A Contraceptive Revolution

Image credit LoveMyLARC campaign, used with permission.

Imagine a future in which a woman becomes fertile only when she wants to have a child—a future in which high school and college students can pursue their dreams and women can plan their lives according to their own values without being derailed by a surprise pregnancy. Imagine a future in which every child is a chosen child.

As I’ve discussed in previous posts, the latest generation of long acting contraceptives comes remarkably close to this ideal. No one method works for everyone, but a woman today can choose among three options—two kinds of IUD and an implant—that each has an annual failure rate of less than 1 in 500. (Contrast that to the 1-in-12 failure rate of the Pill.) Furthermore, high levels of satisfaction with long acting methods leads to high continuation—over 80 percent at the end of one year—and refinements are in the pipeline! By contrast, only half of women who start the Pill are still using the same method a year later.

Women’s lives changed radically with the advent of the Pill, but until recently their ability to time or limit childbearing has been far from perfect. In recent decades one in three American women has relied on an abortion to stop an ill-conceived or unhealthy pregnancy. Even so, half of the publically funded births in the US—including Washington and other Northwest states—are the result of unintended pregnancies. It doesn’t have to be that way.

When long acting methods first became available, regulatory bodies and practice standards recommended them only for married women with children. Now, after decades of cautious research, a broad body of evidence confirms that these methods are safe for teenagers and women of all ages, whether or not they have had a baby, whether or not they are HIV positive, and whether or not they are monogamous.

They are not only safe; they can be life-changing. The challenges faced by individual families and by our society as a whole get compounded when women are subject to ill-timed or unwanted pregnancy. Conversely, broadly accessible and highly effective contraception offers a partial solution to many societal ills. What will it take to ensure that all Northwest women have access to a top tier method of their choice? Doctors, health administrators, lawmakers, educators, and ordinary citizens all have roles to play.

Legal and Government Provisions

Citizens must defend the US national contraceptive mandate. The St. Louis Choice study demonstrates that when the cost barrier is removed, a majority of women choose top tier, long acting contraceptive methods, and the public health gains are dramatic. If our goal is flourishing women and children, the path is clear. We can oppose efforts to exempt Church-managed institutions, such as hospitals, universities, and schools, from the US Affordable Care Act’s requirement that health-care plans offer all medically effective contraception at no cost to employees. Universal free contraception can make the St. Louis experience the norm.

Budget planners must allocate sufficient public funds for contraception. In Oregon, 60 percent of women rely on publicly funded family planning centers for their reproductive health needs, with many depending on the Oregon Contraceptive Care program to cover the cost of contraceptives. Cutting contraception during hard times is shortsighted. According to the Guttmacher Institute, every public dollar spent on contraception saves three dollars that would otherwise be spent on Medicaid payments for pregnancy-related and newborn care. The savings in the long run are even greater. The State of California saved an estimated $2.2 billion over a five year period by increasing birth-control access for residents who fell below 200 percent of the federal poverty level.

Lawmakers must ensure reproductive parity in insurance coverage. In British Columbia, abortions are covered for youth and women who have medical coverage, meaning anyone who has lived in the province for the prior three months. In Olympia, lawmakers currently are debating a law that would do the same for Washington. Uniform coverage means that doctors and advocates can respond to worried patients with clear answers, and women can base childbearing decisions on long-range priorities rather than short-term financial concerns. How does this affect contraception? Variations in coverage, including a failure to cover abortions, not only means that some women fall between the cracks, it reinforces the idea that planned pregnancy is a luxury rather than a pillar of preventive care. It sustains a norm of go-with-the-flow rather than thoughtful, well-timed childbearing. Representatives in Olympia need to hear from their constituents why parity is important.

Health Care System Responsibilities

Health systems and specialists must get the word out to primary care providers. Most family planning services in Washington are provided not by specialists but by primary care teams such as pediatricians and family practice doctors and their staff. These “gatekeepers” are trusted experts on whom women rely for guidance about how best to manage fertility and reproductive health, but many have little time to stay abreast of changes in contraceptive practice. In fall of 2012, Seattle Children’s Hospital brought in the director of the National Campaign to Prevent Teen Pregnancy for a series of lectures on LARC methods. Continuing education and outreach to primary-care providers through health systems and professional organizations can ensure that women receive up-to-date information.

Providers need to know, for example, that simply presenting the most effective methods first can lead to radically different choices.  They also need to know about tools for educating their patients.  Some of the best include a WHO chart that shows contraceptives grouped by efficacy,  Choice Study videos in Spanish and English, a teen-friendly website created by the National Campaign, and a variety of resources from the California Family Health Council, which also offers webinars and continuing education through a “learning exchange for reproductive health professionals.”

