Breaking the Cycle of Poverty: An Argument For Immediate Postpartum Long-Acting Reversible Contraception

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Miriam Stats

Miriam Stats

Miriam Stats is a fourth year student at Northeastern University in Boston. She will be graduating with a bachelor’s degree in Health Sciences and plans to attend medical school with the hopes of becoming a pediatrician. She currently works at Brigham and Women’s Hospital in the Newborn Medicine department and has completed global health work in Panama. Her particular areas of interest in global health are in the fields of maternal and reproductive health.

Every year, the Guttmacher Institute provides data on pregnancy incidence by intention status and outcome worldwide. In 2012, out of the 213 million pregnancies that occurred globally, 85 million were unplanned. Of unintended pregnancies, 50% lead to termination, 13% ended in miscarriage, and 38% resulted in birth. The Guttmacher Institute contributes this information to the public to demonstrate the urgency for family planning programs.1 I take this one step further and write in advocacy for institutional and payment policy changes to support the provision of immediate, postpartum, long-acting reversible contraception (LARC), specifically the intrauterine device (IUD). I believe that optimizing the access and use of immediate postpartum LARC could be an important component in accomplishing the UN Millennium Development Goal of improving maternal health worldwide.2 In the first year postpartum, at least 70% of pregnancies are unintended.3 Additionally, nearly 50% of postpartum adolescents experience another pregnancy within 1 year of delivery. Pregnancies at such a short interval are associated with preterm delivery and adverse birth outcomes.4 While 150 million women worldwide use the IUD, more widespread adoption of immediate, postpartum, LARC methods has been halted by high costs, lack of access, and misconceptions about this type of contraceptive. This is an important issue as increasing access to LARC is a clinical and public health opportunity for obstetricians and gynecologists because the intrauterine device is the best possible reversible method for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.5

Nearly half of pregnancies globally are unplanned, and the majority of these pregnancies are in women that already have children. Those at the highest risk are adolescents and women of minority status. Additionally, there is a strong inverse association between both income bracket and level of education and rate of unplanned pregnancies. This is alarming because unintended pregnancy within a population is an important measure of reproductive health. Because almost half of pregnancies in the world are unintended, this signifies that many women are not freely determining when or if they have children. This not only diminishes individual autonomy, but it is a large public health concern as unintended and mistimed pregnancies are associated with a multitude of negative health, economic, social, and psychological outcomes for both women and their children.2 Additionally, women who have unintended pregnancies are less likely to seek appropriate prenatal care, more likely to smoke or consume alcohol during the pregnancy, and are less likely to breastfeed. Because of this, women with unplanned pregnancies are more likely to have adverse birth outcomes, premature, and low-birth-weight babies.6

The trends in unplanned pregnancies are especially concerning because modern contraceptive methods are incredibly effective. For example, over 150 million women worldwide use the IUD, making it the most widely used type of reversible contraception. Only a handful of adverse events are associated with the IUD, and it has a remarkably low failure rate, making it one of the most effective and safe contraceptive methods on the market.6 Besides providing long-term, effective contraception, the IUD doesn’t interact with medications, is rapidly reversible, doesn’t get in the way of sexual intercourse, doesn’t have any alarming side-effects, won’t impact breastfeeding, isn’t subject to forgetfulness, and won’t be affected by changes in availability or access to healthcare once it is inserted.8 The Centers for Disease Control and Prevention’s (CDC) 2010 U.S. Medical Eligibility Criteria for Contraceptive Use provides guidance about the safety of postpartum contraceptive use. According to the CDC, immediate postpartum initiation of IUDs and implants are classified as Category 1, no restriction for use, or Category 2, advantages generally outweigh theoretical or proven risks.9

While this seems ideal, the IUD is expensive, and requires a trip, or possibly several, to a physician. This is an impossible hurdle for many women of low socioeconomic status. Nearly half of women are having unexpected pregnancies, even though there are top-notch contraception methods available, yet just out of reach. The key is to find an opportunity to provide women with contraception when they are already interacting with the healthcare system. When a woman is directly postpartum, she is not only likely in a hospital, but she is obviously no longer pregnant. This creates a valuable opportunity to introduce women to contraception. Within 10 minutes of delivery, while the mother is still in the delivery room, is the optimal time for LARC insertion.5

For six years, Colorado, United States, conducted a massive experiment with long-acting birth control. Adolescents and poor women were offered intrauterine devices free of cost. According to the Colorado Department of Public Health and Environment, from 2009 to 2013, the rate of abortions fell by 42 percent, with the changes particularly pronounced in the poorest of areas. This study shows that when give the option of free contraception, women overwhelmingly choose long-acting methods, and pregnancy and abortion rates plummet. The program is also cost effective; for every dollar spent on the LARC initiative, it saved $5.85 for the state’s Medicaid program, leading to millions of dollars of savings overall.3 Similarly, in a study in the state of Missouri, when women were offered various forms of birth control free of charge, 75% of the 9,256 women chose a LARC method.12

