When Rachel, a 35-year-old from Colorado, learned four years ago that she was pregnant despite taking birth control pills, she wanted to make sure it didn’t happen again. There were huge stakes: Rachel, a 35-year-old from Colorado, was not interested in having children and also had a uterine defect that made pregnancy dangerous. The pregnancy was terminated and she then started looking for permanent birth control.
Rachel (who asked to use only her first name to preserve her privacy) lives in a rural part of Colorado where the only local health system is Catholic and doesn’t offer most forms of contraception under the Ethical and Religious Directives for hospitals. Even though Rachel had been receiving care there for years, her provider could only refer her to a women’s health clinic an hour away when she asked about birth control methods like diaphragms and intrauterine devices (IUDs).
Though she was initially interested in reversible methods of contraception, Rachel ultimately decided to have her fallopian tubes removed—a type of permanent sterilization—when she made the trip to the women’s health clinic. “My first impulse when [my husband and I] got home was, ‘I need to tell every woman I know to check your local health system. If it’s faith-based, you need to figure out what that means for you,’” Rachel says. “We found out the hard way.”
It is more difficult to obtain birth control in the U.S. that it should. Many options are available—including pills, sterilization, and long-acting reversible contraceptives (LARCS) like IUDs—but people frequently struggle to get the one they want due to provider refusal, inadequate insurance coverage, disparities in access to care, and clinical deserts where few reproductive health clinicians practice.
Many legal and health experts fear that these problems will only get worse. The Supreme Court’s leaked draft decision to overturn the landmark abortion access case Roe v. Wade The Court could make changes before it makes its final decision. The Constitution does not guarantee the right to abortion. Roe‘s central arguments—surrounding a right to privacy—was also used in a case that expanded access to contraception, so some people are concerned about the security of that precedent.
The leaked draft showed Supreme Court Justice Samuel Alito writing that this decision only applies to abortion. But after news of the draft broke, President Joe Biden said that “every other decision relating to the notion of privacy is thrown into question.” Maryland Rep. Jamie Raskin, who is also a Constitutional scholar, raised similar fears on Twitter, writing that “if Alito’s majority destroys the right to privacy, states could jail women and doctors for abortion and contraception offenses.”
In states such as Louisiana, Idaho, Tennessee, lawmakers have either supported policies that would limit access to certain forms of contraception (emergency contraceptives), or decried legal precedents regarding contraceptive accessibility. Mississippi’s governor also refused to rule out the possibility of future limitations on contraception access in an interview with CNN. These comments have made it clear that the stakes are higher when it comes down to accessing birth control.
According to Dr. Aishat Olagunde (a Pennsylvanian ob-gyn who is also a member of Physicians for Reproductive Health), birth control does not replace abortion care. But, she says, “We want to be able to make sure that [people] have access to all of our options, whether that’s contraception, permanent contraception, or abortion.”
Long-term birth control is in high demand
LARCs can prevent pregnancy by more than 91%, which makes them one of the most effective forms of reversible birth prevention. IUDs fall under this category. These small devices, which are T-shaped, can be inserted inside the uterus to prevent pregnancy. A birth control device (also known as the LARC) is an implant-like rod that’s placed beneath the skin of one’s upper arm. It dispenses pregnancies-preventive hormones for three to five year.
Recent years have seen LARCs become much more in demand than they were previously. They were used by only 1.5% in the United States back in 2002. That number had risen above 10% by 2017-2019, according to federal data —only slightly behind the 14% who used birth control pills.
That’s in large part because the contraceptives have gotten safer to use. The Dalkon Shield, an IUD, became very popular in 1970s. However, it was linked with serious health issues, including pelvic inflammation disease. Doctors stopped recommending it. LARCs were not recommended by many physicians for several years. However, safer products eventually became available and were approved.
It is now more common to recommend IUDs. Until 2005, the ParaGard copper IUD was only authorized for people who’d already had children. ParaGard, and all other IUDs, were authorized for use by people who had not yet had children. This allowed the IUDs to be marketed to younger patients, broadening their patient base.
Many people have difficulty accessing these contraceptives despite their increasing popularity and efficacy.
