The Great LARC Debate: facilitating a balanced approach to education and promotion of LARCs

Article taken from July/August Newsletter 2015

Immediately after the birth of her twins, 21-year-old Chantal1 had an IUD inserted, at no cost to her. She has had a very positive experience with the IUD, although she had cramping and intermittent bleeding for a couple of weeks after it was inserted. For the most part, though, she describes having her IUD as “smooth sailing.” Now, five years later, Chantal is in a committed relationship and is eager to add to her family. “I’ve been looking to have my IUD removed, but I don’t have insurance and the self-pay price is over $500, which I can’t afford” she says. “I’ve heard that the local clinic will remove it for free, but only if I am going on another form of birth control. I just don’t know what to do!”

Over the last couple of years, there has been a significant surge in education and promotion of long-acting reversible contraceptives (LARCs). LARCs are reversible birth control methods that are effective in preventing conception for an extended period of time, and work without user action; they include (IUDs (short for intrauterine device) and contraceptive implants.

LARCs are known as “set it and forget it” birth control, since they don’t require any upkeep or attention, and can last anywhere from three to ten years. Many studies have shown that women using non-LARC contraceptive methods (like the Pill, patch, or condom) have, on average, a significantly higher risk of getting pregnant than women using LARCs.2 (It’s not that the non-LARC methods are inferior, but they are more likely to be used inconsistently and/or incorrectly, leading to unintended pregnancy.)

Many in the mainstream reproductive health community are explicitly attempting to increase LARC use by young, low-income, and uninsured women due to their overall safety and effectiveness. Along with this, the Affordable Care Act’s mandate that insurers must cover contraceptives without any costs (like co-pays), have resulted in a recent surge in LARC use. In 2015, the Centers for Disease Control and Prevention reported that, over the last decade, the use of LARCs increased nearly fivefold among women aged 15-44 (from 1.5 to 7.2 percent).3

On a daily basis, we hear reports or announcements touting local or state-wide public health initiatives promoting LARCs as a magic bullet to address unintended pregnancies among young, low-income, and/or uninsured women. For example, Colorado has a program to provide more than 30,000 IUDs and implants for free, or at reduced cost, to low-income women; state officials heralded the program’s success at reducing the Colorado teen pregnancy rate by 40 percent.4

Hoping to replicate Colorado’s success, Illinois adopted a similar free LARC initiative targeted at low-income women within the state Medicaid program. Texas is making it easier for providers to get fully reimbursed for providing IUDs to low-income women and girls; and the New York City Department of Health and Mental Hygiene is exploring the launch of a free LARC access campaign aimed at young, low-income, and uninsured women.

Arkansas is considering a state initiative to financially incentivize single, low-income mothers who are Medicaid recipients to get an IUD. Additionally, both the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have recently revised their guidelines to help expand provider familiarity with LARCs and increase their promotion. ACOG and the AAP advise clinicians to recommend the use of LARCs as a first-line contraceptive option (along with due consideration for other methods such as the Pill and patch) for young women.

The National Women’s Health Network (NWHN) strongly supports the development and access to the full range of safe and effective tools to prevent pregnancy and sexually transmitted infections (STIs) — along with accurate and complete information to help women make informed choices about what method is right for them.

We are encouraged by the tremendous progress made in the last 40 years in the design, safety, and efficacy of LARCs. Access to a bigger range of effective prevention methods is good for women’s ability to make choices about their health and well-being. We also support the elimination of financial, regulatory, and attitudinal barriers that prevent women from getting LARCs.

Yet, the NWHN is deeply concerned that institutional enthusiasm for LARCs runs the risk of hampering individual women’s ability to decide what methods are best for their unique circumstances. We raise our voice to caution against the aggressive promotion of LARCs to the exclusion of other appropriate methods.

Women in the U.S. have long been subjected to coordinated efforts to control and/or limit their fertility in the past — this is particularly true for the very groups targeted:young women, low-income women, and women of color. The NWHN has spoken out against such population control efforts for many years; this history underpins our concern that the unbridled enthusiasm for LARCs risks adoption of programs that infringe on women’s reproductive autonomy.

All of the above-mentioned initiatives that promote free or reduced-cost LARCs for vulnerable women are being promoted at the expense of providing women with comparable incentives for other contraceptive methods like the Pill, patch, or condoms. (It’s important to note that male and female condoms have the advantage of also reducing the spread of STIs).

We are hearing reports that providers are counseling women to use LARCs regardless of the women’s independent sexual and reproductive health needs, desires, or family planning priorities. Furthermore, we’re also hearing troubling reports that young women, like Chantal, face formidable cost and access barriers when they want to stop using LARCs and have their devices removed.

The NWHN rejects the belief that LARCs can single-handedly address unintended pregnancy, and that preventing unintended pregnancy is a cure-all for economic and social inequality. Reproductive justice principles recognize that the main reproductive challenge facing young, low-income, and uninsured women is not unintended pregnancy; rather, it is the socio-economic and cultural factors that penalize certain women for having children and prevent them from fully participating in society.

While we continue to fight the rampant, on-going attacks on access to contraception and abortion care, we must also be cognizant of the need to continue to protect and defend women’s reproductive autonomy from coercive programmatic or provider practices. Women should have complete information about all contraceptives and should be able to choose, without cost or access barriers, the one that is right for her.

 

Coco Jervis is the NWHN Policy Director. She thanks Amy Allina, the NWHN’s former Deputy Director, and current board members (particularly Anu Manchikanti Gomez) for informing this discussion and shaping much of this piece.


References:

1. Names and identifying details have been changed.

2. Raine TR, Foster-Rosales A, Upadhyay UD, et al., “One-year contraceptive continuation and pregnancy in adolescent girls and women initiating hormonal contraceptives,” Obstet Gynecol 2011; 117:363- 71. [PubMed] [Obstetrics & Gynecology]. Also available at: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Adolescents-and-Long-Acting-Reversible-Contraception.

3. Branum AM, Jones J, Trends in long-acting reversible contraception use among U.S. women aged 15–44. NCHS data brief, no 188. Hyattsville, MD: National Center for Health Statistics. 2015. Available online at: http://www.cdc.gov/nchs/data/databriefs/db188.htm.

4. Popovich N, “Colorado contraception program was a huge success – but the GOP is scrapping it,” The Guardian, May 6 2015. Available online at: http://www.theguardian.com/us-news/2015/may/06/colorado-contraception-family-planning-republicans.