On January 2, 2019, the New York Times ran an Op-Ed piece by Drs. Dehlendorf and Holt, titled “The Dangerous rise of the IUD as Poverty Cure.” It comes from two respected experts in the field, whose paper with Langer on quality contraceptive counseling I had listed as one of my favorite papers that I read in 2018 just days earlier in pure coincidence. It is penned to warn the reader about the dangers of promoting long-acting reversible contraceptives (or LARCs, as the IUD and the implant are often termed) with a mind towards poverty reduction. Citing the shameful history of state-sponsored eugenics, which sadly took place both the U.S. and elsewhere, they argue that “…promoting them from a poverty-reduction perspective still targets the reproduction of certain women based on a problematic and simplistic understanding of the causes of societal ills.”
What started as an Op-Ed with an important and legitimate concern starts unraveling from there. A statement that no one I know believes and is not referenced (in an otherwise very-well referenced Op-Ed) “But there is a clear danger in suggesting that ending poverty on a societal level is as simple as inserting a device into an arm or uterus” is followed by: “Providing contraception is critical because it is a core component of women’s health care, not because of an unfounded belief that it is a silver bullet for poverty.” In the process, the piece risks undermining its own laudable goal: promoting the right and ability of women – especially adolescents, minorities, and the disadvantaged – to make informed personal decisions about whether and when to have a child to improve their own individual welfare first and foremost.
I believe that the effect of such prominent pieces is to stifle research on the best ways to improve access to all modern contraceptives – including the very effective LARCs that have been around for close to three decades. Of course, individual or patient experience is the most important aspect of the discussion around contraceptive provision. But, so are cost and public health (within the “Triple Aim” framework, as cited in Holt et al. 2017 as the three organizing principles of optimal health systems). And, yes, one can easily add to that framework human capital accumulation among adolescents, labor market participation among adult women, and societal gains from improved infant and child health – all potential effects of a reduction in unintended pregnancies and better birth spacing via improved access to the most suitable contraceptives for each individual. Because of the history of family planning, are policy makers and researchers not supposed to even mention the benefits of reducing unintended pregnancies for the individuals themselves, their children, and the society as a whole? Let alone explore innovative policies to address the myriad of barriers to access, such as cost, provider bias, insufficient provider training and knowledge, lack of information among patients, etc.?
For all we know, a sensible sexual and reproductive health (SRH) policy – targeted to adolescents and completely consistent with a rights-based approach to counseling clients on modern contraceptives – could be more cost-effective in improving human capital accumulation among school-aged populations than providing them with conditional cash transfers (CCTs) to attend school. But, the former is practically non-existent in the developing world while the latter is ubiquitous (the NYT Op-Ed is US-centric and is mum about developing country settings). Should the economist who dared to suggest that governments should consider evidence-based SRH policy as an alternative (or a complement) to CCTs be chastised because of the loaded history of family planning in the US? Pieces like this Op-Ed serve as a deterrent to those who want to carefully explore alternative counseling techniques for contraceptives, optimal subsidies to providers in pay-for-performance schemes to improve access of patients to expensive methods, etc.
One thing that does not come across to the reader from the Op-Ed is the magnitude of the trade-offs we are faced with when trying to strike a balance between “…protecting unfettered access and preventing abuse, and …encouraging and coercing.” (Gold 2014) Here are some facts:
- LARCs are so much more effective than short-acting methods, such as the injectable or the pill (and, even more so than using condoms), in typical use settings that it is not even close: an oft-cited figure is that, of two people wishing to delay pregnancy for at least one year, someone on the pill is 45 times more likely to become pregnant than another using an IUD (the gap is as large, if not larger, for the implant).
- Currently, almost half of the 6.7 million pregnancies in the United States each year are unintended. 48% of unintended pregnancies in the US occur in the same month when contraception is used.
- Implants were approved for use in the US in 1990 with hormonal IUDs following in 2000. Copper IUD has been available earlier than both.
- Despite these facts, the uptake of LARCs is very small in the US and smaller still in developing countries. Merely 5% of teenagers using contraceptives used a LARC in 2013 (and 8.5% of all such women) in the United States. In Cameroon, for example, 41% of sexually active unmarried women report using male condoms, with 6% using SARCs and less than 1% using LARCs (Demographic Health Survey, 2011).
