Long-acting reversible contraception: A route to reproductive justice or injustice

1 INTRODUCTION

Nearly half of pregnancies in the United States are unintended, meaning that the mother did not want to become pregnant at that time or at all (Finer & Zolna, 2016). To reduce rates of unintended pregnancies, efforts are ongoing to promote the use of Long Acting Reversible Contraception (LARC), which is the most effective reversible contraception available today (American College of Obstetrics and Gynecology, 2017). Many of these promotions are targeted at marginalized women, including those who are poor, of color, or very young (Finer & Zolna, 2016).

Efforts to promote LARC make sense on a number of levels since pregnancies and births covered by Medicaid¹ are huge expenditures, so preventing those pregnancies is beneficial to government from a financial perspective (Sonfield & Kost, 2015). In addition, unplanned pregnancies can have negative effects on women (described later), so it could seem morally responsible to offer them the most highly effective contraceptive options. However, for minority and women's advocacy groups, the policies that direct women toward certain contraceptive practices read as a reinvention of the American eugenics movement and other concerted efforts to limit pregnancies of poor women and those belonging to minorities (Asian Communities for Reproductive Justice, 2005; Black Mamas Matter Alliance, 2018; Ross/SisterSong Women of Color Reproductive Justice Collective, 2006/2011). As such, LARC policies can be easily interpreted as unethical because they can undermine women's reproductive rights and could serve as a means to keep poor and minority women from reproducing. Although endorsing LARC devices (LARCs) for women who choose them freely, the reproductive justice (RJ) movement calls for family planning services that support each woman in identifying her family planning priorities and adopting the method that best meets her current needs. Beyond this, the movement addresses and calls for the rights of women to access equal-quality healthcare and live in healthy and safe environments (Gomez, Fuentes, & Allina, 2014).

The tension between these two perspectives is deep, public, and ongoing; issues at the heart of the debate are highly relevant to infant mental health (IMH) professionals because women's reproductive health and their right to choose the reproductive strategies that are good and appropriate for them and their family can impact women, families, children, and family relationships, and these are the core domains of IMH. In addition, knowledge about reproductive health and justice can broaden the perspective of IMH professionals, encourage their self-exploration as to personal prejudices and biases, improve clinical practice, and offer ideas for new lines of research. Knowledge about RJ also could suggest avenues of cooperation and collaboration between persons who work on behalf of RJ, social justice, and IMH (discussed later).

This article aims to provide IMH professionals with information on the controversies surrounding LARC, incorporating both the positions in favor of promoting LARCs over other contraceptives and those advocating RJ. Since efforts to promote LARC are related to the high incidence rate of unintentional pregnancies in the United States (and elsewhere), this article begins with a review of recent literature on outcomes associated with those pregnancies, followed by caveats to reported findings. We then describe LARCs approved by the U.S. Federal Drug Administration (FDA), followed by a discussion of the advantages and disadvantages and barriers to using them. We then describe some of the current initiatives for increasing LARC use and the variety of ways that they can be encouraged in socially unjust ways. Finally, we discuss the connection between RJ and social justice and between RJ, social justice, and IMH.

2 DEFINITIONS, INCIDENCE, AND RISKS ASSOCIATED WITH UNINTENDED PREGNANCIES

To begin this section on unintended pregnancies, we define focal constructs and describe a few methodological and statistical issues that are limitations of research on the topic.

3 LARCs: INTRAUTERINE DEVICES AND IMPLANTS

The high incidence of unintended pregnancies in the United States (and elsewhere) and the potential risks associated with them point to the need for improved access to effective means of family planning, and LARCs are the most effective reversible means of birth control on the market today (American College of Obstetrics and Gynecology, 2017; Trussell, 2011). Brief descriptions of LARCs approved by the FDA are provided next.

