Long-acting reversible contraceptives, known as LARCs, are revolutionizing American birth control. Pilot programs in St. Louis, Missouri, and in Colorado, where healthcare providers and researchers have made the IUD and hormonal implants available at low or no cost and educated potential users about their nearly foolproof effectiveness, have shown astounding results. In Colorado, the teen birth rate and teen abortion rate both dropped 48 percent over five years. At the start of the study, half the women in the poorest parts of the state gave birth before the age of 21. Five years later, half the women in the same group were over the age of 24 when first giving birth. And in St. Louis, pregnancy and abortion rates among sexually active teens studied dropped to less than a quarter of the rates for their peers nationwide.
Statistics like these, along with new recommendations from major medical organizations, suggest that it’s time for American women to recognize what Europeans have known for years: that IUDs and implants—birth-control devices that, once inserted, are 99 percent effective for three to 10 years—are the most reliable way to prevent unintended pregnancies. Recently, the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists recommended that long-acting contraception be considered a safe and effective option for adolescents, and new programs have made IUDs and implants available to teenagers as young as 14. Unlike the pill, which must be taken daily, and shorter-term birth-control methods such as the Depo-Provera shot, which lasts a few months, LARCs are considered a “set it and forget it” method—something that’s particularly important for teenagers, who tend to be less conscientious in their use of any contraceptive method that they control.
But not everyone is receptive to this message. When considering long-acting methods, many women remember or hear stories about the Dalkon Shield, an early version of the IUD that caused infections and infertility and was linked to more than a dozen fatalities before it was pulled off the market in 1974. Since the mid-1980s, new and improved IUDs have been released, but the cost of these devices—upward of $800 apiece—put them out of reach for all but the well-off or well-insured. The Affordable Care Act requires that new insurance plans cover all FDA-approved birth-control methods without a co-payment, but the National Women’s Law Center, which operates a hotline to advise women on birth-control coverage, has received complaints from every state in the country that plans are refusing to comply. And teenagers may not feel comfortable using a parent’s plan to access contraception, even if it does cover long-acting methods. So philanthropists have stepped in, including the Omaha-based Susan Thompson Buffett Foundation, which has given hundreds of millions of dollars per year to organizations working on reproductive health. A recent Bloomberg investigation found that the foundation has anonymously pledged at least $200 million to promote the use of LARCs in the United States; it has also funded both the St. Louis and Colorado programs. According to the Bloomberg report, the foundation hoped that an infusion of dollars into public-health clinics would “change the perception of IUDs and build political support for the devices,” ultimately convincing state and local legislators to fund LARC programs themselves.
If your sole concern is curbing unintended pregnancies, then it’s hard to argue with the data on implants and IUDs, which are more reliable than the pill (91 percent effective) or condoms (82 percent). For champions of the Buffet-funded programs, that was a major selling point. In Colorado, Governor John Hickenlooper boasted that between 2008 and 2013, the LARC initiative had reduced the infant caseload of the state’s Women, Infants, and Children program by nearly 25 percent. Republican State Representative Don Coram, co-sponsor of the bill to provide state funding to Colorado’s LARC program, told National Journal that “policywise, [the LARC program] may be the best piece of legislation I’ve ever worked on,” in part because “80 percent of teen mothers that become pregnant will be on welfare within a year.” But some reproductive-justice advocates have urged caution: They’re worried that the excitement over LARCs has obscured the fact that efficacy is not the only reason why women choose a birth-control method. And they warn that, from the misuse of Norplant in the 1990s to forced sterilizations in California’s women’s prisons as recently as 2010, contraception has often been used to reduce the fertility of poor African-American and Latina women, often without their consent.
That’s why it’s not surprising that some people, particularly women of color, think the new embrace of LARCs—especially for use by teenagers—deserves closer scrutiny. They point out that if you’re poor, a college degree and a high-paying career will not magically appear simply because you hold off on having a child for a while. In 2013, Jennifer B. Kane and a team of researchers reviewed 40 years of studies on the impact of teen parenting and found that a woman who has a child before age 18 is likely to have from eight months’ to two years’ less education than a woman who waits until she’s older. “Promoting LARC as a way of increasing opportunities for low-income young women ignores the fact that the lack of opportunity is not because of their childbearing decisions,” says University of Pennsylvania law professor Dorothy Roberts, author of the groundbreaking book Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. “It comes perilously close to saying that the reason there are high rates of poverty in some communities is because of the childbearing decisions of women in those communities—which comes perilously close to a eugenicist argument.”
