Long-term birth control can be hard to get in the US

WWhen 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 wouldn’t happen again. The stakes were high: in addition to not wanting children, she has a uterine abnormality that makes pregnancy risky. She terminated the pregnancy and then began seeking long-term contraception.

Rachel (who asked to use only her first name to protect her privacy) lives in a rural part of Colorado where the only local health system is Catholic and doesn’t offer most forms of birth control following ethical and religious hospital guidelines. Although Rachel had been receiving care there for years, her healthcare provider was only able to refer her to a women’s clinic an hour away when she inquired about birth control methods such as diaphragms and intrauterine devices (IUDs).

Although she was initially interested in reversible birth control methods, Rachel eventually 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 back then [my husband and I] came home was, ‘I have to tell every woman I know to check your local health system. If it’s faith-based, you have to figure out what that means to you,” Rachel says. “We found out the hard way.”

Birth control is harder to get in the US than it should be. Many options are available, including pills, sterilization, and long-acting reversible contraceptives (LARCS) such as IUDs, but people often struggle to get the ones they want due to supplier refusal, insufficient insurance coverage, unequal access to care, and clinical deserts everywhere. few reproductive health clinicians are employed.

Some health and legal experts are concerned that those problems could get worse in the future. The leaked Supreme Court draft decision to destroy historic access to abortion Roe to Wade, who could change before the Court makes its final ruling, argues that the Constitution does not guarantee the right to abortion. One of the roeThe company’s central arguments — the right to privacy — were also used in a case expanding access to contraception, so some people are concerned about the security of that precedent.

In the leaked draft, Supreme Court Justice Samuel Alito wrote that the decision only applies to abortion. But after news of the concept came out, President Joe Biden said that “any other decision regarding the concept of privacy is being questioned.” Maryland Rep. Jamie Raskin, who is also a constitutional scientist, caused similar fears on Twitterwriting that “if the majority of Alito destroys the right to privacy, states could imprison women and doctors for abortion and contraceptive offenses.”

Lawmakers in states like Louisiana, Idaho and Tennessee have recently either expressed support for policies that could limit access to certain forms of contraception (namely emergency contraceptives) or have denounced a legal precedent surrounding access to contraception. The Mississippi governor also declined to rule out the possibility of future restrictions on birth control access in an interview with CNN. Recent comments like this have raised the stakes when it comes to maintaining access to contraception.

Birth control is not a substitute for abortion care, says Dr. Aishat Olatunde, a Pennsylvania physician and member of the nonprofit Physicians for Reproductive Health. But, she says: “We want to be able to ensure that [people] have access to all of our options, whether that be contraception, permanent contraception, or abortion.”

The demand for long-term contraception

LARCs are over 99% effective at preventing pregnancy, making them the most effective form of reversible birth control. This category includes IUDs: small, T-shaped devices that are inserted into the uterus that can prevent pregnancy for up to age 12, either by releasing low levels of hormones or by using copper to prevent sperm from reaching and fertilizing the eggs. Another LARC, the contraceptive implant, is a rod-shaped device placed under the skin of the upper arm that releases pregnancy-inhibiting hormones for three to five years.

LARCs have become much more popular in recent years than they used to be. In 2002, only about 1.5% of American women used them. According to federal data, that number had jumped above 10% in 2017-2019 — just slightly less than the 14% who used birth control pills.

That’s in large part because the contraceptives have become safer to use. An IUD, called the Dalkon shield, became popular in the 1970s, but was later linked to serious health problems, including pelvic inflammatory disease, causing doctors to stop recommending it. That left many doctors uneasy about recommending LARCs for years. But over time, better products were approved and found to be safe.

IUDs are also increasingly recommended. Until 2005, the ParaGard copper IUD was only approved for people who already had children. After that, however, ParaGard and other IUDs were approved and marketed directly to younger people without children, expanding the patient base.

However, despite their growing popularity and impressive efficacy, many people struggle to access these forms of birth control.