4 ADVANTAGES, BARRIERS, AND DISADVANTAGES OF LARC

The sharp increase in LARC usage in recent years (Kavanaugh & Jerman, 2018) speaks to promotional efforts and the advantages of LARC as perceived by some women. Still, LARCs are only the third most commonly used type of reversible contraceptives among U.S. women who use contraceptives (26% pill, 15% condom, 12% LARC; Guttmacher Institute, 2016a). This puts women in the United States behind most of the world in usage (United Nations, 2015), and this coalesces with the fact that sterilization is more common in the United States than in many other developed nations (Guttmacher Institute, 2016a). According to a recent, large, representative sample (N = 9,321; National Surveys of Family Growth; Kramer, Higgins, Godecker, & Ehrenthal, 2018), LARC use differs significantly by race and ethnicity: Nine percent of White women, 11% of Hispanic women, and 7% of Black women reported currently using LARC (2011–2013 and 2013–2015 pooled; P = .03). Next, we discuss advantages and disadvantages (negative aspects of LARC), heterogeneity in women's perception of what is an advantage or disadvantage based on personal considerations, and finally, a description of the “external” (policy) barriers that make access to information about LARC or to the devices themselves difficult for some women.

5 LARC: EFFORTS TO INCREASE USE

Because of LARC's effectiveness, initiatives have been designed and implemented to encourage use. A prime example is the Contraceptive CHOICE project, which provided counseling and no-cost contraception to women in the St. Louis, Missouri area in an effort to curtail unintended pregnancies (Birgisson, Zhao, Secura, Madden, & Peipert, 2015; Broughton et al., 2016). Of the nearly 10,000 women counseled on all types of birth control using a tiered approach (with the most effective methods described first; Stanback, Steiner, Dorflinger, Solo, & Cates, 2015), 75% chose a LARC as their method of contraception. This rate is similar to that reported by Madden et al., 2018, who reported a 76.1% uptake of LARCs among a sample of CHOICE-participants compared to 4.8% among a “simulated” comparison group. Estimates of this latter group were based on data obtained from the Missouri Title X program and adjusted for relevant covariates.

Follow-up data from CHOICE-participants show that LARC users were 22 times less likely to experience an unplanned pregnancy, and abortion rates for CHOICE-participants were less than half of those living in the surrounding region (and therefore not eligible for the CHOICE project) (Birgisson et al., 2015). The program had the greatest impact on teen pregnancies, births, and abortion rates, which declined more rapidly than the national average (Birgisson et al., 2015). According to a recent cost analysis (Madden et al., 2018), the total cost savings for the state of Missouri attributable to the Contraceptive CHOICE Project was estimated to be $5.0 million over the project duration.

These results should be regarded with some caution. They may not be entirely generalizable to the larger population because participants were recruited from specific sites that provided contraceptive counseling and services to low-income women, and participants came to the sites seeking contraception. In addition, frontline providers may have guided participants to LARCs over other methods, given the goals and design of the project (Stanback et al., 2015). Women in the study also were not randomly assigned into control and treatment groups. For these reasons, the study cannot provide a firm answer as to what LARC take-up would be if the devices were free and universally accessible and offered along with other devices with ample information on each one (for a full discussion, see Madden et al., 2018).

One other large-scale initiative to increase LARC uptake is the $23 million Colorado Family Planning Initiative (CFPI; Ricketts, Klingler, & Schwalberg, 2014) aimed at increasing the use of LARCs through counseling and the lowering or covering of their costs in Title X clinics. Results of recent analyses have attributed a 6.4% decrease in teen birth rates over 5 years to the project, with higher estimates (10.4%) in counties with poverty rates above Colorado's median (Lindo & Packham, 2017). These findings translate into an overall estimate of about 6,000 LARCs provided to teenagers through the CFPI initiative and approximately 1,500 teenage births prevented between 2009 and 2013. This relatively large effect has suggested that the program had success; however, the findings are limited to teen births and so cannot be generalized to other populations.

Another type of initiative is aimed at facilitating policy: adherence and implementation. One example is the founding of the Immediate Postpartum LARC Learning Community—a cross-state collaboration—to facilitate information-sharing and support states, with the end goal of improving access to LARCs immediately after birth through policy implementation. The initiative can establish best practices and strategies for effective service delivery and serve as a mediator of system change (Kroelinger et al., 2018).

In addition to these and other large-scale projects, there are other smaller initiatives in place. Examples are projects that center on online and telephone tools to complement in-person counseling on LARCs (Gilliam, Martins, Bartlett, Mistretta, & Holl, 2014; Sridhar, Chen, Forbes, & Glik, 2015), projects to increase provider knowledge, and trials to test the efficacy of providing access to LARCs immediately after an abortion in order to prevent repeated pregnancies (Langston, Joslin-Roher, & Westhoff, 2014).

