LARC gaining acceptance among young women

PHS 795 student Kali Boldt points us to an NPR article on increasing use of long-acting reversible contraceptives (LARC) among young women. US rates of adoption have been lower than elsewhere; what determinants might underlie that fact?  Kali writes:

I feel this is very relevant to the lecture we just had about the “pleasure deficit”.  There are many reasons why using contraception has a large benefit for individual health, but also population health outcomes.  Using contraception prevents premature births and low birth weights, but also planning pregnancy can have great benefits for physical and emotional well-being down the road for moms.  Many issues were raised in the article describing ideas that could be better explained from the “pleasure deficit.”  Many young ladies know about the pill.  Because of this, they are more likely to use this contraception method.  They hear about the bad reputation/history surrounding IUDs and implants, which makes them weary of using this type of contraception.  This history includes, high rates of pelvic inflammatory disease and  septic miscarriages in cases when the IUD failed to prevent pregnancy. This history carries into the current use of IUDs and implants.  If these failings continued in new models, when women start to use the device as contraception this would greatly decrease their pleasure.  However, these are long-acting methods that have been improved drastically since past devices.  This type of device would address many factors of the “pleasure deficit” in a positive way.  The power of choice when to have children, ability for spontaneity, effective prevention  making sex more pleasurable, etc.  In Gaston County, they have increased the rate of use of these long term contraception methods, resulting in a decrease in teen pregnancy and reducing the disparity seen between white and African Americans. This does away with the responsibility of taking a pill each day. Many moms on Medicaid were not coming for their post-partum appointments, so right after giving birth, providers started offering an IUD or implant to prevent another pregnancy.  In this way, they reach more moms on Medicaid to offer contraception. Before this, many mothers came back soon after their previous birth pregnant again. 

While this article highlights many  great ideas about contraception use, the article may be more impacting if it addressed the “pleasure deficit” directly.  Simply offering more methods and more access to these methods may not be enough to warrant their usage to many moms.  If providers were trained how to talk with their patients about factors surrounding the “pleasure deficit” many women may be more inclined to use IUDs or implants.  As noted above, these long-acting methods are a great way to prevent pregnancy without much responsibility to the user.  With increased use of these methods, we’ve already seen decreases in teen pregnancy rates and disparities among these rates in Gaston County.  To increase their use, providers need to discuss with their patients the history of old models to the new improved models.  Training programs for providers should include practice in discussing the “pleasure deficit”  to increase IUD and implant use to further decrease high teen pregnancy rates and disparities within these rates.

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6 thoughts on “LARC gaining acceptance among young women

  1. I completely agree that the history of the IUD and its complications have played a role in the unpopularity of this contraceptive method, not only in the minds of patients’ but also in the minds of providers. A Time article from 2014 that was recently shared with me on Twitter detailed some of the reasons why IUD use may be so limited and a national survey suggested that greater than 50% of women had never even heard of an IUD. While not directly asked in this survey, I imagine that more than 50% of these women had visited a healthcare provider at least once in the years prior. I think this speaks volumes to the amount of provider education that is still needed. While the “pleasure” aspect should be a part of the conversation, we need to work on having this conversation in the first place.

    http://time.com/the-best-form-of-birth-control-is-the-one-no-one-is-using/

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  2. While I agree that the topic of contraception relates to Dr. Higgins’s lecture on sexual and reproductive health, I think this article and contraception method still fail to address the “pleasure deficit”. Endorsement of these methods has focused on convenience, not pleasure. There is no mentioning of enhancement or reduction of sexual pleasure whatsoever.

    Furthermore, I am concerned about the article’s failure to address STIs. It is true that the prevalence of teen pregnancy has decreased in the North Carolina counties that adopted IUD and implant birth control. What I would like to know, however, is how condom usage has been affected and how STI rates have changed as a result of increased IUD/implant usage. If sexually active individuals are more susceptible to STIs as a result of IUD/implant usage, than extensive cost-benefit analysis would need to be conducted to determine if this method truly has a positive impact on women’s health.

    Another concern I have is in regards to accessibility of IUD/implant methods. I understand that some public health departments have subsidized the cost of long-acting, reversible contraception; however, this is the exception, not the norm at this point. Additionally, this article implies that teens are the population utilizing this contraception method most. However, implants are costly and visible on the bicep. Therefore, I would imagine parental approval to be a major barrier for teens seeking LARC. Lastly, I would argue that the costliness of LARC poses a gender equality issue. LARC (which women are responsible for) costs hundreds of dollars whereas condoms (aimed toward men) cost a mere couple of dollars. So does it really matter that women utilizing LARC are less likely to discontinue their method if fewer women in general have access to LARC to begin with?

    To prevent readers from judging this contraceptive method based on prior failure, I think it would have been beneficial for the author to discuss the mechanism of reversibility of LARC, associated infertility risks, and effect on menstruation.

