It is more important than ever to expand access to a broad range of safe and effective contraceptives that includes long-acting reversible contraception (LARC) methods. We are living in a new era in the US. As of early November, 2022, abortions are banned from the point of conception in 12 states and severely restricted in many more (see map). More than 58% of Americans ages 13 to 44 now live in a state that is hostile or extremely hostile to abortion rights. A national abortion ban is on the table.
Because nearly half of all pregnancies in the US are unplanned (either mistimed or unwanted), the situation for those in states where abortion is banned or severely restricted is dire.
Figure: State policies on abortion as of November 1, 2022
Source: Guttmacher Institute, https://states.guttmacher.org/policies/
What Are LARCs?
LARCs, which include intrauterine devices (IUDs) and contraceptive implants, are the most effective forms of reversible contraception. Depending on the type, LARCs have nearly 100% effectiveness and can last from 3 to 10 years. Once placed by a trained clinician, they require no further action by the user and can be removed at any time if one’s preferences or needs change. In contrast, other types of birth control must be taken or administered every 3 months, every month, every day, or each time one has sex to prevent pregnancy. LARCs are “set and forget” contraceptives.
Since LARCs require placement by a trained clinician, it is imperative that primary care providers proactively obtain LARC training and include LARCs among the range of services they offer—directly or through referral—to their patients.
Confronting Stigma
LARC use in the US is growing. According to a 2021 brief, 18% of all women ages 15-44 using contraception relied on a LARC (mostly IUDs) in 2016. That rate is more than 7 times higher than in 2002 (2.4%).
The increase in LARC uptake is largely due to the Affordable Care Act, which substantially reduced patient cost-sharing for LARCs. LARCs are available for free or at low cost with most health insurance plans and in some government programs. For example, Medicaid programs must cover LARC insertion and removal.
Some of the stigma associated with LARCs may be related to the legacy of structural racism—such as the shameful forced sterilization programs of the past. From the Dalkon Shield scandals of the 1970s through the Norplant scandals of the 2000s, LARCs have been associated with harm and coercion.
For this reason, we emphasize that we argue for improving access to, and education about, LARCs and are not suggesting any perpetuation of harmful, coercive, or racist policies. We also encourage primary care providers to educate themselves about this racist history to understand the importance of culturally appropriate, sensitive communication on this subject.
What About the Men?
About 75% of sexually active men used some form of contraception when they had last had sex with an opposite sex partner. More than one-third used male condoms and about one-quarter relied on their sexual partners’ birth control pills. Condoms are the only reversible contraceptive option for men; unfortunately, they have an average failure rate of 13%. Vasectomy, which is used by only 4% of US men, is highly effective but intended to be permanent. More effective reversible methods of male contraception are still being developed.
Clinicians should assess the need for contraception among their male patients. A 2018 study found that this was rarely the case: only 23% of men reporting sexual activity received a sexual risk assessment that would help the clinician determine their patients’ need for information, counseling, and services to prevent unplanned pregnancy and sexually transmitted infections. A sexual risk/health assessment should be part of routine health care for people of all genders.
Our Call to Action
As previously described on this blog, research shows that LARC methods are safe and effective. We also know that many people will choose LARC methods over other methods when barriers to LARC access (e.g., lack of information, high cost, multiple and medically unnecessary visits) are reduced. LARCs should be part of a broad range of safe and effective contraceptive services that are offered in all primary care settings.
Policymakers, clinicians, public health professionals, and others need to renew their focus on helping individuals prevent unplanned pregnancies by ensuring access to safe, effective, acceptable, and affordable contraception. In this new era of abortion bans, the urgency is great.
Lisa M. Lines
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