* * *
Nine years ago, at the age of 15, Gloria Malone, now a reproductive-justice advocate in New York City, gave birth to her daughter. A couple of weeks later, she paid a visit to her ob-gyn, and her doctor told her that she had an appointment to have an IUD inserted. Malone, who is black and Latina, had heard her older sisters talk about the Depo shot, and she’d heard about condoms in a sex-ed class, but she’d never heard of the IUD, and she didn’t learn much more about it from her doctor. “There was no ‘These are your options. Go home and see what you think about it.’ There was no ‘This is going to be the appointment where we talk about birth control,’” Malone recounted. “It was all telling me what was going to happen.”
Malone says she was told that the IUD was expensive and that, at 15 years old, she was lucky to be getting one. (The Mirena, a T-shaped device that releases pregnancy-preventing hormones and lasts for five years, typically runs upward of $500. Both the device and the insertion were free, covered by Medicaid.) But seven years later, after a series of related health complications and a difficult time finding a provider who would remove it, Malone didn’t feel so lucky. “I wasn’t given a choice—I was just given an IUD,” Malone, now 25, says. “That’s a problem, and it needs to be spoken about.”
Malone was steered toward an IUD, perhaps because she was a teen mother. But until recently, doctors tended to use an “informed choice” approach to counseling women about birth control, offering a menu of options with no real hierarchy to it. In 2012, the CDC presented research on use of the “tiered effectiveness” approach among teen patients, in which a provider begins by suggesting what’s most effective in preventing pregnancy. The American Academy of Pediatrics endorsed tiered-effectiveness counseling in 2014. While this approach gives a patient the clear guidance of a medical professional (in fact, one health researcher told me that a common criticism of tiered counseling is that the guidance isn’t directed enough), it can also leave a patient feeling like considerations other than efficacy are less valid. She may go into an appointment wanting a method she can stop using anytime, or one that doesn’t have any side effects, and come out convinced that an IUD or implant is the best or only real option, regardless of her personal preference. “If [tiered effectiveness] is the cornerstone of counseling, that’s not actually centering what the patient wants,” says Anu Manchikanti Gomez, an assistant professor at the University of California at Berkeley’s School of Social Welfare. Gomez is co-author of a widely circulated paper published last year, “Women or LARC First? Reproductive Autonomy and the Promotion of Long-Acting Reversible Contraceptive Methods.” In it, Gomez, Liza Fuentes, and Amy Allina advocate “a woman-centered framework” in which providers tailor their counseling script to support a patient’s own family-planning and health priorities.
Providers’ preferences can creep into the conversation even when they’re not using tiered-effectiveness counseling. In her research on young women’s perspectives on IUDs, Gomez talked with a woman who’d discussed birth control with her provider at a six-week postnatal appointment. “Her provider said, ‘Here’s the ring, here’s the pill—and here’s the IUD!’” Gomez recounted, her voice filling with enthusiasm at the final option. The provider offered a lot of information on the IUD and not much on other methods, so the patient did additional research on her own.
But when I asked Daniel Grossman, an ob-gyn and professor at the University of California at San Francisco, whether providers were overly aggressive in promoting LARCs, he directed me to a recent study of 800 women who’d recently given birth in Austin and El Paso, Texas, and who said that they didn’t want to have another child for at least two years. Six months after delivery, they were asked what form of birth control they were using; 34 percent of the women said they’d like to use a long-acting reversible method, but only 13 percent were doing so. “We’re finding that there are many more women who are interested in this method than are able to get it,” says Grossman, who co-authored the study. Cost, lack of insurance coverage, and the inability to find a provider trained in LARC insertion accounted for the gap between women who had an IUD or hormonal implant and those who wanted one. And the cost barrier was significant: Women with household incomes greater than $75,000 per year were almost 11 times more likely to use LARCs than those whose household incomes were less than $10,000.
The Texas study looked at women between the ages of 18 and 44, but the St. Louis and Colorado programs also found high demand among young people. In St. Louis, where counselors used a LARC-first counseling approach and offered all forms of birth control without cost, 72 percent of the 1,404 teenagers participating in the study chose an IUD or implant. (Nationally, about 5 percent of teenagers use long-acting contraceptives.)