Birth control barriers
Cost is one obstacle, says Mara Gandal-Powers, an attorney and director of birth-control access at the National Women’s Law Center (NWLC). Under the Affordable Care Act, most insurers must fully cover at least one brand of each type of contraception available in the U.S.—including pills, LARCs, patches (which are replaced weekly), and rings (which are replaced about once a month). An IUD buyer should have the ability to obtain at least one brand of each available in the U.S.
But the NWLC’s consumer hotline receives enough calls from people who received huge bills to know that the system isn’t working as intended, Gandal-Powers says. Some insurers don’t comply with the law, in some cases covering the contraception itself but refusing to pay for costs associated with administering it or follow-up visits.
For approximately 10% of the population in America who do not have insurance, LARCs might be more difficult to access. For example, the Mirena IUD costs $1,049 with no insurance.
Another problem is the national shortage in health care professionals. While birth control pills can be prescribed virtually and delivered to many patients’ doors, LARCs require an in-office visit for insertion, removal, and follow-up care. Even though there are fewer doctors and more reproductive health professionals in some parts of the United States, it can be hard to find a clinic that can perform a LARC. According to the American College of Obstetricians and Gynologists (ACOG), half of U.S. states did not have one gynecologist as of 2017.
Rachel discovered that it can be difficult to find the right provider in an area dominated by religiously-affiliated health care networks, which can prohibit reproductive care. About 16% of all hospital beds in America were located in Catholic hospitals, while in other states up to 40% are found in religiously affiliated facilities.
There are problems looming
With the Supreme Court’s final decision on Roe V. Wade These problems could get more serious as the future of contraception access is uncertain and looming. In Idaho, for example, Republican state representative Brent Crane said he plans to hold hearings on banning emergency contraception, like Plan B. Crane originally said he was not “certain” about where he stood on access to IUDs, before walking back that comment, the Idaho Stateman reports.
Rachel Bervell (a resident in medicine) is the founder of the Black ObGyn Project. This online project aims at integrating anti-racism and reproductive care. Roe V. WadeThis raises more concerns regarding bodily autonomy. “It feels like a slippery slope,” she says.
Dr. Amanda Bryson, a medical fellow at Boston Children’s Hospital who has studied contraception access, says these issues are likely to be especially pronounced among people from historically marginalized backgrounds, who already often struggle to access equitable contraceptive care. She says that this includes low-income people, persons of color, people with a history of sexual orientation, undocumented people, people from incarceration, as well as people with disabilities.
For people living in these areas, LARCs can cause problems. LARCs can present problems for people from these communities. People seeking long-lasting contraception may find it difficult to obtain it if their finances are tight, live in remote areas, and cannot take time off work to go to medical appointments. Reproductive justice organizations have expressed concern about the recommendation of birth control pills by doctors without considering patient preferences. A 2016 joint statement from SisterSong and the National Women’s Health Network, two reproductive justice organizations, warned that “too much LARC zeal can easily turn into coercion, becoming just the most recent in a long line of population control methods targeted to women of color, low-income and uninsured women, indigenous women, immigrant women, women with disabilities, and people whose sexual expression is not respected.”
“These are two sides of the same coin,” Bryson says. “It comes down to the ability for somebody to be able to exercise the human right to self-determine family planning.”
Olatunde believes that it is important to offer contraception from a patient-centered perspective. Physicians must listen to what each person actually wants—whether it’s an abortion, long-acting contraception, short-term contraception, or no contraception at all—rather than pushing their agenda.
“Medicine historically has been this very patriarchal environment where the thought is that the doctor knows best,” Olatunde says. “The reality is, we are not in our patients’ shoes.”
Even though politicians in the US place limitations on reproductive health care provision, there is a growing number of clinicians who are accepting patient autonomy. In January, ACOG released new guidance that directs clinicians to “solicit an individual’s values, preferences, and insight into what matters most to them as it relates to contraception,” echoing reproductive justice groups that have been pushing that message for years.
The March 2022 Congressional Democrats urged the U.S. Department of Health and Human Services to simplify the contraception insurance process so people could get the birth control they desire. HHS, for its part, said in January that it is “actively investigating” insurers’ compliance with the ACA’s standards around contraception coverage.
It is possible to change medical culture. But policy-level protections are also crucial for preserving reproductive access—as the Supreme Court’s draft decision on abortion has shown.
That’s the message that Rachel carried away from her experience in Colorado. “No one is as protected as they think they are,” she says. “Especially now.”
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