It was recently revealed that the anonymous donor that provided $24 million dollars to fund the six-year effort in Colorado as well as the $20 million dollar study in St. Louis came from the Susan Thompson Buffett Foundation, which has been the most influential supporter of research on intrauterine devices and expanding access to LARC. Meanwhile, a nonprofit organization called Medicines360 received a donation of $74 million dollars from the same foundation. With this hefty sum, the organization was able to produce Liletta, an IUD that costs only $50, to replace the IUDs that were already on the market, retailing for nearly $800 each.13 Like the Susan Thompson Buffett Foundation, The Bill & Melinda Gates Foundation has showed devotion to dismantling the barriers to LARC access. While the Buffet family has focused their energy on the United States, the Gates family has made it a mission to provide poor women in developing countries access to LARC. The foundation has already donated over $1 billion dollars toward family planning efforts, and plans to continue donations this year. Melina Gates has set a goal to provide 120 million women with birth control by 2020. By providing women with a tool to prevent births, it may help to break the cycle of poverty for many women. Additionally, providing contraception has the potential to prevent millions of unsafe abortions by avoiding undesired pregnancies.14

Because of the clear significance of long-acting reversible contraceptive methods, many family planning advocates are endeavoring to promote practices and policies that will reduce barriers to widespread use of devices such as the IUD. However, some supporters of reproductive rights are cautious due to the historical context of coercive practices related to contraception. These practices were targeted at groups of low socioeconomic status and ranged from offering financial incentives to use contraception to involuntary sterilization procedures. As recently as March of last year, state legislators in Arkansas were pressing forward a bill that would incentivize unwed, low-income women on Medicaid with a $2,500 reward for getting an IUD.15 Because of this not so distant dark history of abuse, it is vital that providers ensure the autonomy of their patients. Clinicians must be educated on providing unbiased, accurate, and comprehensive information on all of the available options so that women are empowered to exercise self-determination regarding contraceptive methods. The ability to make decisions about whether or not and when to have a child is a basic human right that must be safeguarded. LARC methods are a powerful tool for women to exercise this right, but vulnerable women across the globe must be protected from possible abuse.

Additionally, there are some that argue to varying degrees, that contraception of any kind is unnatural, anti-life, or even a form of abortion. Consequentialist arguments against contraception claim that contraception is dangerous, prevents potential humans from being born, and may be used as a eugenic tool. Others believe that contraception shouldn’t be permitted because it causes “immoral behavior” in that it will lead to people having sex for pleasure.16 These beliefs are held by many, especially in deeply religious organizations. However, possible pushback from steadfast anti-contraception advocates does not warrant denying women procreative liberty.

In conclusion, systems should be in place to ensure that immediate postpartum LARC should be introduced prenatally as an option for postpartum contraception. LARC methods such as the IUD are a powerful tool for women to safely and effectively prevent unwanted pregnancies, while protecting the gender equality and autonomy of women. As the studies in the United States show, women overwhelmingly choose LARC when given the option, resulting in dramatically lower rates of unplanned pregnancies and abortions. Finally, while provisions must be made to ensure that coercion and abuse do not occur, and while the political environment is often polarized regarding issues of reproductive rights, the public health and clinical benefits of reducing barriers to access of LARC far outweigh potential opposition.

 

 

References:

  1. Sedgh G, Singh S, Hussain R. Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends. Studies in family planning. 2014;45(3):301-314.
  2. The Millennium Development Goals Report 2006. United Nations. http://www.un.org/zh/millenniumgoals/pdf/MDGReport2006.pdf. Accessed December 15, 2016.
  3. Colorado’s Effort Against Teenage Pregnancy is a Startling Success. New York Times. July 5, 2015. http://www.nytimes.com/2015/07/06/science/colorados-push-against-teenage-pregnancies-is-a-startling-success.html. Accessed December 15, 2016.
  4. Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol. 2012; 206:481.e1–7.
  5. Committee Opinion: Immediate Postpartum Long-Acting Reversible Contraception. ACOG. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Immediate-Postpartum-Long-Acting-Reversible-Contraception#20 Published August 2016. Accessed December 15, 2016.
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  8. Kaneshiro B, Aeby T. Long-term safety, efficacy, and patient acceptability of the intrauterine Copper T-380A contraceptive device. Int J Womens Health. 2010; 2: 211-220.
  9. Update to CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of contraceptive methods during the postpartum period. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2011; 60:878–83.
  10. Markus AR, Andres E, West KD, Garro N, Pellegrini C. Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform. Women’s Health Issues. 2013; 23: 273-280.
  11. Medicaid Finds Opportune Time to Offer Birth Control: Right After Birth. New York Times. October 28, 2016. http://www.nytimes.com/2016/10/29/health/birth-control-medicaid.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=stream&module=stream_unit&version=latest&contentPlacement=47&pgtype=sectionfront. Accessed November 26, 2016.
  12. Diedrich JT, Zhao Q, Madden T, Secura GM, Peipert JF. Three-year continuation of reversible contraception. Am J Obstet Gynecol. 2015; 213(5): 662.e1-8.
  13. Warren Buffett’s Family Secretly Funded a Birth Control Revolution. Bloomberg Buisnessweek. July 30, 2015. http://www.bloomberg.com/news/articles/2015-07-30/warren-buffett-s-family-secretly-funded-a-birth-control-revolution Accessed December 15, 2016.
  14. For Melinda Gates, Birth Control Is Women’s Way Out of Poverty. New York Times. November 1, 2016. http://www.nytimes.com/2016/11/01/health/melinda-gates-birth-control-poverty.html?rref=collection%2Fsectioncollection%2Fhealth&action=click&contentCollection=health&region=stream&module=stream_unit&version=latest&contentPlacement=26&pgtype=sectionfront Accessed November 29, 2016.
  15. Gold RB. Guarding Against Coercion While Ensuring Access: A Delicate Balance. Guttmacher Institute. 2014; 17(3).
  16. Moral case for contraception. BBC. http://www.bbc.co.uk/ethics/contraception/in_favour.shtml Accessed November 29, 2016.