6 LARC AS ROUTES TO SOCIAL INJUSTICE

The initiatives to promote LARC are in keeping with the national health goal of reducing the number of unintended pregnancies in the United States (Healthy People 2020, 2011). On one hand, this can be justified as favoring the public good, assuming that such efforts promote the well-being of current and future generations. On the other hand, childbearing, pregnancies, contraception, and sexual activity are private behaviors and involve profoundly private decisions that society should leave for individuals to decide for themselves.

In this context, it is critical to acknowledge a historical legacy, perpetrated by calculated acts of White supremacy, colonialism, classism, able-ism, and misogyny that pushed for and legislated policies that were said to be aimed at the public good, but overrode the rights of some individuals, particularly the most vulnerable women, to curb or stop their reproduction. Examples of past abuses include the control of Black women's fertility and sterilization during slavery; of Native Americans during the settlement of the United States; and of poor people, immigrants, prisoners, and men and women hospitalized in psychiatric facilities in response to the American eugenics movement (late 1800s–1940s) that sought to increase births among the “fittest” and limit births among the “unfit” (Currell, 2006).

Other, more recent examples include the arrests of and forced interventions (e.g., cesarean sections) on women whose pregnancy was a necessary factor leading to attempted and actual deprivations of their physical liberty. Paltrow and Flavin (2013) described 413 such cases from 1973 to 2005. According to records, the basis for the arrests and/or interventions in many of the cases was related to “saving” the fetus, mostly under extremely dubious circumstances such as wanting to have a vaginal birth after having a cesarean section or due to a miscarriage or still birth that was blamed on the mother. Although Paltrow and Flavin noted that such intrusive practices have occurred in every region of the country and affect women in all sectors and strata (p. 333), they also described disturbing disparities by race, ethnicity, and SES, with poor and/or African American women (especially from Southern states) being particularly vulnerable to many of the insults (Paltrow & Flavin, 2013).

Injustice toward women's reproductive rights, especially among women who are socially marginalized, continues today. Examples pertaining to LARC include recent policies adopted by a number of U.S. states that create incentives or disincentives to limit childbearing by women receiving public assistance (for a full discussion, see Strasser et al., 2016). Other examples of discrimination include biased renditions of contraceptive options offered to some women, particularly women of color and poor women (Dehlendorf et al., 2010). Subtle discriminatory biases also are seen in a lack of funding in some state Medicaid programs for device removal if the recipient intends to get pregnant (South Dakota Department of Social Services, 2016).

These past and present policies serve as examples of discriminative acts against marginalized populations of women by directing them toward a particular contraceptive and reproductive “strategy.” Such policies and practices can cause women to distrust the “system” and their provider and can elicit fears of being forced to use a particular contraceptive strategy without their permission and to their physical detriment. Ethically, such targeting practices negate the rights of women to choose the kind of contraception that they want to use. In this context, advocates of RJ call for putting the priorities, needs, and preferences of individual women—not the promotion of specific technologies—first.

As well, policies that impinge on women's freedom to use the contraceptive method of their choice must be expunged and rewritten to allow all women full reproductive rights. In these ways, women across the sociodemographic continuum would be offered contraception with the respect and freedom that they deserve.

7 PRO-CHOICE VERSUS RJ

Ensuring the rights of all women to choose the contraception that they deem appropriate is an important goal. However, proponents of RJ have argued that assuring choice is not enough because decisions about reproduction are very complicated, and the right to make a choice does not help a woman figure out what “choice” means in her individual context and what the best choice might be. For this, women may need guidance, information, real options, and meaningful support to mindfully make a decision. Practically, this calls for more education, access to a good health provider, health insurance, resources, transportation, the ability to take time off from work to get to an appointment, childcare during a medical visit, and documentation of immigration status. Above all, RJ calls for ensuring that people have full bodily autonomy, have the rights to reproductive choice, and are provided with the chance for them and their children to live healthy lives with promising futures. The movement also calls for the persons most affected by discriminative policies and practices to serve as leaders in shaping the collective analysis and by leading efforts toward reimagining and building just communities and societies. As such, it emphasizes social justice, which removes reproductive decisions from an individualized space and makes it part of a broader set of community and national priorities (Ross, 2006/2011).