Physicians must make LARC discussion routine in adolescent medicine. The guidelines from the American Congress of Obstetricians and Gynecologists are clear: “Counseling about LARC methods should occur at all health care provider visits with sexually active adolescents, including preventive health, abortion, prenatal, and postpartum visits.” ACOG could have added a long list of health conditions that bring adolescents into contact with medical providers, ranging from acne to sports injuries to diabetes to cancer. Teens who are medically compromised or on medications for chronic health conditions have all the more reason to need excellent fertility management tools.

Obstetricians and gynecologists must make LARC discussion routine in maternity care. One of the easiest (and most painless) times for a woman to get an IUD is right after an abortion or after delivering a baby. A woman who has just terminated an unwanted pregnancy has little desire to find herself pregnant again by accident. An IUD or implant can be inserted immediately after an abortion, and research shows a dramatic drop in repeat abortions. Similarly, a mother who has just delivered usually wants to space future pregnancies for the health of her babies and possibly her marriage. A “post-placental” IUD inserted within ten minutes after delivery or during cesarean section can help her to fulfill her pregnancy intentions while keeping her nursing baby free of extra hormones.

Insurance companies must disseminate clear, simple information about contraceptive coverage. When most women first learn about LARCs, perhaps in a conversation at a medical visit, they don’t know whether their insurance covers these options. In turn, providers feel reluctant to recommend a LARC because they fear that patients will end up paying the high up-front cost. In the absence of information, they may recommend a method like the Pill that they know has a manageable monthly cost—or they may require preauthorization. For teens in particular, the lag can be the difference between protection and pregnancy.

Health care systems must increase points of access in community health centers and school-based clinics. For a teen who is living in the moment, simple, immediate access to a LARC can be the difference between graduation and dropping out. For a woman trying to juggle the demands of job and children, it can be the difference between employment and poverty. Improved standards of care, streamlined reimbursement, and professional training all help to ensure that excellent contraception is available to women when and where they seek it.

Advocate and Educator Opportunities

Advocates must defend privacy for teens seeking reproductive health care. The law in Washington and British Columbia has long recognized that some teens—for example, those with mentally ill or drug-abusing parents or who come from homes plagued with domestic violence or incest—cannot talk with their parents about their need for reproductive health or mental health services. By contrast, two Texas laws that forced teens to obtain parental consent for abortion and contraception increased the rate of second trimester abortions, teen births, and sexually transmitted diseases, costing the state an estimated $40 million annually. Despite the clear health benefits of teens having a right to seek services independently, religious conservatives regularly attempt to erode this right through legislation like the parental notification bill proposed by Republicans in Olympia in February 2013.

Educators must improve contraceptive information in high school health and science classes. Only 40 percent of girls who give birth before age 18 go on to complete high school. A mere 2 percent graduate from college by age 30. Knowledge about contraceptive methods strongly correlates with use. In one study of unmarried women aged 18–29, every correct response on a contraceptive knowledge scale increased the odds that a woman was currently using a hormonal or LARC method by 17 percent, and decreased the odds of using no method by 17 percent.

Public health agencies must enlist the Media. Websites such as Bedsider.org and SafeAndEffective.org provide up-to-date information about LARCs, but without publicity, accurate information gets lost in a stew of gossip, outdated recommendations, and misinformation. Public service announcements or candid media conversations about the contraceptive revolution could change that.

Each year across Cascadia, thousands of babies are born to teenagers who did not want to be pregnant. Tens of thousands are born to women who would have preferred to delay pregnancy or not have another child. The costs and added challenges ripple through families and communities. But this fall, the St. Louis Choice Study, called an “Obamacare simulation,” showed that state-of-the-art contraceptive technologies together with good information and universal access, can make most unintended pregnancy a thing of the past.

As we look toward the future, one of the bright spots on the horizon is our growing ability to ensure that children are born when parents are ready to welcome them with open arms. Melinda Gates has written about speaking with a woman in Nairobi, Kenya, who told her, “I want to bring every good thing to one child before having another.” Northwest parents want the same thing. Today, we are at a technology tipping point that could make chosen childbearing the norm. But it won’t happen automatically. It will take a push from all of us.

Valerie Tarico, Ph.D., Sightline fellow, is a psychologist and writer in Seattle. She is the author of Trusting Doubt and Deas and Other Imaginings and the founder of WisdomCommons.org. Her articles can be found at Awaypoint.Wordpress.com