October 30, 2014 —Summary of "Women or LARC First? Reproductive Autonomy and the Promotion of Long-Acting Reversible Contraceptive Methods," Manchikanti Gomez et al., Perspectives on Sexual and Reproductive Health, September 2014.
The "enthusiasm" surrounding long-acting reversible contraceptive (LARC) methods, such as intrauterine devices (IUDs) and implants, "has skyrocketed among U.S. reproductive health care providers" in recent years because of their "potential to budge the rate of unintended pregnancy," according to a commentary by Anu Manchikanti Gomez, assistant professor at the University of California-Berkeley's School of Social Welfare; Liza Fuentes, senior project manager at Ibis Reproductive Health; and Amy Allina, deputy director of the National Women's Health Network.
However, "unchecked enthusiasm for" LARC methods could "lead to the adoption of programs that, paradoxically, undermine women's reproductive autonomy," they argue.
When "efforts move beyond ensuring [LARC] access for all women to promoting use among 'high-risk' populations," the result "is that the most vulnerable women may have their options restricted," the authors write.
Putting Social, Reproductive Health Inequalities in Context
Given the "[c]lear disparities in levels of unintended pregnancy" rates among black, Latina and low-income women, providers and reproductive health researchers have developed intervention strategies to target these "high-risk" populations to increase the use of LARC methods, Manchikanti Gomez and colleagues write. However, such "targeted approaches to LARC promotion" can lead to "'statistical discrimination'" because a woman's risk is estimated not by her "unique history, preferences and priorities," but by "epidemiologic data or previous clinical experiences," according to the authors.
It is important to note that "settings that serve the most vulnerable women seeking contraceptive care do not operate in a neutral context," but rather in an environment of "[p]ersistant racial and socioeconomic inequality," the authors continue.
Thus, the family planning community "must take steps to make certain that use of [LARC] methods is driven by women's own expressed desires for them, and not by a programmatic attempt to reduce population-level unintended pregnancy rates by encouraging 'risky' women to use them," they argue.
Looking Beyond Effectiveness
LARC methods are often touted for their "forgettable" nature and high rates of effectiveness, but this "conceptualization implies that these methods offer women the most control over their reproduction -- an implication that may not be reflected in the experiences of women who are currently the least likely to use LARC methods," according to the authors.
In addition, the implication that a low failure rate represents "optimal control" for all women is misguided, as some women might prioritize control over stopping or starting a method without a health care provider's involvement or control over their menstrual cycle with a certain method, the authors contend.
Further, an emphasis on a method's effectiveness in the context of the public health goal of reducing unintended pregnancies overlooks "the historical legacy and ongoing reality of reproductive coercion" in the U.S. and detracts from the importance of ensuring that women have the "resources and knowledge to be able to effectively use a contraceptive method of their choice."
The authors write, "When a woman is provided counseling to steer her toward the most effective methods, even if that is not her priority, the public health imperative plays a more significant role than it does when counseling starts with the woman and her concerns."
The authors recommend an improved LARC promotion and delivery strategy that appeals to all women, rather than targeting certain populations.
Providers should develop family planning services that "suppor[t] each woman in identifying her family planning priorities and in adopting the method that best meets her current needs." In addition, training for providers "should go beyond a 'LARC-first' counseling approach," which would enable providers to better "respon[d] respectfully to a woman's concerns and ... her choice not to use a LARC method, as legitimate and even successful."
Overall, they write, "LARC promotion must expand -- not restrict -- contraceptive options for all women."
"We can increase women's ability to prevent and plan pregnancies by ensuring that as we devise solutions that eliminate barriers to LARC use for all women, we do not inadvertently diminish the reproductive autonomy of some women," the authors conclude.