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    • Thank you for your post Kallie! I agree that this article doesn’t address the pleasure deficit in a big way, and indeed, LARCs have sexual side effects too (for example, copper IUDs increase menstrual bleeding, particularly in the first year, that can potentially affect sexuality). It is a good question how increase in LARC use affects STI prevalence. My question would be how do you fully account for the costs and benefits of pregnancy vs contracting an STI? I’m sure there are metrics for these questions, but it’s hard for me to imagine a study that could possibly encapsulate all of the effects, particularly of pregnancy. Dr. Higgins mentioned that we don’t have perfect measures for sexuality- I would imagine that studying the overall costs and benefits for pregnancy is a challenge, particularly when context is so important.

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  3. To address some of Kallie’s points:
    1) Really great point about the spread of STIs. There were a couple of studies done that found that when gay/bisexual men started using PrEP as HIV prevention, condom use went down and transmission of other STIs went up. There is some concern that the same thing will happen with increased LARC use, if it means that condom use decreases. There is probably significant differences between men on PrEP and women using LARC to consider, but I think it’s an interesting question about unintended consequences and how something designed to do good could potentially also do harm. http://www.hivplusmag.com/prevention/2016/4/12/condom-use-declines-prep-french-study-shows
    2) While I do not want to suggest that there are not systemic issues with access, it should also be pointed out that the ACA has made significant strides in this area. Under the ACA, preventative health care, including LARC, is covered without cost sharing to the patient. And, as women are signing up for Medicaid, community based/ FQHCs have access to Medicaid reimbursements for providing these services, meaning they are not reliant on Title X. (https://www.guttmacher.org/article/2016/08/through-aca-implementation-safety-net-family-planning-providers-still-critical)

    One critical piece of the LARC conversation that is often missing is the long history of reproductive coercion and control in this country. Research shows that women of color are more likely to be offered a LARC than white women. Additionally, there are proposals to incentivize the use of IUDs for women on Medicaid with children or tying benefits to agreeing to get a LARC method. (Link below) So, as we think about programs to increase the use of these methods, we should also be careful of the implications of such programs. There is a very real concern that these programs could become coercive. Additionally, the economic benefits of LARC programs is only one small piece of the LARC methods can definitely be a tool to prevent unintended pregnancy. But our intentions in promoting these programs really matter. Economic interests can certainly be one consideration, but above all women’s choices and autonomy should be the focuses of these programs.
    http://www.slate.com/blogs/xx_factor/2015/03/24/free_iud_programs_arkansas_legislator_wants_them_for_the_sake_of_taxpayers.html

    https://rewire.news/article/2015/03/23/arkansas-republican-wants-low-income-women-fewer-children/

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  4. Everyone who has replied to this thread has brought up really important points about using LARC for birth control. I would also like to add to this the importance of knowing how effective your birth control actually is for peace of mind and for some women, this knowledge could increase the pleasure deficit. While the majority of birth control methods for women have a 99% theoretical effectiveness, their actual effectiveness varies due to how well they are used and other factors. And lets face it, as far as the pill is concerned, most people probably have made a mistake in the timing of taking their pill over the course of being on it. IUDs and Implants have very similar theoretical and actual effectiveness levels of over 99%, don’t require people to do something in a time sensitive manner, and some can even be more effective than female sterilization, but are reversible so that women and couples can decide when they want to get pregnant. As Dr. Higgins also discussed there are generally fewer pleasure decreasing side effects of implants and IUDs than the pill, but this will not be true for every woman. IUDs can also be extremely unaffordable on some insurance plans, but others (primarily due to the ACA) will cover them in full. Overall I think it is on the clinician to thoroughly explain birth control options, side effects, and costs to help women choose which method would be best for them as well as affordable.
    https://www.optionsforsexualhealth.org/birth-control-pregnancy/birth-control-options/effectiveness
    https://www.cdc.gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_508.pdf

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  5. There have been some interesting comments on this article that I think are really important. First off, I agree with Kallie that the emphasis on convenience of LARC over its impacts on pleasure further highlight the pleasure deficit that we discussed in class. I would be interested (as would many, I think) to see studies looking at the effect of these hormone-based birth controls on not only sexual pleasure, but also lifestyle and emotional wellbeing. I know for some, different types of birth control can affect their mood and life outside of the bedroom, which overrides any convenience benefit that LARC might provide. I can, however, understand that the base cost of female contraceptives would be higher than that of condoms, due to the mechanics and manufacturing differences involved. However, I do think this is something that should be addressed by the healthcare system, to make contraceptives equally available to both sexes. Additionally, it looks like there might be more options for male birth control that are undergoing clinical studies, which could help share the “burden” of birth control.
    Secondly, I find Emma’s point about reproductive control to be concerning, but certainly important. I think it speaks to a history of disparity in this country that goes far beyond any pleasure deficit, and it’s an important reminder that we cannot forget to consider historical perspectives and their impact on health decisions.

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