Around 7 percent of reproductive-age women in the United States currently use an IUD or hormonal implant, but around a quarter of women could be expected to use these long-acting reversible contraceptives (LARC) if existing barriers such as cost were removed. That’s according to more than 100 LARC experts who responded to a voluntary survey about the highly effective form of birth control that is stirring debate on the ethics of birth-control counseling and the history of reproductive coercion in the United States. An article reporting the findings of the survey appears in this month’s issue of the peer-reviewed medical journal Contraception.

Programs and initiatives promoting the use of LARC have been successful in places such as Colorado and St. Louis. In the St. Louis Choice Project, which counseled girls and women on their options beginning with the most effective methods and made all contraception available free of charge, three-fourths of participants chose an IUD or implant. But while pilot programs may have produced a high rate of LARC adoption, most of the survey’s respondents don’t expect that trend to continue outside of controlled settings. Even if the devices were made more affordable and if education about LARC and training of providers improved, those surveyed largely anticipate that women in the United States would use these devices at rates similar to women in France and Norway, where between 25 percent and 29 percent of women use them.

It will take time and the involvement of community leaders who can help “improve the reputation of LARC,” explained respondents who chose to write in longer responses. Feedback from 104 researchers with clinical or social science expertise—“thought leaders in LARC delivery,” as the report calls them—suggests that an uptake in LARC use alone cannot be counted on to reduce unintended pregnancy. Instead, other advances in contraception access should be pursued as well, such as providing over-the-counter access to the pill, dispensing one-year supplies of birth control, and developing new methods.

As I reported in a recent article, reproductive-justice advocates have drawn attention to the potential for coercion in efforts to expand LARC use. Some have expressed fears that health care providers, driven by conscious or unconscious bias, will disproportionately recommend the provider-controlled birth control method to women of color and poor women. The authors of the Contraception article asked the survey respondents—37 percent of whom are clinicians who regularly provide implants or IUDs to patients—their thoughts on incentivizing providers for placing LARC and incentivizing women for agreeing to use them. Among their findings:

• 98 percent disagreed or strongly disagreed with this statement: “Public assistance programs should be able to restrict benefits if a woman does not use a LARC method.”
• 92 percent disagreed or strongly disagreed with this statement: “Corrections agencies should be able to offer reduced jail time if a woman uses a LARC method.”
• 91 percent disagreed or strongly disagreed with this statement: “Women receiving public assistance should have access to free LARC methods but not to less effective methods for free.”

In addition to this broad condemnation of coercive tactics, one respondent mentioned reproductive justice explicitly, writing, “We need a reproductive justice approach to LARC that starts with a woman’s right to decide what’s best for them and right to science-based, unbiased information about all contraceptive methods. We need to engage women of color who are leaders in reproductive justice work and community partners.”

But respondents were split on whether to incentivize doctors and nurses to provide LARC to patients. One respondent likened the practice to other areas of medicine, writing, “We know from providers and their interactions with pharma[ceutical] companies that something as small as a free pen does influence them to dispense medication that may not be in line with the patient’s best interests. Doing this with LARC will have the same effect and will turn women off of LARC and us.” There was a clear gender divide here. Two-thirds of men surveyed supported the idea of health plans and funding agencies setting higher LARC placement goals, compared to 30 percent of women surveyed. Similarly, 43 percent of men, but just 16 percent of women, supported the use of financial incentives for providers to place LARC. Throughout the article, no conclusions are drawn about how opinions differed by experts’ race or ethnicity, as 86 percent of those surveyed were white. There were too few participants of any one non-white racial or ethnic group to make meaningful comparisons between groups.

Another key finding: 97 percent of those surveyed agreed that women receiving public assistance should have access to all forms of birth control for free. One clinician who regularly works with patients who choose to use LARC clarified his or her response with a comment: “I agree that women receiving public assistance should have access to all methods of contraception for free because I think all women should have access to all methods for free. These women are no different.”

Survey respondents were invited to participate because they’ve authored peer-reviewed articles on LARC, so they’re more knowledgeable about these devices and not representative of the larger community of healthcare providers. Still, their sensitivity to the possibility of coercion and their measured approach to setting expectations around more people choosing LARC is promising. Hopefully the results of the survey ripple out to and influence a broader pool of providers.