Barriers to Contraception

Cost is an obstacle, says Mara Gandal-Powers, an attorney and director of birth control at the National Women’s Law Center (NWLC). Under the Affordable Care Act, most insurers must fully cover at least one brand of every type of birth control available in the U.S., including pills, LARCs, patches (which are replaced weekly), and rings (which are replaced about once a month). . Someone who wants an IUD should be able to get at least one of the five brands available in the US without paying anything.

But the NWLC’s consumer hotline gets enough calls from people who’ve received huge bills to know the system isn’t working as intended, Gandal-Powers says. Some insurers don’t follow the law, in some cases they cover the birth control itself, but refuse to pay for the costs associated with administering it or follow-up visits.

For the roughly 10% of people in the US who are uninsured, LARCs may be even further out of reach. For example, the Mirena IUD costs $1,049 without insurance.

Another problem is the national shortage of health care providers. While birth control pills can be virtually prescribed and delivered to many patients’ doorsteps, LARCs require an office visit for insertion, removal, and aftercare. In parts of the country where there are few medical providers and even fewer reproductive health specialists, it can be challenging to easily make an appointment with a doctor who can fit a LARC. According to the American College of Obstetricians and Gynecologists (ACOG), as of 2017, half of U.S. counties have not had a single gynecologist practicing there.

As Rachel has learned, finding the right health care provider can be especially difficult in areas dominated by religiously affiliated health care networks that may refuse to provide reproductive care. As of 2016, about 16% of hospital beds in the US were in Catholic medical centers, and in some states as many as 40% of beds are in religiously affiliated facilities.

Trouble on the horizon

With the final decision of the Supreme Court on Roe v. Wade looming and the future of access to contraception is uncertain, those problems could get worse. In Idaho, for example, Republican State Representative Brent Crane said he plans to hold hearings about banning emergency contraception like Plan B. Crane originally said he wasn’t “sure” about where he stood on access to IUDs. , before withdrawing that comment, the Idaho Statesman reports.

dr. Rachel Bervell, a physician assistant who leads the Black ObGyn Project, an online initiative to bring anti-racism into reproductive care, says the potential overthrow of Roe v. Wade raises greater concerns about limitations of physical autonomy. “It feels like a slippery slope,” she says.

dr. Amanda Bryson, a physician at Boston Children’s Hospital who has studied access to birth control, says these problems are likely to be especially common among people from historically marginalized backgrounds, who often struggle to access equitable contraceptive care. That includes people of color, people on low incomes, people who are not straight or cisgender, undocumented migrants and people who are in prison, she says.

LARCs in particular can present complex problems for people from these communities. On the one hand, people who want long-term contraception may not be able to get it if they face financial impediments, live far away from health care providers, or are unable to take several days off work for medical appointments. But at the same time, reproductive justice groups have expressed concern about doctors recommending them without listening to patient preferences. A 2016 joint statement by 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 latest in a long line of population control methods targeting on 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. “The bottom line is that someone can exercise the human right to make their own decisions about family planning.”

A patient-centered approach is crucial when offering birth control, Olatunde says. Doctors should 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 has traditionally been this very patriarchal environment where the thought is that the doctor knows best,” Olatunde says. “The reality is that we are not in the shoes of our patients.”

Even as politicians across the country are putting limits on reproductive health care, more clinicians are embracing patient autonomy. In January, ACOG released new guidelines that instruct clinicians to “ask an individual’s values, preferences, and insights about what matters most to them when it comes to contraception,” echoing reproductive justice groups that have been promoting that message for years. .

In March 2022, Congressional Democrats urged government agencies including the U.S. Department of Health and Human Services (HHS) to streamline the birth control insurance coverage process so that people can get any kind of birth control they want. HHS, for its part, said in January it is “actively investigating” insurers’ compliance with ACA standards around contraceptive coverage.

Changing medical culture can go a long way. But policy-level protection is also critical to maintaining reproductive access, as the Supreme Court’s draft decision on abortion has shown.

That is the message Rachel carried from her experience in Colorado. “No one is as protected as they think they are,” she says. “Especially now.”

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write to Jamie Ducharme at jamie.ducharme@time.com.

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