Stephanie Teal, medical director for the family-planning program at the Colorado Department of Public Health and Environment, said positive experiences and word of mouth have driven the demand for LARCs among young people, both during the statewide pilot and, since the legislature declined to appropriate $5 million to keep that program running last year, in the scaled-down LARC program that continues to run out of family-planning clinics in the state. Teal directs a clinic, located blocks from Aurora Central High School, that serves a racially and ethnically diverse population: 36 percent of her patients are Hispanic, and 11 percent are African American. “We did not do a lot of marketing per se,” she said. “What happened in Colorado, especially among communities of color, was a slow initial uptake. Then, as more young women saw their friends and key opinion leaders showing off their implants and saying, ‘Yeah, I don’t even have to worry about that anymore,’ we would get more people coming in. More in the early years, but even now, people are brought into our clinic by their friends or by their sisters.”
* * *
Do adolescents truly understand the pros and cons of using IUDs and implants, as opposed to a barrier method of contraception? Unlike a condom, which protects against both pregnancy and sexually transmitted infections, a long-acting method leaves its users exposed to possible STIs. That’s of particular concern for young people—in the United States, those between the ages of 15 and 24 account for half of all STIs acquired each year, despite making up just a quarter of the population. In black communities, the situation is even more dire: The chlamydia rate for young black women is five times that of their white counterparts, while young black men contract the disease at nearly 10 times the rate of young white men. Among people between the ages of 13 and 24, black youth account for 57 percent of all new HIV infections. Regarding the success of LARCs in bringing down the teen birth rate—already at a record low—“we have to be really careful not to say, ‘Problem solved,’” explains Melissa Gilliam, a professor of obstetrics, gynecology, and pediatrics and head of the Division of Family Planning at the University of Chicago. “One of the greatest causes of infertility is STIs. That’s where the public-health alarm needs to be.”
Teal says that research she’s conducted suggests that teens with IUDs use condoms less frequently than those on the pill. She and her colleagues compared two groups of young women—the first using LARCs, the second using other methods—and found that the members of both groups were just as likely to have a different sexual partner six months after the study began, but that those using a short-acting method such as the pill were more likely to have used a condom during that period. Even so, Teal adds, “our recommendation based on that data is not to give people crappier birth control; it’s to tell people that when you put in an IUD, this does not protect you from STIs.”
The laser focus on reducing births, rather than a comprehensive approach aimed at keeping those same teens safe and healthy, troubles Dorothy Roberts. “That is the history of birth control in America,” she says. “It’s been used as a way of increasing people’s reproductive freedom, and as a way of reducing populations that weren’t valued.” At least 30 states had government-run eugenics programs until the 1970s, many of which focused on black and brown girls and women. In 1990, days after the Food and Drug Administration approved the use of Norplant (a hormonal implant in capsule form that was inserted beneath the skin of a woman’s arm), a Philadelphia Inquirer editorial suggested that poor women could be incentivized to use it in order to “reduce the underclass.” States including Kansas, Connecticut, and Louisiana considered legislation making the receipt of welfare benefits conditional on Norplant insertion. Baltimore started a program that encouraged teen girls considered at risk of getting pregnant to have Norplant inserted on the state’s dime. Meanwhile, women complained of terrible side effects, including excessive bleeding, pain, and infection after the capsules were inserted. As recently as 2010, nearly 150 people in women’s prisons in California were sterilized at the urging of doctors who didn’t have informed consent from their patients. The state paid $147,460 to doctors to perform the surgeries, leading one such doctor to comment: “That isn’t a huge amount of money, compared to what you save in welfare paying for these unwanted children.” As Roberts notes, “The idea that we’ve gone past eugenicist thinking, past racist thinking, past population-control ideology, is just false.”
Loretta Ross, co-founder of the Atlanta-based reproductive-justice organization SisterSong, has a particularly chilling story. She told an interviewer that in the early ’70s, her doctor misdiagnosed symptoms from a pelvic inflammatory disease related to her Dalkon Shield as sexually transmitted infections; that assumption came easily because she was a black woman, Ross has said. His failure to remove the IUD over the course of six months left her infertile at 23. The company that made the Dalkon Shield would eventually face $12 billion in lawsuits and discontinue its production.