Yes, the matter is complex. Pregnancy intention is not binary. Effectiveness is but one concern women have in choosing a method. Side effects are significant and can vary from merely annoying to painful and unacceptable. It is unlikely that the first method someone chooses will be the method for them – often it will be a search to find the right method for themselves that align with their preferences for side effects, discretion, convenience, etc. and their goals in life.
However, benefits of increased voluntary uptake of long-acting reversible contraception may extend to wider populations than previously thought. It is very unlikely that the current equilibrium of low uptake of LARCs is optimal – both from an individual welfare and a public health perspective. Effectiveness may not be the determining factor in contraceptive choice, but it has to be a factor. It should not be controversial to say that, conditional on other considerations (or all else equal), more effective methods should be more preferable to less effective ones. Especially when the typical-use effectiveness gap between LARCs and other methods is so large. And, that providers can help provide this information and encourage them to consider these methods…
One important thing to note here is that we don’t live in a world that prioritizes LARCs over other methods. In fact, adolescents everywhere live in the opposite world: providers are reluctant to recommend LARCs to adolescents for a variety of reasons: cultural or religious bias about what that implies about a teenager’s sexual behavior; fear of backlash from parents or husbands of adolescent females; urban myths like “LARCs are not suitable for nulliparous women,” etc. Often, LARCs are more expensive than other methods and adolescents (and poor women) are less likely to be able to afford the upfront cost of these methods.
So, if anything, we should be trying to undo a harmful bias that is present in the current status quo that prevents young women anywhere in the world from being able to access a technology that might significantly improve their welfare. And, I do wholeheartedly believe that there is a way to do this, namely to promote LARCs for adolescents and adults, poor and non-poor alike, without sacrificing a rights-based approach to contraceptive policy in general and counseling in particular.
That path starts, however, with researchers and policymakers pushing the boundaries – even if just a bit – to challenge the orthodoxies of the past half century. Almost everyone I know agrees that informed choice and consent is a sine qua non in any quality counseling framework, but at the same time most people also agree that it is not realistic, especially in a busy primary care setting, to present the average client with a large number of options and ask her to choose for herself, which is still the prevailing norm. Even if it were realistic, it would be hard to argue that this is what we want informed choice to mean. Shared decision-making, like the framework that Dehlendorf and Holt advocate, in a setting where the clients’ preferences and goals are being elicited and incorporated into recommendations will inevitably lead to more LARCs being recommended to many people being counseled. And, that should be a good thing…
But, if those clients believe that such recommendations are a result of biased and ill-willed policy makers who want to restrict the fertility of poor and minority women rather than evidence-based recommendations of well-meaning researchers and providers, Op-Eds like this will be partly to blame. It is time to admit to ourselves and everyone else that there is a way to promote LARCs and encourage women to consider them that is conscientious, ethical, deliberate; that is empathetic and trust-building rather than suspicion arousing; that is respectful and rights-based.
When we do so, it is also OK to allow for the fact that the benefits of supporting such approaches extend beyond the individual – that they may improve not only health, but also educational outcomes, incomes, women’s bargaining power, and the like. And those things matter, because we are concerned with allocating limited resources to various human capital accumulation policies. If a sensible and ethical school- or community-based SRH policy is more cost-effective than CCTs in reducing dropouts, we would like to know.
I’d like to finish with the final paragraph from Gold (2014), a paper that is cited in the NYT Op-Ed only in reference to the Norplant controversy of the 1990s in the United States:
“In sharp contrast to events of past decades, today’s conversation is motivated primarily by providers and advocates wanting individual women to have unfettered access to the extremely effective methods now available, as opposed to serving some perceived greater social good. The questions on the table now are much more nuanced and complex, and certainly no less important. Given the historical examples of women not having received the information they needed to make free and informed choices, what is the best way for practitioners to convey that some methods are more effective than others, while still ensuring that women are given the full information they need to make decisions about what is most appropriate for them? Because financial incentives have been inappropriately used to influence women’s choices in the past, how can payment systems that financially reward providers when more women opt for the most effective methods, such as LARCs, be structured to avoid undermining the quality of the information and range of choices women receive? This is a conversation that the reproductive health field—united as it is in its unshakeable commitment to the basic human right of individuals to make personal choices about childbearing freely and without coercion—should welcome.”