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Collection: Twenty Times Better than the Pill

Intrauterine Bling

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Picture a series of copper beads on a fine titanium alloy wire curved in a graceful sphere. It looks like an earring, but you won’t find it in a jewelry store. It’s made to go in your uterus.

Intrauterine contraceptives are the fastest growing method of birth control in the US. One study showed that use doubled in just two years. Why are IUDs suddenly hot among young women? And what should you tell your friend or daughter when she says she wants one?

Stones in Camels?

Photo by Neil & Kathy Carey, cc.
Photo by Neil & Kathy Carey, cc.

The idea of putting something small in the uterus to prevent pregnancy goes way back. When nomadic traders needed to keep a female camel from getting pregnant during long treks across the desert, they put stones into the animal’s uterus. Or so the story goes. When Arab gynecologists hear Europeans repeating this tale, they snort and ask, “Have you ever tried to put a stone in a camel’s uterus?” Since the time that a sun-beaten trader might have contemplated camel contraception, intrauterine birth control has come a long way.

Silver and Gold Pessaries

IUD Wishbone. Photo courtesy of the Dittrick Medical History Center, Case Western Reserve University, used with permission.
IUD Wishbone. Photo courtesy of the Dittrick Medical History Center, Case Western Reserve University, used with permission.

The ancient Greek father of medicine, Hippocrates, is credited with first suggesting small objects in the human uterus to prevent pregnancy. But such a practice would not become common for another two millennia. The precursors of modern IUDs emerged in the late 19th century in the form of “stem pessaries.” The pessary was a curved disk that fit the upper part of the vagina like a cervical cap with the “stem” passing through the cervix to hold it in place. The most elegant designs were made of 14 karat gold and finely crafted, but in the absence of flexible materials, antibiotics, and sterile technique, women who used pessaries risked injury and infection.

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A Contraceptive Revolution

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Image credit LoveMyLARC campaign, used with permission.
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.

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Exorcising the Dalkon Shield

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In 2002, 26 percent of Norwegian contraceptive users relied on a long acting method that they could simply fit and forget, the IUD. In the United States, that rate was 2 percent. Long acting reversible contraceptives (aka LARCs) such as IUDs and implants are rapidly growing in popularity, but the US and Canada lag behind many other countries in making these top tier methods widely available. Around the world, IUDs are the most popular form of reversible contraception, with rates of use as high as 40 percent  in China, and over 50 percent in seven smaller countries. By contrast, in the US, the rate of LARC use, while increasing, is still under 10 percent. That means we have a huge and largely untapped public health opportunity.

No one contraceptive works for everyone, but LARCs have a failure rate that is 1/10 to 1/50th of that for the most widely used American contraceptive, the Pill, and they are cheaper in the long run. More effective contraception means fewer unintended pregnancies, with all that implies: healthier babies, lower teen pregnancy rates, less abortion, less strain on public services and budgets, and more flourishing families. Giving women better tools to attain their pregnancy intentions has benefits that ripple through their communities.

Not only are LARCs more effective than the Pill at preventing unwanted pregnancy, they tend to have fewer side effects, higher continuation rates (over 80 percent at one year vs. under 40 percent for other hormonal methods), and higher rates of overall satisfaction. As one doctor put it, “If you ask any OB what they use or what their wives use, it’s an IUD.” So why haven’t American women had better access to these potentially life changing technologies?

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The Pill Is 1965 Technology

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Futurist Sara Robinson has called modern contraception the most disruptive technology of the last hundred years. From the time our ancestors first walked out of the Great Rift Valley—perhaps even before—culture, religion, and division of labor enshrined the simple, universal fact that women had little control over their fertility. When modern contraception arrived in the middle of the 20th Century, it triggered a tidal wave of culture change that left the guardians of tradition frantically trying to shore up their aging structures. Now, a second wave of contraceptive technologies is further threatening the notion that women must allow gods and men to decide whether they end up pregnant.

Today, the most widely used contraceptive in the US is the Pill, released almost half a century ago and refined in intervening years to reduce the hormone load and side effects. For two generations, the Pill has been a game changer. But it is far from perfect. Very few human beings are able to take a daily medication with perfect consistency, and that fact alone largely accounts for an annual pregnancy rate of 1 in 12 for women on the Pill. (For couples using condoms, the rate is 1 in 8. With no contraception, it is over 8 in 10.)

One of the most carefully controlled studies of Pill use required women to keep diaries and remove each pill from a container that electronically recorded missed doses. The participants reported missing only one pill per month on average; the boxes recorded an average of four missed pills per month! Only 16 percent of women in the study kept missed pills down to one per month or less. An estimated 750,000 American women get pregnant each year while on the Pill. With failure rates like that, a woman can plan for her future and her children with confidence only if she has access to abortion as a back-up plan. More than half of women seeking an abortion say that they were using a contraceptive method in the month they got pregnant.

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New Contraceptives for Cascadia

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Last fall, researchers in Missouri caught the attention of public health experts and advocates across North America. Some 9,000 St. Louis women had been offered their choice of contraceptives for free in a study that has since been called an “Obamacare simulation.” Two years later, the teen pregnancy rate was at 6 per 1,000 instead of the US average of 34. The abortion rate was less than half the rate of other St. Louis women.

Why did they get such dramatic results? The free birth control triggered a technology shift in a microcosm. When presented with simple, accurate information and a buffet of no-cost options, a majority of the study’s participants, almost 75 percent, switched from old contraceptive technologies like the pill, condoms, and other barrier methods like cervical caps to state-of-the-art “long acting reversible contraceptives” (LARCs).

Unintended pregnancy rates in the US have been frustratingly flat for decades, hovering around half of all conceptions. Now, health advocates and community health agencies are eyeing a potential technology tipping point that could radically change the equation. What would it take to make the St. Louis results the new norm? And what might that mean for Cascadia?

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