset of the recession, suggests that attitudes have changed since the days when older generations of Latinos prized large families and more closely followed Roman Catholic teachings, which forbid artificial contraception.

Interviews with young Latinas, as well as reproductive health experts, show that the reasons for deciding to have fewer children are many, involving greater access to information about contraceptives and women’s health, as well as higher education.

When Marucci Guzman decided to marry Tom Beard here seven years ago, the idea of having a large family — a Guzman tradition back in Puerto Rico — was out of the question.

“We thought one, maybe two,” said Ms. Guzman Beard, who gave birth to a daughter, Attalai, four years ago.

Asked whether Attalai might ever get her wish for a little brother or sister, Ms. Guzman Beard, 29, a vice president at a public service organization, said: “I want to go to law school. I’m married. I work. When do I have time?”

The decisions were not made in a vacuum but amid a sputtering economy, which, interviewees said, weighed heavily on their minds.

Latinos suffered larger percentage declines in household wealth than white, black or Asian households from 2005 to 2009, and, according to the Pew report, their rates of poverty and unemployment also grew more sharply after the recession began.

Prolonged recessions do produce dips in the birthrate, but a drop as large as Latinos have experienced is atypical, said William H. Frey, a sociologist and demographer at the Brookings Institution. “It is surprising,” Mr. Frey said. “When you hear about a decrease in the birthrate, you don’t expect Latinos to be at the forefront of the trend.”

D’Vera Cohn, a senior writer at the Pew Research Center and an author of the report, said that in past recessions, when overall fertility dipped, “it bounced back over time when the economy got better.”

“If history repeats itself, that will happen again,” she said.

But to Mr. Frey, the decrease has signaled much about the aspirations of young Latinos to become full and permanent members of the upwardly mobile middle class, despite the challenges posed by the struggling economy.

Jersey Garcia, a 37-year-old public health worker in Miami, is in the first generation of her family to live permanently outside of the Dominican Republic, where her maternal and paternal grandmothers had a total of 27 children.

“I have two right now,” Ms. Garcia said. “It’s just a good number that I can handle.”

“Before, I probably would have been pressured to have more,” she added. “I think living in the United States, I don’t have family members close by to help me, and it takes a village to raise a child. So the feeling is, keep what you have right now.”

But that has not been easy. Even with health insurance, Ms. Garcia’s preferred method of long-term birth control, an IUD, has been unaffordable. Birth control pills, too, with a $50 co-payment a month, were too costly for her budget. “I couldn’t afford it,” she said. “So what I’ve been doing is condoms.”

According to research by the National Latina Institute for Reproductive Health, the overwhelming majority of Latinas have used contraception at some point in their lives, but they face economic barriers to consistent use. As a consequence, Latinas still experience unintended pregnancy at a rate higher than non-Hispanic whites, according to the institute.

And while the share of births to teenage mothers has dropped over the past two decades for all women, the highest share of births to teenage mothers is among native-born Hispanics.

“There are still a lot of barriers to information and access to contraception that exist,” said Jessica Gonzáles-Rojas, 36, the executive director of the institute, who has one son. “We still need to do a lot of work.”

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Hispanic Pregnancies Fall in U.S. as Women Choose Smaller Families

ORLANDO, Fla. — Hispanic women in the United States, who have generally had the highest fertility rates in the country, are choosing to have fewer children. Both immigrant and native-born Latinas had steeper birthrate declines from 2007 to 2010 than other groups, including non-Hispanic whites, blacks and Asians, a drop some demographers and sociologists attribute to changes in the views of many Hispanic women about motherhood.

As a result, in 2011, the American birthrate hit a record low, with 63 births per 1,000 women ages 15 to 44, led by the decline in births to immigrant women. The national birthrate is now about half what it was during the baby boom years, when it peaked in 1957 at 122.7 births per 1,000 women of childbearing age.

The decline in birthrates was steepest among Mexican-American women and women who immigrated from Mexico, at 25.7 percent. This has reversed a trend in which immigrant mothers accounted for a rising share of births in the United States, according to a recent report by the Pew Research Center. In 2010, birthrates among all Hispanics reached their lowest level in 20 years, the center found.

The sudden drop-off, which coincided with the onset of the recession, suggests that attitudes have changed since the days when older generations of Latinos prized large families and more closely followed Roman Catholic teachings, which forbid artificial contraception.

Interviews with young Latinas, as well as reproductive health experts, show that the reasons for deciding to have fewer children are many, involving greater access to information about contraceptives and women’s health, as well as higher education.

When Marucci Guzman decided to marry Tom Beard here seven years ago, the idea of having a large family — a Guzman tradition back in Puerto Rico — was out of the question.

“We thought one, maybe two,” said Ms. Guzman Beard, who gave birth to a daughter, Attalai, four years ago.

Asked whether Attalai might ever get her wish for a little brother or sister, Ms. Guzman Beard, 29, a vice president at a public service organization, said: “I want to go to law school. I’m married. I work. When do I have time?”

The decisions were not made in a vacuum but amid a sputtering economy, which, interviewees said, weighed heavily on their minds.

Latinos suffered larger percentage declines in household wealth than white, black or Asian households from 2005 to 2009, and, according to the Pew report, their rates of poverty and unemployment also grew more sharply after the recession began.

Prolonged recessions do produce dips in the birthrate, but a drop as large as Latinos have experienced is atypical, said William H. Frey, a sociologist and demographer at the Brookings Institution. “It is surprising,” Mr. Frey said. “When you hear about a decrease in the birthrate, you don’t expect Latinos to be at the forefront of the trend.”

D’Vera Cohn, a senior writer at the Pew Research Center and an author of the report, said that in past recessions, when overall fertility dipped, “it bounced back over time when the economy got better.”

“If history repeats itself, that will happen again,” she said.

But to Mr. Frey, the decrease has signaled much about the aspirations of young Latinos to become full and permanent members of the upwardly mobile middle class, despite the challenges posed by the struggling economy.

Jersey Garcia, a 37-year-old public health worker in Miami, is in the first generation of her family to live permanently outside of the Dominican Republic, where her maternal and paternal grandmothers had a total of 27 children.

“I have two right now,” Ms. Garcia said. “It’s just a good number that I can handle.”

“Before, I probably would have been pressured to have more,” she added. “I think living in the United States, I don’t have family members close by to help me, and it takes a village to raise a child. So the feeling is, keep what you have right now.”

But that has not been easy. Even with health insurance, Ms. Garcia’s preferred method of long-term birth control, an IUD, has been unaffordable. Birth control pills, too, with a $50 co-payment a month, were too costly for her budget. “I couldn’t afford it,” she said. “So what I’ve been doing is condoms.”

According to research by the National Latina Institute for Reproductive Health, the overwhelming majority of Latinas have used contraception at some point in their lives, but they face economic barriers to consistent use. As a consequence, Latinas still experience unintended pregnancy at a rate higher than non-Hispanic whites, according to the institute.

And while the share of births to teenage mothers has dropped over the past two decades for all women, the highest share of births to teenage mothers is among native-born Hispanics.

“There are still a lot of barriers to information and access to contraception that exist,” said Jessica Gonzáles-Rojas, 36, the executive director of the institute, who has one son. “We still need to do a lot of work.”

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