From this perspective, whether a woman can or should use LARCs is really not the issue, although they are an effective means of curtailing unwanted pregnancies. Rather, the central issue is the challenges facing poor women, women of color, and in fact, to some extent, all women, grounded in the socioeconomic and cultural biases perpetuated in a society that allow for some persons to attain individualized goals more than do others. Seen in this way, the remedy is no less than to make social equity a primary priority everywhere and for everyone. According to advocates, although unbiased consultations and free and easy access to LARCs could be significant advances toward this goal, they are seen as only relatively small steps on the road to social and RJ.

8 RELEVANCE TO IMH PROFESSIONALS

IMH professionals should learn about and contribute to these efforts because RJ affects the well-being and future of parents, families, and children, who are the focus and aim of work in the field of IMH. For professionals, as individuals, learning about RJ can help them develop a more critical awareness regarding their own social identities, consider how these identities situate them within hierarchical social systems of privilege and oppression, and examine how their identities impact their attitudes and care of families. Learning about RJ can also prompt IMH professionals to learn more about multicultural issues that promote a better appreciation of the impact that past and present social conditions (including all kinds of oppression and discrimination) can have on individuals, their health, personal/family relationships, and the manner in which they negotiate their world.

IMH professionals also can contribute a great deal to the RJ movement via their research, clinical practice, teaching, and advocacy. As a few examples of IMH research that could contribute to RJ: (a) Studies that examine whether LARC use, indeed, improves women's and children's lives (e.g., mental health) in the long-term, and if so, whose lives and in what ways; (b) research with an end goal of designing and evaluating tools and interventions to increase the resilience of adults and children in the face of discrimination by institutions or individuals in efforts to empower those who are discriminated against and help them cope and protect themselves, and (if age-appropriate) to encourage action toward progress and reform; (c) qualitative research that offers an understanding of the perspectives of women from different sectors regarding reproductive health and of the broader contextual forces that contribute to their contraceptive choice; and (d) studies that provide insight on when and how to talk to children about discrimination, racism, and personal rights, including those related to gender and reproduction. As a final suggestion, IMH researchers could offer a further understanding into the meaning of “racism” as it is displayed and transmitted in contemporary society, now that some aspects of overt racism have been made illegal (Bradby, 2010). A failure to update our thinking in this regard will undermine efforts to address the complexity of racism and the many ways that it influences care providers and clients as well as their perceptions of one another and their interpersonal communication (Peek et al., 2010).

In the clinic, practitioners who are knowledgeable and sensitive to issues related to RJ and social justice may better appreciate the diversity of women's stories. They also may be better able to help clients (adults and children) cope with past personal traumas related to reproductive and social injustices. In this way, clinicians can help clients work toward resolution so that going forward, these individuals can be healthier and, if they are parents, can raise their children without the negative impact of stress and trauma on body, brain, and behavior (Geronimus et al., 2006).

As teachers, IMH professionals can integrate social justice theory into training programs and clinical supervision of students (e.g., see Mallinckrodt, Miles, & Levy, 2014). In this regard, it will be important to go beyond cultural and linguistic competence, which is mandated in some clinics and medical schools, to address larger questions of systemic bias (Metzl, Petty, & Olowojoba, 2018). Attainment of competency in these matters (called structural competency) calls on mental health care providers and students to recognize the ways in which institutions, markets, and healthcare delivery systems shape symptom presentations, clinician–client communication, and healthcare disparities.

As advocates, IMH professionals can help destigmatize contraception and abortion through open discussions with clients and inform them, the public, and policy makers of the many ways in which RJ affects family and children. More broadly, putting forth the conceptualization of the child, as seen within the IMH framework, could serve the discourse on RJ and social justice by offering a nuanced understanding of the diversity of children's experiences and the routes by which diseases and health are exacerbated by social, economic, environmental, and political milieus.

In all of these ways, specialists in IMH can stand in solidarity with advocates of RJ and contribute to the building of a society where all women have the right to health literacy, personal bodily autonomy, have children or not have children, and parent their children in safe and sustainable communities. By advancing toward this goal—together—there will be louder voices, more advances, and greater hope that all women and their families and children will be afforded the best possible conditions and opportunities to grow, develop, and prosper.

CONFLICT OF INTEREST

The authors report no conflict of interest.