IUDs and other methods of long-acting reversible contraception offer to help millions of women escape poverty—so why aren’t we making them more available?
By Stephanie Auteri
Bronze cast of an IUD. (Photo: Sarah Mirk/Flickr)
Six years ago in Colorado, the state’s Department of Public Health & Environment began providing more than 36,000 IUDs and other contraceptive implants, at no costs, to teenage and low-income women at 68 family planning clinics across the state. The experiment was a notable success; as a result, the birth rate among teenagers across the state dropped by 48 percent between 2009 and 2014.
Concurrently, a related study, which came to be known as the Contraceptive Choice Project, was conducted in St. Louis, Missouri. This study of almost 10,000 women, which ran from 2007 through 2011, found that, when health-care providers offered women all forms of contraception for free, 75 percent chose IUDs and hormonal implants.
Thanks to recent educational campaigns in the wake of these stories, we now know how effective such policies can be. Long-acting reversible contraception (LARC) is simply more effective than other forms of birth control, primarily because it removes the possibility of user error. Unfortunately, while the use of IUDs in particular has since exploded, it’s still difficult to get LARCs to the people who need it most. If health-care providers could improve accessibility to young, low-income women, it could cut down on the number of unplanned pregnancies in those populations, allowing them to finish their education and have greater job flexibility.
The Adverse Impact of Unplanned Pregnancies in Underserved Communities
According to a fact sheet released by the Guttmacher Institute just last month, 51 percent of pregnancies are unplanned, meaning that they are either mistimed or unwanted. And these rates are highest among poor and low-income women, young women, cohabiting women, and minority women. While an unplanned pregnancy can obviously be difficult for any woman, the stakes are much higher when she is already struggling.
This is due to several reasons. For one, women who have unplanned pregnancies are less likely to seek out timely prenatal care, leading to poorer birth outcomes, such as premature birth. Women who have unintended pregnancies also experience higher rates of domestic violence, which can extend beyond the pregnancy, eventually leading to child abuse or neglect. Unplanned pregnancies can also lead to an unstable family structure, says Greta Klingler, the family planning supervisor at the public health department in Colorado. “I was raised by a single mom who did an amazing job, so I hesitate to mention this as a negative,” Klingler says, “but I think you’ll agree that if there are two parents, and they are bringing in a stable income, it sets the parents and child up for more long-term success.”
All these elements can affect a mother’s chances of upward mobility. Klingler notes that women who get pregnant younger are less likely to finish their schooling, whether they’re in high school or college, which can adversely affect their earning ability later on in life. And a recently released study shows a high correlation between women who have children before the age of 30 and lower lifetime income. “There’s a trickle-down effect,” Klingler says. “If you have an unplanned pregnancy at a young age, it’s more likely you’re going to live in poverty.”
Isabel Sawhill — a social policy researcher and a senior fellow in economic studies at the Brookings Institution, who has worked on issues of equality and poverty for decades — agrees. Just this past fall, Sawhill told the New York Times: “If we want to reduce poverty, one of the simplest, fastest, and cheapest things we could do would be to make sure that as few people as possible become parents before they actually want to.” In a more recent conversation, Sawhill champions LARCs as being the best option in achieving this. “I think it’s really important to tell people that both the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics have both said publicly that LARCs should be the first line of defense for any woman who does not want to get pregnant,” Sawhill says. “And this means all women,” she adds, referring to a long-held myth — even among health-care providers — that IUDs are not appropriate for teenagers, and are most appropriate for women who have already given birth in the past.
Luckily, while LARC use is still fairly low in the United States, it is rapidly gaining popularity. “The word is getting out,” Sawhill says. “Those I know in health clinics tell me more women are coming in and asking about IUDs and implants.”
Barriers to Contraception in Underserved Communities
Still, there are many women who don’t have access to LARCs — or, if they do, it’s limited by several factors, including misinformation and financial limitations. For one, IUDs can retail for more than $800 each. And while the Affordable Care Act guarantees free contraception to most people, there is still a gap in coverage, and health centers themselves often can’t afford to keep the devices in stock. There are lower-cost IUDs, such as Liletta, which clinics can now procure for as low as $50 each, but not all IUDs are so affordable.
“Over time,” Klingler says, “an IUD or an implant may be cheaper than taking a pill every day but, especially for someone already living in poverty, or living from paycheck to paycheck, they have to think twice about spending that chunk of money all at once.”
As for knowledge, Klingler says that all providers need to be trained to do IUD and implant insertions, and to counsel their patients around the various available methods of contraception so that women can make informed decisions about which method is best for them.
The Politics Behind Securing Funding for Contraceptive Access Programs
“I have been somewhat frustrated we haven’t made greater progress,” says Sawhill in reference to poverty. “As fast as we can come up with new social programs and new funding for them, the need goes up — partially due to unwed and unplanned births — and it’s hard to keep pace with that need.”
A further complication: Many in public office are hesitant to throw their support behind programs that address this need. “There’s still a knee-jerk resistance on the conservative side of the political spectrum,” Sawhill says. “You’d think conservatives would like something that led to a reduction in unwed single mothers, that saved the government money, and that had huge impacts on abortion rates. What’s not to like about that? It’s a win-win-win. But I think they think people who are not married should abstain from sex, and they don’t like what they see as too much casual sex, and they sometimes conflate — or worry their constituents will conflate — options such as IUDs with abortion.”
Meanwhile, when Colorado’s Family Planning Initiative approached the state legislature last year to get additional state funding, their proposal was not passed for a variety of political reasons, including the misguided conflation of LARCs and abortion, and the pernicious myth that LARCs encourage casual sex and an increase in STIs. Lawmakers also expressed skepticism about the necessity of such programs in the wake of the Affordable Care Act. “When we went to ask for additional money,” Klingler says, “they asked: ‘Doesn’t everyone have access now because of the Affordable Care Act?’ We had to explain that more people had access than before, but that we still have big gaps we need to fill.”
In order to keep the Colorado program afloat, a consortium of foundations stepped forward and offered the Initiative a year’s worth of funding, with the understanding that they would approach the state legislature again the following year and try again.
In a bit of happy news, it looks as though — in a reversal from the legislature’s decision last year — funding from the state will actually come through. On April 15, the Colorado state senate and house passed the “long bill,” which should be signed by the governor in the coming weeks. This state budget will include funds for the Family Planning Initiative.
With luck, other states will look to this program’s continued success and move to create their own initiatives.