* * *
When it comes to evaluating ways to make effective but costly birth-control methods affordable to low-income women and girls, raising the history of coercion in state-sponsored birth-control programs can sound paranoid to some clinicians and reproductive-health advocates. But disregarding the impact of such stories, which are often passed down from one generation to the next, leaves LARC proponents unprepared to effectively engage with patients who have taken family members’ advice to heart, says Aimee Thorne-Thomsen, vice president for strategic partnerships at Advocates for Youth. Her organization trains healthcare providers in long-acting forms of contraception, letting them know that young people can be good candidates if IUDs or implants are their preference. Her group also educates communities about various forms of contraception. “Some of our colleagues don’t fully understand that the conversation around LARCs is much more complicated than simply a public-health message or a contraception-access message,” says Thorne-Thomsen, who is Latina. “There is a context that already exists in many communities of color and low-income communities around the country, and some of that is medical mistrust based on real, lived experiences.”
When Elizabeth Dawes Gay, a reproductive-justice advocate who works in public health, talked to friends and family about her decision to get an IUD, she found that anxieties about the quality of care offered to women of color persist. At 24, Gay decided after extensive research that the ParaGard, a hormone-free copper IUD, was right for her. She’d been taking the pill but needed to stop after learning that its mix of hormones put migraine sufferers like her at an increased risk of stroke. Gay, who is black, read up on the IUD’s potential side effects, corrected friends who warned that it would cause infertility, and met with a provider at Planned Parenthood, where she had the device inserted. She felt good about her choice and still does now, five years later. But an older relative was initially worried for her. “Somehow it came up that the nurse practitioner that inserted it was a white lady,” Gay said. “She said, ‘How do you know that she did it right or that she didn’t do something to hurt you?’”
The fears of Gay’s relative were unfounded, but some healthcare providers can be insensitive to patients, often unintentionally. Natasha Vianna was given DepoProvera two weeks after she gave birth at age 17. The nurse who’d suggested the shot pointed out that Vianna had conceived her daughter while on the pill, which the nurse offered as proof that the teen couldn’t use that method responsibly. Vianna said the nurse encouraged her to get back on birth control that day rather than wait until her six-week appointment. She doesn’t remember the nurse asking her about her preferences or telling her what side effects to expect from the injection. A decade later, Vianna describes their short exchange as awkward and uncomfortable. Still, she stayed on Depo for more than a year; it never occurred to her that she could stop using it. “After someone basically told me that I was irresponsible with birth-control pills, I didn’t feel I could walk back in there and say, ‘You guys are wrong,’” she said. “I didn’t feel confident enough to do that.”
Vianna, now a reproductive-justice activist who spent five years with the Massachusetts Alliance on Teen Pregnancy, remembers the demographics at the clinic clearly: People who were there for pre- or postnatal services were young women of color, like her. The doctors and nurse practitioners were white. “I look back and wonder: Do these people have such unconscious biases that they were making assumptions about young Latinas?” Vianna says.
Research suggests that bias, including the unconscious kind, is at work when providers recommend birth-control methods to patients. In 2010, Christine Dehlendorf, an associate professor of family medicine at the University of California at San Francisco, conducted a study that found that providers were more likely to recommend the IUD to low-income black and Latina patients than to low-income white patients with comparable reproductive-health histories. A 2007 study came to a similar conclusion, this time from the patients’ perspective: It found that during conversations with their healthcare providers, low-income black and Latina women felt more pressure to limit their family size than middle-class white women did. That’s why the doctors and public-health researchers I spoke with stressed the importance of including information about the history of medical coercion, as well as what Gomez at Berkeley called the social determinants of health, in medical education: Clinicians need to better understand the context in which they’re providing care. “Race matters in contraceptive recommendations,” Dehlendorf says, “and specifically in recommendations around IUDs. And it shouldn’t matter.”
One way to overcome latent bias, Dehlendorf adds, is to use a counseling model that explicitly focuses on a woman’s preferences. That approach positions the healthcare provider to offer decision support—something that many people say they want when choosing a method. It’s one way to encourage providers to respect everyone’s right to determine her own reproductive destiny. It may also be a way to teach healthcare professionals how to offer the kind of care that Vianna said she was looking for 10 years ago, when she was a young mother in need of information about birth control. “I didn’t ever want people to look at me like I was data,” Vianna says. “Look at me like a person, and talk to me like a person.”